another case of the missing P waves

Ever gone on a trip, come back, and realized that a bunch of people didn’t even notice you were gone?  I wish I could say this had happened to me recently since it’d mean I’d gone on a trip!  Let’s circle back to that thought in a couple months.  But most of you noticed where the P waves were gone here…

50 y.o. woman with palpitations

Though I wonder if I had given her Chest Pain instead if the interpretations would have been different.

The rate looks to be in the 60’s; we’ll move on to the rhythm.  What most of you noticed is that the rhythm is not perfectly regular and that it changes about halfway through the EKG.  There aren’t P waves in the first half of the EKG; there are P waves in the second half.  The width of the QRS changes as well; it’s narrow complex where there are P waves and wide complex where there are not.  Many of you called it a junctional escape rhythm of some sort; I think technically this would be a ventricular escape.  Junctional beats should still be narrow complex, these are wide.  As to why the P waves are just missing in some sections of the EKG, probably this is a form of sick sinus syndrome.

We’ve talked about the QRS, let’s look at the ST waves.  We do see ST elevation in the inferior leads.  We also see ST depression in the lateral limb leads.  However, we shouldn’t be surprised to see those in the setting of wide complex ventricular complexes.  To say whether there is ischemia present we’d either need A.) an old EKG that had wide complexes in this area to apply Sgarbossa criteria to, or B.) a repeat EKG now with narrow complex beats in the first half of the EKG.

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