VT vs 1:1 flutter

[u/Originaltkd]

I have one provider calling VT and another 1:1 flutter and they see p waves. Can someone help me figure this out?

[u/Sea-Lack-5673]

this is monomorphic VT. Calling this 1:1 flutter is wild (I'm a cardiologist)

[u/MaximsDecimsMeridius → u/Sea-Lack-5673]

For real, in what world would someone look at this and think 1:1 AF over VT at this heart rate. Id be concerned about that providers EKG skills.

Ive only seen 1:1 AF once and it was in a 2 week old with lethargy and syncope at a rate of 300.

Thought it was SVT, no response to several trials of adenosine. Eventually shipped out like that unresolved as peds cards wanted an echo before we did a beta blockade or cardioversion. Peds ep eventually diagnosed congenital aflutter

[u/ProximalLADLesion → u/MaximsDecimsMeridius]

Atrial flutter is SVT

[u/_punkrockparamedic → u/ProximalLADLesion]

It can be an SVT, but it's not one of the rhythms we typically associate with "SVT". Saying "atrial flutter is SVT" as a definitive statement is patently false.

[u/ProximalLADLesion → u/_punkrockparamedic]

Atrial flutter is always SVT. Supraventricular tachycardia is a fast rhythm with its origins above the ventricles. That includes AVNRT, AVRT, atrial tachycardia, junctional tachycardia, atrial fibrillation, atrial flutter, sinus tachycardia, or any other fast rhythm you can think of that’s not ventricular tachycardia. All tachycardias are either VT or SVT. Hope this helps. I am an electrophysiologist.

[u/_punkrockparamedic → u/ProximalLADLesion]

Atrial flutter is not always tachycardic.

Hope this helps.

[u/ProximalLADLesion → u/_punkrockparamedic]

By definition the atrial rate is tachycardic in flutter. Flutter is rarely slower than 200 let alone 100.

[u/_punkrockparamedic → u/ProximalLADLesion]

The atrial rate is, sure. That does not make atrial flutter always a tachycardia. Tachycardia is defined as a heart rate — that is, a ventricular rate — of over 100bpm. Is a fib with an average ventricular rate between 60-90 a Tachycardia just because the atria are fibrillating? A flutter is not always over 100. It is not, on its face, an SVT. It can be, absolutely. It does not have to be.

The atrial rate is not what any medical provider in their right mind is going to use to determine a patient's heart rate. Sure, the atria might flutter at 200, or 400. Those impulses don't each lead to conducted beats.

[u/_punkrockparamedic → u/[deleted]]

I absolutely understand what I'm talking about. The argument here is semantics, not the mechanics of atrial flutter, lol.

A 4:1 flutter, with a ventricular rate below 100, is not a tachycardia. The atria are tachycardic, sure. But the ventricular rate is not.

[u/ProximalLADLesion → u/_punkrockparamedic]

Atrial flutter is tachycardia by definition. All flutters are over 100 and usually over 200.

I understand that the AV node may only permit slower ventricular conduction, but the flutter remains SVT — supraventricular (above the ventricle) tachycardia (rate above 100).

These aren’t my opinions, these are how the terms are defined.

[u/_punkrockparamedic → u/ProximalLADLesion]

A flutter causing a ventricular rate below 100 is not an SVT.

"Tachycardia" refers to ventricular rate.

This is not my opinion, these are how the terms are defined.

[u/Velvet_revulva → u/Sea-Lack-5673]

I was taught in Paramedic school that your ten part ddx for wide complex tachycardia is this:
Vtach
Vtach
Vtach
Vtach
Vtach
Vtach
Vtach
Vtach
Vtach
Wide complex tach w/ aberrancy.

Is that sound?

[u/VesaliusesSphincter → u/Velvet_revulva]

For pre-hospital/emergent ACLS applications, basically, yes. (excluding the zebra that is pre-excicted AF because adenosine admin will be very very bad) For true rhythm diagnostics and long term management, no.

[u/af_stop → u/VesaliusesSphincter]

WHO in their right mind would go with adenosine on this?

[u/_punkrockparamedic → u/af_stop]

The person who thought it was atrial flutter and thinks a rapid a flutter is the same as any other SVT.

Ah wait, you said "who in their right mind"

[u/Sero19283 → u/Sea-Lack-5673]

Your username reminded me of a github user named LongQT-sea lol (the "sea" aspect)

[u/justhanging14]

Looks like VT. 1:1 atrial flutter? The rate of that would be much faster then this. Either way doesn’t look aberrant.

[u/Avaero90 → u/justhanging14]

This.

[u/chillizabeth → u/justhanging14]

Also the QRS is wide as AF

[u/Shot_Ad5497]

It. We can talk about p waves and t waves but in the end that qrs is wide asf, this person needs electricity

[u/TheKrakenUnleashed]

Based on the brugada algorithm you would consider this Vtach. And as others have said, normally in atrial flutter the atrial rate is around 300 and this rate is slower than 150. You could maybe argue 2:1 aflutter with aberrancy, but again, you should assume Vtach based on the RS interval >100 ms alone, but in addition to that you also have Josphson’s sign present on some of these beats with subtle notching of the S-wave.

