EMS 12-Lead: No, doubling the paper speed will not reveal hidden P-waves

Apparently I went to the Rick Bukata School of Titling Articles.

A 22-year-old male presents with agitation and delirium after smoking an unknown substance that an equally unknown person on the street offered him. You note a rapid radial pulse at around 150 bpm and attach him to the cardiac monitor:

Figure 1. Initial rhythm at normal paper speed.

Figure 1. Initial rhythm at normal paper speed (25 mm/s).

Well now we’re in a tough spot. It’s difficult to tell whether Fig. 1 shows sinus tachycardia or some non-sinus narrow-complex tachycardia (we’ll use the colloquial shorthand of “SVT” to include all those other options on the differential, including AVNRT, AVRT, ectopic atrial tachycardia, junctional tachycardia, etc…). If it is indeed sinus tach, then the requisite P-waves must be those upright deflections in II and III and superimposed on the T-waves.

Is there something we could do to see if those really are P-waves buried in the T-waves?

If you’re like me, you were probably taught that it would be a clever move to double the paper speed in a situation like this to separate the P’s from the T’s, revealing the diagnosis of sinus tachycardia. Let’s see what happens when we do that.

For the rest of this case and discussion please follow this link or click on the rhythm strip above.

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EMS 12-Lead: Spot the STEMI #1

You have a 50/50 shot at getting this one right. Are you feeling smart… or lucky?

Two 50-year-old men present complaining of chest pain x 1 hour. One patient is suffering from a very subtle acute STEMI while the other has a non-cardiac cause for his chest pain.

For the conclusion of this challenge please follow this link or click on the ECG above.

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EMS 12-Lead: Conclusion to 43 Year Old Female – Chest Discomfort After Eating

This is the conclusion to our case from last Saturday. I suggest reviewing the original case presentation before diving into the discussion here.

A 43-year-old female presents feeling like there’s a knot behind her sternum. It began suddenly just after eating lunch. This is her initial ECG:

For the conclusion to this case please follow this link or click on the ECG above.

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EMS 12-Lead: 59 Year Old Male – Unwell

It’s the middle of the afternoon when you are dispatched to the residence of a 59 year old male with a chief complaint of general illness.

When you arrive on scene you encounter a middle-aged man in obvious distress, lying on a couch. He is pale, gray, diaphoretic, and drowsy. He states that he has felt drained for the past 8 hrs—unable to catch his breath or get up off the couch—with a heavy sensation in his chest. 30 minutes prior to your arrival he vomited and felt like he was going to pass-out so he decided to call 911.

For the rest of this case follow this link or click the ECG below.

Click image for case details.

 

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