All good things must come to an end, be they Samson-like flowing manes of hair, handlebar mustaches, or Patriots’ Super Bowl chances (wait, that one is still intact for now). What does that have to do with today’s EKG? Wait and see…
Starting always with rate, we can tell immediately that it’s slow. It’s a bit irregular so probably just best to count the complexes and multiply by 6, which nets us a rate of about 48.
What’s the rhythm? Well there certainly aren’t P waves close to the QRS. There is an extra positive deflection in the V5 rhythm strip immediately following the T wave. That is either a U wave or a near record 1′ AVB. The QRS’s are identical, even the one following the very long pause so I’m inclined to say those aren’t P waves and that this rhythm is either a very slow Afib (which can imply fairly high grade block), or a junctional escape rhythm of some sort. Given the history of A fib it would seem most likely this is a slow A fib with some degree of block).
There’s a Left axis.
Looking at the QRS’s, they aren’t normal. They look narrow inferiorly but wide pre-cordially. Let’s look more closely at the abnormal precordial leads:
We again see Osburn like waves that we saw last week with the hypothermic patient. They look a little RBBB-like, but it would be odd for the 2nd hump to be wider than the first and to have the curve at the top.
Speaking of curves, let’s look at the ST waves. There’s ST depression to the chest leads, fairly typical in appearance laterally, but look at the smooth curves of the repolarization again in V2 and V3. Could that look like half of a handlebar mustache?
This is the so-called Salvador Dali ekg effect, named after a famous painter with a very long handle-bar mustache. I tried to find a pic of other people in Emergency Medicine with a handlebar mustache to super-impose over the EKG but no dice. This appearance on an ekg is consistent with Digoxin toxicity. In this case his dig level was 2.8.
Digoxin toxicity can look like a lot of things, but some of the more suggestive are Osborn-like waves, Salvador Dali T waves. Frequently an EKG that’s fast and slow at the same time can be consistent with digoxin’s effect of increasing irritability but slowing the AV node. Examples of this include accelerated junctional rhythms, or tachycardias with heart block.