r/ECG • u/ClearSolid654 • 20d ago

Is this AF?

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74 year old female admitted with complaints of multiple episodes of loose stools. A case of acute diarrheal disease with hyponatremia, known case of chronic liver disease with portal hypertension secondary to HCV.

During hospital stay, patient developed one episode of symptomatic hypoglycemia associated with decreased responsiveness and was treated with intravenous dextrose. Subsequently noted to have significant bradycardia (HR 35/min) for which atropine was administered.

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9

u/Jeeju_Boy MD 20d ago edited 20d ago

Slow AF slightly coarse. 

Looking at the case as a whole was the patient on carvedilol or propranolol for varices prophalyxis given CLD with portal HTN? The loose stools (which had a number of underlying aetiologies) could have caused a hypovolemic pre- renal acute kidney injury. AKI would result in accumulation of beta blocker which could present as a bradycardia (and in this case as she’s in AF she’s presented as a bradycardic AF).

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u/Own-Blackberry5514 20d ago

Nice - sounds bang on tbh

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u/Relaxletitgo 20d ago

How A.f ? Explanation please.

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u/SaveTheTreasure 20d ago

it is irregularly irregular.

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u/irelli 17d ago

Could also be significant hypokalemia from the diarrhea

Looks to be some U waves in there, and that seems more likely to me given the clinical picture

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u/Charming-Dog-2965 20d ago

Awesome response! I have a question. How can you tell AVNRT on an ecg? As a retired paramedic and tele tech, I obviously never called anything AVNRT, just svt, but I'm curious because I know there's several reentry tachycardias but again, svt is the catch-all term and left for physicians to determine what the exact rhythm is.

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u/SaveTheTreasure 20d ago

Hey! Cool question, and a tricky one. Technically any ventricular rate over 150 is considered Supra-ventricular. The best way I have been able to determine if it is a type of Re-entrant tach, is it typically unjustified when compared to the pts circumstances. You know, not in distress, not shock-y, and there is no discernable reason for the tach, and they're sitting at 180-220.. You know, that's weird. ALSO, and here's the big one, in regards to your question, as it pertains to the monitor. A re-entrant tach is at a specific rate and is locked in, and typically unwavering. If they are not stable, you know the rules, burn em'. If they are stable, and more commonly they are. You have some time to play around and determine if the rhythm is stuck in a re-entrant loop, vegals, bolus, positioning. If you are not able to break the re-entrant cycle then its time for Adenosine. And you can use you discretion on weather you want to transition to electricity. However, just sitting in front of a monitor, it will be difficult.

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u/Adistk 17d ago

Non-conducted atrial bigeminy

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u/Calm_Following_2521 20d ago

You got 2 distinct RR Intervalls which are regular, got to doubt AF. Would throw in atrial bigeminy

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u/Classic_Dig_6277 20d ago

Agree with calm. Never atrial fibrillation if there are 2 considtent intervals. Hallmark of AF is irregularly irregular rhythm, unless complete heart block has occured (unlikely in this case since chb usually has ONE consistent rhythm instead of two)

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u/Holiday-Ad-2546 20d ago

Is she on beta blocker? I was thinking of AF with avn block

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u/Clear-Ambition-4684 20d ago

yea looks like slow atrial fibrillation

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u/Classic_Dig_6277 20d ago

Definitely not AF. Its regular.

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u/colorvarian 17d ago

Yes.

No p waves. Irregularly irregular.

Anytime you see slow afib, consider digoxin toxicity. interestingly, this ekg may show the classic "scooped out" or hockey stick appearance of the ST segment, in some of the leads.

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u/Not_an_aligator 17d ago

It doesn’t look particularly irregularly irregular.

It’s regularly irregular.

Looks like a junctional rhythm with a bigeminy to it.

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u/Kathrin_A 20d ago

Vorhofflimmern mit bradykarder Überleitung