March EKG Quiz

Answers below — remember there are prizes! Dr Smer and Dr Abu Hazeem will join in after a few!

14 Responses

  1. Nagarjuna R Gujjula

    EKG Anatomy
    Rate: 102 Bpm
    Rhythm: RR intervals are irregular
    Axis: Left axis deviation
    P waves: inverted P waves ( seen in lead II)
    QRS wave: wide complex, normal QRS alternating with PVC’s, rSR pattern is present ( evident in V2)
    PR and QT intervals: slightly prolonged PR interval and normal QT intervals
    ST segments: no ST elevation or depressions, cannot be determined accurately due to underlying RBBB
    T waves: inverted T waves in V 2 and V 4, non specific

    This is normal sinus rhythm with ventricular bigeminy, underlying RBBB, Left axis deviation, possible left posterior fascicular block and nonspecific T wave changes.

  2. Rahma

    Standardized EKG, Unidentified patient, H/O CM, MVR, Regularly irregular rhythm in couplets, rate in 90s, left axis (LAFB) with RBBB (bifascicular) P wave present of abnormal morphorology (inverted in lead II), PR interval less than 200 msec, widened QRS about 160 msec in couplets with similar morphology ( less likely to be bigiminy). non-specific TWI in I, avL, II, III, avF, V1, 2, 3. has atrial and ventricular pacing. My answer would go with sinus rhythm with ?? retrograde conduction, atrial non sensing, bi-ventricular pacing with intermittent non-captured beats.

  3. Mohammad Selim

    There are spikes of Pacemaker. Firing of pacemaker is haphazard, with some spikes pre and post P wave, some spikes fall on QRS complexes.

    – Under-sensing pacemaker.
    – Regular Irregular rhythm.
    – Atrial rhythm (P waves inverted in lead II) with junctional bigeminy, followed by compensatory pause.
    – Borderline 1st degree heart block.
    – RBBB.
    – Tachycardia with HR of 102.
    – LAD.
    – Possible old inferior infarction.

  4. Abhi

    Patient with history of MVR and cardiomyopathy..
    Presenting with palpitations
    EKG shows:
    – Narrow complex tachycardia (a type of SVT) with regularly irregular rhythm.
    – left axis deviation
    – RBBB
    -Inverted p waves in lead 2,3 and avF: from Atrial Ectopic or junctional rhythm. But pr interval is >120 which is against junctional.
    – Two types of p waves are seen in lead II, first one is inverted P wave which is marching at regular intervals and are of same morphology. The second one I believe is between qrs complex and T wave.(which is not clearly seen). MAT is excluded as it does not have 3 or more p waves.
    – In lead I there are p waves embedded in the QRS complex. which may be from junctional rhythm or AVNRT.
    Conclusion: Type of SVT which may be
    – Junctional tachy with atrial ectopic or
    – AVNRT

  5. Duc Le

    102 bpm. Reg irregular atrial tach with coupled ventricular complexes. LAD. RBBB. 1st degree AV block. Old inferior ischemia.

  6. Faysal Alghoula

    HR around 105 with regularly irregular rhythm, LAD with RSR patern in V1&2 with Prolonged R wave peak time in aVL indicating Bifascicular block (RBBB+LAFB).
    I think there is an accelerated idioventricular rhythm

  7. Rahma

    The other possibility I have here is:
    standardized ECG, regularly irregular
    atrial rate is regular at 150/min, ventricular response is 102/min, every 3rd beat is dropped.
    LAD, inverted P wave, RBBB with TWI, wide QRS complexes,
    This is junctional tachycardia at 150/min with Mobitz type 2 AV block, ventricular response at 102/min with a dropped beat every third beat with fixed PR duration around 200msec, that can explain the regularity) together with the bifascicular block.
    spikes are too erratic, either atrial non-sensed, ventricular non captured or baseline artifact.

  8. Dr. Smer

    Great input guys..! I think all of you got the bifasicular block (LAFB & RBBB) correct. Some of you noted the atrial pacing spikes, which is very subtle.

  9. Dr. Smer

    One point I want to clarify that once you think the rhythm is irregular, it is very unlikely to sinus, unless there is marked sinus arrhythmia, frequent PACs/PVCs. If there is pattern, you start thinking about atrial or ventricular bigiminy.

    To identify the rhythm is sinus tach or atrial tachy, you look at the P wave morphology in the inferior leads, if it is positive, it is likely sinus tachy, but if it is negative in inferior leads, it is probably Atrial tachy, like this case.

    Hope this help.

    Luay good job on getting the correct diagnosis.

  10. Mohammad Selim

    I’m confused about the following 2 things:
    If it is Mobitz type 2 with 3:2 block, the p wave should fall after QRS complex and not conducted. In this EKG what I see is P wave falling just before T wave which is the refractory period and won’t be conducted any way regardless of the presence or absence of the block.

    The other thing this erratic pattern of pacemaker spikes what should be called? Isn’t under sensing?

So, what do you think?


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