Hey Docs, whats the rhythm?

fiznat · Mar 6, 2009

I asked 3 separate EM docs in my area and got 3 different answers, so I thought I'd see what you guys thought:

Here's links to higher res versions: 3 lead 12 lead

Now I know the actual specific rhythm doesn't often matter THAT much to you guys (and us Paramedics), but this is a bit of a pet interest of mine and I like to try and figure these out when I can. If you can help it would definitely be appreciated.

WilcoWorld · Mar 6, 2009

I see at least 3 types of p's, so I'm going with multifocal atrial tachycardia.

Was the patient a COPD'er?

fiznat · Mar 6, 2009

There was a long history of lung CA, if you want to call that a COPD...

NateintheED · Mar 6, 2009

Subtle, but agree with Wilco's MAT call. Not sure I would've picked that detail up myself.

146233 · Mar 6, 2009

I like MAT as well.

DeLaughterDO · Mar 6, 2009

Agreed: MAT

TerraMedicX · Mar 6, 2009

That's interesting...I'm not sure I've ever heard of multifocal atrial tachycardia before, although it certainly seems to fit. What is the diagnostic criteria for MAT? Is MAT a grouping of dysrhythmias like superventricular tachycardias or is it a specific diagnosis? Does it respond to treatment like other atrial tachycardias (i.e. adenosine) or does it respond more like an atrial fibrillation/flutter (Ca++ channel blockers)?

Nate.

fiznat · Mar 7, 2009

Yes, I was going with MAT as well. I was pretty sure I saw several different p wave morphologies, as well as a varying P-R interval. The interesting part to me is that none of the docs I talked to included MAT in their possibilities. I got answers like sinus arrhythmia, and junctional rhythms with retrograde P waves and ectopy.

Now, these were EM docs. Maybe a cardiologist would think differently about it, I donno. I got the distinct impression (right or wrong) that a lot of the EM docs really could care less what the actual rhythm was. They looked at it, sure, but I didn't get the sense that it mattered to them whether it was a multifocal atrial tach or an accelerated sinus arrhythmia.

Would you folks, as a group of EM professionals, agree with the statement that it doesn't matter what the actual rhythm is? Assuming this guy was otherwise stable, how much time would you really spend trying to figure this rhythm out? This is interesting to me because the truthful answer for us Paramedics is probably "not that long at all." Is it the same in the ED?

DogFaceMedic · Mar 7, 2009

fiznat said:
Yes, I was going with MAT as well. I was pretty sure I saw several different p wave morphologies, as well as a varying P-R interval. The interesting part to me is that none of the docs I talked to included MAT in their possibilities. I got answers like sinus arrhythmia, and junctional rhythms with retrograde P waves and ectopy.

Now, these were EM docs. Maybe a cardiologist would think differently about it, I donno. I got the distinct impression (right or wrong) that a lot of the EM docs really could care less what the actual rhythm was. They looked at it, sure, but I didn't get the sense that it mattered to them whether it was a multifocal atrial tach or an accelerated sinus arrhythmia.

Would you folks, as a group of EM professionals, agree with the statement that it doesn't matter what the actual rhythm is? Assuming this guy was otherwise stable, how much time would you really spend trying to figure this rhythm out? This is interesting to me because the truthful answer for us Paramedics is probably "not that long at all." Is it the same in the ED?

Depends on why the guy showed up in the first place. If he was having symptoms from MAT then you have to address it. If it was less than 48hrs from onset AF can get a cardioversion. But MAT can be caused by digitalis. So, recognizing the rhythm and a good history will take you down somewhat different roads. If you are really busy in a big teaching hospital, then the treatment is the same: consult cardiology.

NateintheED · Mar 7, 2009

DogFaceMedic said:
Depends on why the guy showed up in the first place. If he was having symptoms from MAT then you have to address it. If it was less than 48hrs from onset AF can get a cardioversion. But MAT can be caused by digitalis. So, recognizing the rhythm and a good history will take you down somewhat different roads. If you are really busy in a big teaching hospital, then the treatment is the same: consult cardiology.

Do you really have to observe the 48 hour rule for MAT? Seems to me that these folks have organized atrial activity, albeit from multiple foci, and shouldn't develop mural thrombus like the a-fibbers.

For TerraMedic - MAT is characterized by a tachycardic rate and at least 3 different P-wave morphologies. It is a specific rhythm and not a diagnostic group, though could be a member of the supraventricular tachycardias since the driving impulse is above the ventricles. The normal rate equivalent is known as "wandering atrial pacemaker".

DogFaceMedic · Mar 8, 2009

NateintheED said:
Do you really have to observe the 48 hour rule for MAT? Seems to me that these folks have organized atrial activity, albeit from multiple foci, and shouldn't develop mural thrombus like the a-fibbers.

For TerraMedic - MAT is characterized by a tachycardic rate and at least 3 different P-wave morphologies. It is a specific rhythm and not a diagnostic group, though could be a member of the supraventricular tachycardias since the driving impulse is above the ventricles. The normal rate equivalent is known as "wandering atrial pacemaker".

I'd only cardioconvert a MAT in the ER under ACLS guidelines when the 48hrs is not as relevant. And, in those cases distinguishing MAT from AF or Flutter is not precise anyway. If stable and genuinely MAT, then cardiovert is rarely done -- but a good question for caridology -- instead the major therapies are rate control or invasive ablation deoending on the cause. For AF and >48hrs the cardiologists will do an echo and assess for clots and may give 'em the juice if symptomatic enough. Otherwise, anti-coagulate for a few weeks and then do it controlled with propofol/versed.

Hey Docs, whats the rhythm?

fiznat

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WilcoWorld

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fiznat

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NateintheED

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146233

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