Returning to my latest book club reading, The Subtle Art of Not Giving a F*ck, one of the points that the author makes is that ego is over-rated. If you’re too invested in being right then it’s very difficult to learn from mistakes. Here’s an EKG I got wrong when one of the residents was telling me about the interesting case they’d seen the week before.
It’s a 30’s y.o. man with weakness and abdominal pain. The computer read was Sinus Tachycardia.
Clearly he’s tachy with a 2 big box R-R interval, so right around 150. At least one of you commented that at 150 consider A flutter; that’s a good thought but I don’t however see any evidence of flutter waves (remember they show up best inferiorly generally). It’s clearly a narrow QRS so if we cross off A flutter (and it’s regular so fib is less likely) we’re really left with SVT or sinus tach. I don’t appreciate P waves and neither did the original providers so adenosine was given in standard fashion. It didn’t work. Can we look closer and see why not? Are there in fact subtle P waves?
There’s an extra inflection point after the peak of the repolarization T wave in V3. You also get a sense of that in the V1 rhythm strip directly beneath it.
Rounding out our analysis of the EKG, as mentioned before the QRS is narrow. There is some lateral T wave flattening of unclear significance (more on that next week!).
For this patient, after the adenosine didn’t work the patient received IV hydraion as the providers continued working up the abdominal pain and discovered a source of sepsis. Aggressive management of the sepsis improved the Sinus Tachycardia.
Take-homes from this EKG? First, P waves can be subtle, but if the computer is seeing them, you really have to look carefully to see what it’s seeing (or not seeing). Next, always ask yourself if the presentation makes sense. Not that medicine always does make sense, but SVT doesn’t generally cause abdominal pain, make sure you’re keeping the differential wide when things don’t seem clearcut (and honestly keep them wide even when they are).