In actuality, 40-50% of acute LAD occlusion have upwardly concave ST segment morphology in all of V2-V5. We are taught in medical school that concave upward ST segment morphology is a feature of benign STE, pericarditis, etc. He was found to have proximal LAD occlusion, but other outcome details are not available. I received this also by telemetry, and again we agreed with their plan of the nearest cath center and activated their cath lab protocol. V5 has very diminished voltage and poor quality, suggesting some combination of lead misplacement and/or physical object between it and the patient (hair, defibrillation pad, medical cables, clothing, etc.). STEMI criteria met by the STE in V6, I, and aVL. I was unable to get back in touch with them for the outcome. Before our conversation was finished, the patient went into VF arrest and they hung up. There was another cath center closer than our institution, so we agreed they should go there and advised they activate their cath lab immediately.
I received this ECG via telemetry from an ambulance far from our hospital. Sinus bradycardia with first degree heart block present, clearly high risk for worsening bradycardia and/or heart blocks. V1 may be in a tug-of-war between STD from posterior involvement and STE from possible RV involvement. V2 shows STD indicating posterior involvement. Obvious STEMI and OMI with massive STE in the inferior and lateral leads, even extending back into V3.Īll STE has concave upward (smiley face) morphology. Atypical atrial flutter originates from the left atrium or areas in the right atrium, such as surgical scars, and has a variable appearance on ECG in regards to the flutter waves.Here are two striking examples from a single shift highlighting the fallibility of the standard "smiley face" or upwardly concave ST segment morphology "rule". This appears as positively-directed flutter waves in the inferior leads. This results in negatively-directed flutter waves in the inferior leads.Īt times, the direction of the circuit can reverse, causing clockwise atrial flutter from the same anatomical location. Typical atrial flutter rotates counterclockwise in direction, from a reentrant circuit around the tricuspid valve annulus and through the cavo-tricuspid isthmus. Also, atrial flutter can be described as “clockwise” or “counterclockwise” depending on the direction of the circuit. In this situation, giving adenosine will transiently slow the ventricular rate, unmasking the atrial flutter waves and allowing a more definitive diagnosis to be made.Ītrial flutter can described as “typical” (type I) or “atypical” (type II) based on the anatomic location from which it originates. When the heart rate is significantly elevated - that is, greater than 150 bpm - it is often difficult to determine atrial flutter from atrial fibrillation, atrial tachycardia or atrioventricular nodal reentrant tachycardia, or AVNRT. This results in the rhythm becoming “irregularly irregular.” There are only two other rhythms that are commonly irregularly irregular, including atrial fibrillation and multifocal atrial tachycardia, or MAT. In this situation, there may be three P waves to one QRS complex, then a quick change to two P waves to one QRS complex, and so on any combination of P waves to QRS complexes can occur. The regularity of the QRS complexes frequently present with atrial flutter helps to distinguish it from atrial fibrillation, though atrial flutter with variable conduction of the P waves can also occur. In this situation, the ventricular (QRS) rate will be exactly 150 bpm and regular.ĬLINICAL PEARL: A narrow complex tachycardia at a ventricular rate of exactly 150 bpm is very commonly atrial flutter. Typically, the atrial rate will be about 300 bpm, and only every other atrial depolarization will be conducted through the AV node. Just as in atrial fibrillation, not all of the P waves are able to conduct through the atrioventricular node, and thus the ventricular rate will not be as fast as the atrial rate.
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