I learned this from Amal Mattu

But we’ll get there in a moment.  Ever get the feeling that you’re missing something?  Something important?  Like the presence of sunlight?

Of course the presence of that dramatic looking cloud meant I saw totality for all of 30 seconds 

Because there’s a lot of things missing from last week’s EKG.  Let’s take a look at it


The first thing that leaps out is that it’s VERY slow.  There’s only 5 narrow complex QRS’s so it’s entirely possible this person is having 30 perfusing beats per minute.   It can be hard to know what to do with the bigeminous beats; do they count or not?  It’s best probably to feel the pulse and see if you can feel them.

What is the rhythm?  The people who felt this was a sinus brady with first degree heart block are probably looking at the V1 rhythm strip where there’s a couple of P-like deflections.  The problem is they aren’t consistent in V1.  Sometimes they’re suggested, sometimes they’re not.  When they are suggested they aren’t a consistent morphology.  The other thing that argues against the presence of P waves is that this isn’t a regular rhythm.  If you count the big boxes between the narrow complexes you get about 10, about 12.5, just under 11, and about 10.5.  Who can name an irregular rhythm without P waves?  It’d be a lay-up if this was a tachycardia.  Of course the answer would be A Fib.  But in bradycardia?  Actually the answer is still A fib, just with complete heart block.  Amal Mattu high-lighted this effect in a lecture of his I went to once, and I’ve seen it every couple years ever since.

Rounding out the EKG, the narrow complex QRS’s have fairly low amplitude in the limb leads, of unclear significance.

Looking at the ST segments, there’s a lot of T wave flattening and some fairly odd inversions to the lateral chest leads.  Note that the rhythm is so slow we don’t really see an entire narrow complex QRS/ST in the 2nd segment of the EKG at all!  You’d have to ask the techs to repeat the EKG so we can see this section.

In real life, this patient was admitted to the cardiology service and had his permanent pacemaker placed the next day.

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