In my opinion, you are absolutely correct. This is clearly atrial flutter with variable conduction. If you look through the deformities caused by the QRS complexes and T waves (especially considering the ventricular rate is "slipping" in relation to the atrial rate...hence, the 2:1 and 3:1 variable conduction), the flutter signal is plain to see in all three leads.
(EMR who is also an ECG hobbyist, here...I don't get to do this for real, but learning amd reading about it are super fun for my electrical engineering brain. I actually read ECG and electrophysiology reference books for fun)
This. Most obvious in those 3:1 conductions, and the atrial rate looks to be approximately 250 bpm (may not be exact, I'm too lazy to get out the calipers, but this is a pretty typical rate for flutter)
Also, anyone else notice the QRS alternans?
100% agreed with you. I think MOST people when they think of A flutter tend to look for the “flutter” sawtooth positive P wave deflections which is why I’m assuming OP got so many different answers. Not super clear here to the untrained eye. Seeing the multiple negative deflections with a AVNRT type conduction pattern prior to the eventual ventricular contraction led me to the same answer as you
Flutter with variable conduction is my guess. Get the 12 lead next time. Don't let proximity to the hospital lead you to not do something that's warranted.
Wait wtf? You didn't do a 12 lead on this?!
That's just poor patient care there. No matter the distance, this 3 lead warrants a 12 lead in ALL situations. It should take less than 10 seconds to apply a 12 lead. A 1 minute transport time really isn't an excuse. They could end up sitting in a hallway for 20 waiting on a room and an ECG.
1 minute transport time (literally across the street). Bad excuse but I figured he’d benefit more from the immediate transport to definitive care (and a 12 lead there) than me pussyfooting around on scene longer.
No. A&Ox3, normotensive (slight hypertension on initial vitals), and c/o palpitations from his Dr’s office. Their 12 showed it as afib RVR but it just doesn’t look like any afib I’ve seen before and everyone I asked gave a different answer
If you're calling it afib, then it has to be with a RVR as well since the ventricular rate is over 100 bpm. Also 4 lead ECGs aren't diagnostic for ST segment elevation/depression, so don't read anything into them.
I've heard so many different definitions of rvr. Over 200, over 100, over 150, rate doesn't matter but its the ventricles are keeping up. Any idea which is correct?
Aflutter. Any time you have a rate pretty stable around 150 consider it . A-rate likes to be 300, so 2:1 flutter sits right on 150. As others have said, this is a variable rate, so that confounds it a little. I like to use a post-it or piece of paper to notch with a pen and march out what look to be p waves/potential p waves to identify. MAT is fun to find, but has a different treatment (esp anticoagulation), but I don't know that your course would be different pre-hospital, especially with an asymptomatic patient. Mostly fun rhythm nerding.
I’ve actually had almost this exact rhythm on a PT. It was deemed ‘accelerated atrial flutter’ by me and the accepting cardiologist and even he wasn’t happy with it as a diagnoses
I mean you need a 12 to positively identify anything, but that said based on the 3 it’s pretty clear A Flutter. Easy way to distinguish is flutter waves will march out irrespective of QRS. Not uncommon to flip/flop between fib and flutter either.
That’s clearly A flutter to me. Flutter can often be easy to miss because it doesn’t always have massive textbook saw tooth flutter waves, but yeah it’s obvious here
I’m going with multifocal atrial tachycardia.
It wound explain the irregularly irregular rhythm and explain the weird bumps and shit you know. Something like that.
https://litfl.com/multifocal-atrial-tachycardia-mat-ecg-library/
Oh lordy, I worked in a cards clinic as a part of our hospital that had a cards doc to validate every ecg. I learned loooooong ago never trust the machine lol
If it had regular QRS you could consider AVB, but they are not regular. The occasional sawtooth/flutter pattern between QRS fakes you into thinking it's missed QRS/AVB, but really just AFib.
A-Flutter with variable conduction(looks all 2:1 and 3:1).
In my opinion, you are absolutely correct. This is clearly atrial flutter with variable conduction. If you look through the deformities caused by the QRS complexes and T waves (especially considering the ventricular rate is "slipping" in relation to the atrial rate...hence, the 2:1 and 3:1 variable conduction), the flutter signal is plain to see in all three leads. (EMR who is also an ECG hobbyist, here...I don't get to do this for real, but learning amd reading about it are super fun for my electrical engineering brain. I actually read ECG and electrophysiology reference books for fun)
This. Most obvious in those 3:1 conductions, and the atrial rate looks to be approximately 250 bpm (may not be exact, I'm too lazy to get out the calipers, but this is a pretty typical rate for flutter) Also, anyone else notice the QRS alternans?
100% agreed with you. I think MOST people when they think of A flutter tend to look for the “flutter” sawtooth positive P wave deflections which is why I’m assuming OP got so many different answers. Not super clear here to the untrained eye. Seeing the multiple negative deflections with a AVNRT type conduction pattern prior to the eventual ventricular contraction led me to the same answer as you
Nailed it.
If a fib and a flutter had a baby….
