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Arrhythmia Recognition Webcast Series
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Practice ECG 4
This patient is clipping along at a rate of about 140 to 145 BPM. So, what's the rhythm? If you said sinus tachycardia, go back and take a look at all of the ST segments. Notice anything unusual? Look at lead II, especially the third and fifth beats. Do you notice a slight double hump in the ST segment? Now look at V1. With your calipers, measure the distance from the P wave in front of one QRS complex to the P in front of the next QRS. Divide that distance in half. Go back and place the half-distance on top of the first P wave and see if you get another bump regularly appearing in the ST segment. Map those through. Do they map out? Now look at the third beat in V5: it, too, has a hump on top of the ST segment. Is that the same distance from the preceding P wave as the half-distance you measured in V1?
If your answer to these questions shows that there is a consistent bump at those distances, you have to think that there are two P waves for every QRS complex. In other words, this is an atrial flutter with 2:1 block.
What about the rest of the ECG? Does that constant ST segment elevation in most of the leads make sense? Sure it does. This is pericarditis. Also notice the PR depression evident in many leads, another sign of pericarditis. Most probably, the atria are irritable because of the pericarditis, and this is causing the atrial flutter to develop.
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