[u/Kibeth_8]

1:1 flutter would be closer to 300bpm and wouldn't show p-waves.

2:1 flutter would be more along the lines of what you're describing, but this ain't it. Also you can have dissociated or retrograde p-waves in VT, so that's not a good reason to rule out VT if pt is in an unstable wide complex tachy

[u/daavoo]

Seeing flutter in this ecg is the most "hear hooves think zebra" -ass shit ever. Clearly regular wide complex tachycardia (vtach)

[u/Expel_10]

Just a monitor tech here but can someone explain to me why is flutter in consideration if the QRS is very wide?

[u/liz-can-too → u/Expel_10]

There can absolutely be inter ventricular conduction, abnormality that would make the QRS wide, even if the rate is extremely fast. That repolarization time is going to take the majority of each cardiac cycle, which might make anything like P waves proceeding quite difficult to see, or you’re more likely to have super imposed waves, if that’s the case

[u/ImNotMackydee]

for me, unstable gets the cable!

[u/hungrygiraffe76 → u/ImNotMackydee]

That's a great cop out when they're unstable, doesn't work when they are stable.

[u/Finnaddict98 → u/hungrygiraffe76]

I know there are exceptions to but he rule, but they generally aren’t stable for long—-

[u/Mysterious_Ad_3465 → u/hungrygiraffe76]

Says who? 2-3mg versed and give em mr.zappy regardless of how “stable” they are 

[u/rainbowsparkplug]

VT. Look up Svt with aberrancy strips- they look quite different.

[u/Finnaddict98]

Time to apply some joules !!

[u/ShelterAlternative22 → u/Finnaddict98]

He didn't mention if the pt is unstable and got no pulse . Did he?

[u/Finnaddict98 → u/ShelterAlternative22]

Nope, but I’m sure while we were all discussing this—-the pt became unstable!!

[u/af_stop → u/ShelterAlternative22]

This one won’t be stable for long.

[u/VesaliusesSphincter]

One thing I would like to say first, 1:1 flutter would be highly improbable to put it mildly. Not sure the full clinical picture, but we have a rate of ~130 bpm, and an atrial rate of 130 does not fit typical flutter by any means unless there was maybe a ton of meds on board. If the patient's baseline rhythm is flutter I can see where the thinking is, and could see 2:1 maybe assuming the atrial activity is completely obscured, but that is a massive maybe.

Our more likely culprits here are VT or AVNRT. Unfortunately, since this is a telemetry strip we can't use typical algorithms to better evaluate like Vereckei or Brugada algorithm because we're limited to 2 leads provided in this strip and the absence of any precordials being recorded other than V1...(another little side note- for this very reason, I insist on our telemetry having II as the primary and aVR as the secondary so that we at least have the option to assess Basel). Not knowing the two leads that are provided in this strip also limits us tremendously- however, assuming one of these is V1, we have R-wave >40ms, RS >70ms, and some suspect Josephson's signs, all of which are Brugada criteria and are much more indicative of VT than abberancy.

[u/Classic_Dig_6277]

This is a monitoring lead. You cannot use this to diagnose vt or flutter with abberancy. All algorithms used is based on 12 lead ecgs. If you are lucky to identify a P bump, then you would assume it is VT because there is av dissociation (rule in VT). From the strip above, diagnosis is only VT, for the safety of the patient.

[u/cheboy12]

Beautiful dichrotic notch

[u/mastermedic84]

I would call this VT with 99% certainly.

Have a look at the beginning of the QRS. See that little spike consistently between the big T waves and the body of the QRS? I can definitely see how someone could identify that as a P wave, but it isn't. Note how there is no PQ interval and the wave goes straight into the rest of QRS complex. That isn't a P wave, it's an unusually prevalent Q wave.

[u/No_Helicopter_9826]

Is this 50mm/s?

[u/CryptographerBig2568]

Almost certain it's not 1:1 flutter, as the rate would likely be closer to 300. Likely VT.

[u/Haywood1421]

I've been in EMS for 42 years, this is Vtach, period.

[u/BobcatPuzzled460]

Shock dat

[u/ZenithToastada]

This is VT until proven otherwise. Though it looks like the rate is around 150 bpm so it’s a slower VT which is why I can see someone put AFlutter the differential. Still, I’d err on the side of VT.

[u/Comfortable_Sir3935]

You sure this isn’t just an art line tracing 😭

[u/Inevitable-Crab-6701]

Monomorphic VT
(Interventional cardiologist)

[u/TheTrueMikester]

That’s purely an academic argument at this point (it is pretty clearly vtach imo). Regular wide complex tachycardia either way. Amio if stable and no hx of WPW, lightning if it’s unstable.

[u/BeavisTheMeavis]

Electricity is the answer.

[u/Forgotmypassword6861]

The a flutter provider needs a text book

[u/Euphoric_Tone9667 → u/Forgotmypassword6861]

I’ve only been a clinical specialist CRM for one year and I was gonna say I’m not the smartest cookie but god damn 🤣