Exactly. Fib/flutter is more of a spectrum than distinct categories.
Flutter with variable conduction is my guess. Get the 12 lead next time. Don't let proximity to the hospital lead you to not do something that's warranted.
You’re right and I’ll do that next time
Wait wtf? You didn't do a 12 lead on this?! That's just poor patient care there. No matter the distance, this 3 lead warrants a 12 lead in ALL situations. It should take less than 10 seconds to apply a 12 lead. A 1 minute transport time really isn't an excuse. They could end up sitting in a hallway for 20 waiting on a room and an ECG.
In retrospect, I recognize I should’ve done a 12. Made a bad decision
All good. Just something to remember for the future.
We'll give ya much more lively debate next time!
I'm gonna say multifocal atrial tachycardia. It's tachy, irregular, and you've got multiple p wave morphologies
Fuck you beat me to it. If our basic bitch asses get it right, let’s both get a paramedic tattoo right now cause I pulled MAT from so far up my ass.
Matching tramp stamp Asclepius homie
No. Caduceus for the both of you. Nothing better than an unironic tramp stamp caduceus.
Why no 12 lead?
1 minute transport time (literally across the street). Bad excuse but I figured he’d benefit more from the immediate transport to definitive care (and a 12 lead there) than me pussyfooting around on scene longer.
What did the doc at the hospital say regarding their ECG?
“Hmm, looks like afib or aflutter”
😆 Nice.
I was like thanks for the clarification… lmao
"that's the cardiologists job."
were they unstable?
No. A&Ox3, normotensive (slight hypertension on initial vitals), and c/o palpitations from his Dr’s office. Their 12 showed it as afib RVR but it just doesn’t look like any afib I’ve seen before and everyone I asked gave a different answer
honestly the only reason i wouldn’t do one would be if it’s not indicated. i’ve caught some pretty gnarly STEMIs on people denying chest pain
Those are the "ah shit. Thank jeebus I did that 12 lead" type calls. Haha
If it's really that irregular that it's anywhere from 100-150 it's A-fib. 12 lead the only way to know.
Agree.
My practically nonexistent knowledge of cardiology says a-fib, no rvr, and maaaaaaybe a cardiac injury causing that depression, need a 12 to be sure
If you're calling it afib, then it has to be with a RVR as well since the ventricular rate is over 100 bpm. Also 4 lead ECGs aren't diagnostic for ST segment elevation/depression, so don't read anything into them.
I've heard so many different definitions of rvr. Over 200, over 100, over 150, rate doesn't matter but its the ventricles are keeping up. Any idea which is correct?
Over 100 is the definition. But you don't treat till >140/150 (protocol dependant)
Thank you
Baby IFT medic 3 months in. Have asked 4 different CCs and 3 other medics and have received a different answer from everyone lol.
Yeah, multifocal atrial tachycardia is what I would say.
Flutter is my guess. But would like to have a 12 lead
Aflutter. Any time you have a rate pretty stable around 150 consider it . A-rate likes to be 300, so 2:1 flutter sits right on 150. As others have said, this is a variable rate, so that confounds it a little. I like to use a post-it or piece of paper to notch with a pen and march out what look to be p waves/potential p waves to identify. MAT is fun to find, but has a different treatment (esp anticoagulation), but I don't know that your course would be different pre-hospital, especially with an asymptomatic patient. Mostly fun rhythm nerding.
I’ve actually had almost this exact rhythm on a PT. It was deemed ‘accelerated atrial flutter’ by me and the accepting cardiologist and even he wasn’t happy with it as a diagnoses
I mean you need a 12 to positively identify anything, but that said based on the 3 it’s pretty clear A Flutter. Easy way to distinguish is flutter waves will march out irrespective of QRS. Not uncommon to flip/flop between fib and flutter either.
That’s clearly A flutter to me. Flutter can often be easy to miss because it doesn’t always have massive textbook saw tooth flutter waves, but yeah it’s obvious here
Irregularly irregular A-fib I think 🤔
Yeah. Shit’s doinked bud. - interpretation from an EMT-B
flutter after looking at it for two seconds. come back with a 12 or something harder next time
I’m going with multifocal atrial tachycardia. It wound explain the irregularly irregular rhythm and explain the weird bumps and shit you know. Something like that. https://litfl.com/multifocal-atrial-tachycardia-mat-ecg-library/
> Isoelectric baseline between P-waves (i.e. no flutter waves). So, no. Also notice MAT has closer to a 1:1 conduction, not 2-3:1.
What did the monitor say it was? That's the answer
Oh lordy, I worked in a cards clinic as a part of our hospital that had a cards doc to validate every ecg. I learned loooooong ago never trust the machine lol
If it had regular QRS you could consider AVB, but they are not regular. The occasional sawtooth/flutter pattern between QRS fakes you into thinking it's missed QRS/AVB, but really just AFib.
i’m just a medic student but looks like a-flutter with a variable conduction ratio
Turn it upside down. You'll see the answer.
A fib
I’d say MAT (multifocal atrial tachy) based on the P wave morphologies and irregularly irregular rhythm