clinical Question

[chetnarayan]

BACKGROUND


A 68-year-old woman of Persian descent presents to the emergency department complaining of intermittent substernal chest pressure and progressive dyspnea for 4 days. She denies having similar symptoms in the past. Today, her symptoms worsened significantly, and she is now dyspneic at rest. Her chest pressure is constant, moderate in intensity, nonradiating, nonpleuritic, and nonpositional. She has no paroxysmal nocturnal dyspnea, orthopnea, or lower-extremity edema. She denies long-distance travel, recent surgery, or immobilization. Her medical history is significant for diabetes mellitus for which she takes an oral hypoglycemic agent.


During triage, the patient is awake, calm, and alert. She has a respiratory rate of 30 breaths per minute, a heart rate of 40 bpm, a blood pressure of 138/76 mm Hg, and an oxygen saturation of 82% on room air. The patient was immediately given oxygen by means of a nonrebreather face mask and attached to a cardiac monitor with continuous pulse oximetry. An intravenous line is started, external cardiac-pacing pads are placed on her chest, and a cardiac resuscitation cart is brought to the bedside. An initial rhythm strip (see Image) is obtained.





What are the clinically significant findings, and how is the condition treated??

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[unseennude]

Its very difficult to interpreat the rhythm stripe of this patient without looking at the 12 lead ECG.
Anyway, what I think about this case is that:
1. the patient has sever bradycardia
2. constant PR inverval with dropped beats
3. Some of the P waves are not conducted ie. not followed QRS complex.
4. the QRS complex is very narrow

so from the above findings we can say that the patient has Second degree AV block.
It has high probability of being Mobitz type II second-degree AV block.
Looking forward to having the correct answer.

[Hero]

Yes, there are dropped beats with fixed PR interval and without any AV dissociation --which suggests 2* AV block--Mobitz type II. Mobitz type II are generally managed by permanent pecemaker insertion in our hospital.

[de.malady]

me still not bein able to interprete this here; with only 1 -ecg- not easy..

[Hero]

Originally Posted by Graduate 06

me still not bein able to interprete this here; with only 1 -ecg- not easy..

I can see lots in this SINGLE ecg. Look at the rate-brady. Rhythm- sinus rhytm, but some P waves are not followed by QRS. It suggests there is block in AV conduction. If it was Weckebach type AV block there should be gradual PR prolongation before one dropped beat, but there is no such--so it's type II mobitz. There is no AV dissociation so it's not a case of 3*(complete) AV block. So I don;t think more strips are necessary coz we can also interpret possible diagnosis from this ecg strip