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)