Wednesday, 15 May 2013

ECG of the Week - 13th May 2013 - Interpretation


This ECG is from a 23 year old female presenting with epigastric pain.






Click to enlarge

Rate:
  • 78 bpm (average rate)
Rhythm:
  • Two distinct rhythms
  • Sinus rhythm
    • Complexes 1-3, 9-12
    • Sinus arrhythmia
    • Rate varies 70 - 100 bpm
  • Junctional rhythm
    • Complexes 4-8,13
    • Rate ~70 bpm
Axis:
  • Normal
Intervals:
  • Sinus Complexes
    • PR - Normal (140ms)
    • QRS - Normal (60ms)
    • QT - 360ms (QTc Bazette ~ 450 ms)
  • Junctional Complexes
    • QRS - Normal (60ms)
    • QT - 360ms (QTc Bazette ~ 395 ms)
Additonal:
  • Nil T wave or ST segment changes

Interpretation:

  • Alternating sinus rhythm and accelerated junctional rhythm
As many of the comments have alluded to it is unlikely this is directly related to our patient's presentation - abdominal pain in a young female.
Junctional rhythms are reasonably common in young patients under general anaesthetic and rarely require intervention.
The case in this patient is a bit of a mystery, we don't see sinus slowing prior to rhythm changes although excessive vagal tone secondary to pain could be a culprit.

We have had a flurry of comments on this post, including a discussion on energy drinks and the risk of sudden cardiac death. I'd advise people to have a look through these comments which can be found on this page, scroll to the bottom. 

Also don't forget to check out the Google ECG+ Community where there are a host of interesting ECG's and ECG discussions.

VAQ Corner

A 23 year old female presents to your ED complaining over several hours of epigastric pain.
Her obs are normal and stable. An ECG has been performed.

a) Describe & interpret her ECG (70%)
b) Briefly outline your management of the patient (30%)

In this patient with normal vital signs the rhythm change does not require specific intervention and management should focus on symptomatic treatment e.g. pain, nausea, etc, and identification and subsequent treatment of underlying cause of abdominal pain.

References / Further Reading

Life in the Fast Lane

  • Junctional Rhythm here
Anaesthesia UK
  • Junctional Rhythm here
Textbook
  • Chan TC, Brady WJ, Harrigan RA, Ornato JP, Rosen P. ECG in Emergency Medicine and Acute Care. Elsevier Mosby 2005.