Monday, May 30, 2016

Undifferentiated Rhythm

I don't really consider myself an EKG expert, but in a general context, (amongst my peers) I suppose I am. I have been teaching basic Rhythm analysis for almost 15 years, and have studied the science for over 30 years. When I discover a misidentified rhythm in the hospital setting, it causes me some concern, and particularly, when it is a physician making that improper identification. A rhythm such as new onset Atrial Fib or Atrial Flutter, demands immediate therapy, for a patient who presents with the complaint of "just not feeling right". Most of us know, that our current day EKG machines, misread rhythms about 40% of the time. But to have a doctor, look at that Rhythm and call it Sinus Tachycardia, because that's what is printed on the paper (and because their skills must be lacking), is a problem that needs to be corrected.

Undifferentiated Rhythm

That is what the Doctor said, and the Nurse repeated
But one day later, they both were unseated,
When it all turned out to be Atrial Flutter,
And then, when I read the chart
I muttered, stuttered and sputtered.

The patient presented with chest pain
Saying, somethin's wrong with me,
So by the Chest Pain protocol
They performed an EKG,
Where the machine mis-identified
Naming the rhythm, Sinus Tach,
The Doctor agreed, and that was all wack,
Because it was clearly obvious
From Precordial Lead V1,
Flutter waves at 300, right under the sun,
Unfortunately, 2 Doctors, 2 Nurses
And one Monitor Tech,
Couldn't read that EKG
And baby, what the heck?
Proper treatment was delayed
For at least one day, and more,
How can we change this?
It's an overwhelming chore.

Here are the clues:

# 1: New onset Atrial Flutter with a 2:1 conduction ratio, typically produces a heart rate of exactly 150. Rock solid, unchanging 150. That's the clue: 150. 

# 2: Look for flutter waves in Lead II, and V1. They are not always saw-tooth in shape, but may be little pointy things, but when that pointy thing is zipping along at 300........those are flutter waves. 

And # 3: If you are any Doctor, and you think it's Ok to call a tachycardia undifferentiated, then you need to call in a Cardiologist to look at that EKG. Because frankly, not properly identifying Atrial Flutter, or Atrial Fib, is a dangerous misdiagnosis.

In this particular case, after the patient was discharged from the ED to a Med-Tele floor, the first Nurse (and monitor tech) identified the rhythm as Sinus Tach, because that was the report, and what the EKG algorithm identified. Then later, the next Nurse was seen to chart Sinus Tach with PAC's, as the flutter ratio showed some variation. Another EKG was in the chart, where clearly there was a lot of movement artifact, and the machine identified this one as A. Fib (wrong again). Finally, 24 hours later, the patient had a long pause of about 2+seconds, and at last, the flutter waves were clearly seen on the rhythm strip. At this point, the Monitor Tech wrote "Ventricular Standstill" on the the rhythm strip paper. And after that long pause, they called a Rapid Response and transferred the patient to the ICU.

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