EKG Strips


Two EKG strips for my fellow EMS bloggers, and others of course, to study and interpret. Strip #1 is from a 55 year old male with a complaint of near syncope when he got up to go to the bathroom. He has a history of Chronic Renal Failure and is due to for dialysis later in the day. No other complaintsBlood Pressure initially 90/60, RR 18, Skin cool 1+ diaphoretic. Some nausea without vomiting. . Clear lungs, no dyspnea.

What is the rhythm? What is your differential diagnosis? What course of treatment do plan to take?

Strip #2 is a mystery. Not my patient and I don’t have a 12 Lead. All I know is that the patient was 55 year old female. A bunch of us looked at this and no one could come up with a definitive answer. So, I leave it to my faithful readers to give me their best guesses.

Discuss in the comments section. No prizes for correct guesses, but I thought I’d do some EMS blogging on this EMS blog, for a change.

Speaking of prizes, I haven’t forgotten this A Gadget And A Contest post. It’s been longer than I planned, but I didn’t receive the number of replies I’d hoped for, so I’m going to run it for one more week. After that, I’ll pick a winner and make arrangements to deliver the prizes. Place entries in the comments section for that post, please.

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After a long career as a field EMS provider, I'm now doing all that back office stuff I used to laugh at. Life is full of ironies, isn't it? I still live in the Northeast corner of the United States, although I hope to change that to another part of the country more in tune with my values and beliefs. I still write about EMS, but I'm adding more and more non EMS subject matter. Thanks for visiting.


  1. Hmm.Anytime I hear "renal failure" and "dialysis" I'm thinking hyperkalemia before I even hook up the monitor.I think I can see P waves superimposed on the ST-segments in several leads (with a very long RP interval).So what happened to the sinus node? It's sleeping on the job.With the narrow QRS complexes, it's not the classic sine-wave ECG one usually associates with severe hyperkalemia, but it has be part of the differential diagnosis.Also sinus arrest, other metabolic/electrolyte derangement, all of the Hs and Ts in fact.I'd probably start with an IV and a fluid bolus and supportive care.The second strip is another oddity! At first glance it looks like interpolated PVCs, but the R-R intervals of the narrow complexes are shorter with the PVC than they are without the PVC.I know this means something to electrophysiologists (short-long-short, blah blah blah) but I never could grasp the concept.Tom

  2. I'm going to hold off until a few more people have a chance to comment. At some point, I'll let you know what we did with the patient from the first strip. The second one has baffled everyone who has looked at it. It's real mystery and further proof that the patients don't read the text books. One comment that I'll make about that strip, because I don't have the answer lurking, is that the P-R interval in the complex after the FLB seems too short to be sinus. At least to my eyes.

  3. As far as his symptoms, my first guess would be orthostatic syncope, but one would expect that sort of thing post-dialysis, not before.I'm with Tom on the hyperkalemia suspicians, although one would expect to see AV blocks or sine waves with profound hyperkalemia.Rhythm looks like a junctional escape rhythm with the pacemaker low enough that the retrograde impulse reaches the atria after the antegrade impulse reaches the Purkinje system.

  4. Man…Tom commented first before I could look at this. He's the expert and I'm not. Soooo…. at the risk of sounding dumb, here goes. The 12-lead. I'm marching those P waves out in a regular, albeit bradycardic rhythm. The QRS complexes are junctional and seem to be completely disassociated from the P waves. Isn't that a 3rd degree AV block? I'm with you guys on the treatment though. Fluid for pressure. Maybe TCP (pacing) if the patient is very symptomatic or not doing so well with the fluids. The second one? Well that's a tough one. Sinus beat, PVC, PAC, rest period.That's why cardiologists make more money than I do.

  5. I think there may be some consensus on strip number 1 and the question of hyperkalemia. Based on the information you provided with the strip I would likely think that there is something going on there. However, the T-waves don't look especially pointy; not knowing this patient's background, I suspect that consideration of hyperkalemia would be easily overlooked. He is markedly bradycardic, also, and there isn't a P-wave to be found which makes me think junctional escape as well. His initial pressure is higher than I would have expected, though.I'd treat this somewhat conservatively; gentle IV fluid adminstration (probably start with 250ml and reassess from there), Oxygen, and cardiac monitoring with a repeat 12-lead to look for possible changes. Supportive care is appropriate unless there are changes to his condition that warrant intervention.As for strip number 2, that is just plain weird. Seeing no extra-electrical activity in lead III makes me suspicious, but I don't know what I would even start to look for. Initial impression says to me that it's either an atrial or junctional complex that shows up between the regular ones, but they don't morph out differently each time; they look unusually uniform. And I think that's wht's weirding me out with this one. Could it be something really off the wall like a pacemaker that is malfunctioning?Thoughts worth $0.02 before taxes, of course…

  6. Ckemtp, by definition it's a complete heart block, but that doesn't tell the complete story. The cause is likely electrolyte imbalance and is relatively easy to correct. We opted for Atropine 0.5mg repeated at five minutes. That increased his rate into the 50s and he told us that he felt more clear headed. We opted not to use fluid because he was due for dialysis and we were concerned about fluid overload. Pacing would have meant sedation, and we were also leery of that. We took what we considered the least invasive, yet effective course. Walt, there is electrical activity in Lead III, it's just hard do see through the craptastic baseline. The 12 Lead looks even more weird. I'll post it as an update if I can find it. Our best guess on strip 2 was sinus, some sort of abarrantly conducted sinus beat, followed by a PAC. Incredibly odd rhythm.

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