We originally published this ECG in 2012. It was generously donated to the ECG Guru website by our friend and ECG Guru Extraordinaire, Jason Roediger. We are re-publishing it today, as it is a great ECG for illustrating how helpful laddergrams can be for showing conduction in dysrhythmias.
Nice, clear example of ventricular bigeminy with an underlying sinus rhythm. We do not know from this strip if the sinus rhythm is a bradycardia at a rate of about 42 per minute, or if the underlying sinus rhythm is actually at a rate of 85 per minute, with every other sinus beat inhibited by the occurance of a PVC. In the first possibility, the ventricular beats would be considered "escape" beats, positively contributing to the patient's heart rate.
Unbelievably, this inferolateral ST elevation M.I. was missed by the treating paramedics in the field. An elderly woman stepped off a curb and was hit by a very slow-moving car. She fell and sustained a Colle's fracture of the right wrist. While the paramedics assessed her, she complained of chest pain, prompting them to perform a 12-Lead ECG. The machine's interpretation called attention to the inferior and lateral walls' injury pattern, but the paramedics did not believe it, because "she was a trauma patient".
This is a nice example of sinus rhythm with ventricular bigeminy in a patient with intermittent chest pain and hypertension. The underlying rhythm is most likely normal sinus rhythm, but every other sinus P wave is most likely hidden in the PVCs, and not conducted due to the refractory state of the ventricles after the PVCs. Often, signs of the "hidden" P waves will show in some leads, but that is difficult to demonstrate here.
This ECG shows a nice, clear atrial flutter with 4:1 conduction. Also, there are frequent PVCs. Good for students who have mastered the criteria for the basic arrythmias and who need to see combinations. That is, PVCs are not only seen with NSR, and it is important to state the underlying rhythm. For your more advanced students who understand how to plot frontal plane axis, the axis of the PVCs is nearly straight up - a very strong argument for the ventricular origin of the beats.
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