COPY of Blog #504- AMELIA's CASE — COPY

XXXXXX

==============================

 — Today's case is an ECG Video!

==============================

The 3 successive lead II rhythm strips shown in Figure-1 — are from a 10-year old child with palpitations.

QUESTIONS:

• What is the rhythm? 
• What to consider clinically?

Figure-1: Succesive rhythm strips from a 10-year old child with palpitations.

===================

Below is the Video presentation of today's case (9 minutes):

==================================

Acknowledgment: My appreciation for today's case — sent to me from an anonymous follower.

==================================

 

 

==================================

Related ECG Blog Posts to Today’s Case: 

• ECG Blog #188 — Reviews how to read and draw Laddergram (with LINKS to more than 100 laddergram cases — many with step-by-step sequential illustration).
• ECG Blog #192 — AV Dissociation by Usurpation — Default — or by AV Block?

 

==================================

ADDENDUM (11/XXXX/2025): 

==================================

The 2:30 minute ECG Video below reviews:

• The Ps,Qs,3R Approach — for systematic rhythm interpretation.
• Some additional general tips on rhythm interpretation.

ECG Media PEARL #9 (4:45 minutes) — reviews the 3 Causes of AV Dissociation — and emphasizes why AV Dissociation is not the same thing as Complete AV Block.

 

 

Hello everyone!

Today's ECG Video — is from a 10-year old child with palpitations.

The case consists of 3 successive lead II rhythm strips — that I wanted to present — because they illustrate a series of important concepts regarding arrhythmia interpretation.

Here are the 3 rhythm strips. What's going on?

So — LET's GET to today's case.

===============

========================

Amelia — VERY interesting tracings — and I DO plan to make an ECG Blog of this. I will definitely draw a laddergram — but I haven't yet decided if I'll be doing an audio recording blog or a written one. And to keep it fairly simply (and more easy to understand) — I think I wil just use the lead II record from 3 of the 4 tracings that you sent me (similar to the attached figure).

The lead II from ECG #1 — There is an underlying junctional rhythm that is almost but not quite regular. Now, whereas the usual normal junctional escape rate in adults = 40-60/minute — it is FASTER in children (and the general rate range that I use in kids = 50-80/minute — which means that in your 10yo child, most of this tracing is NOT an "accelerated" junctional rhythm — but instead, a junctional escape rhythm that is unusual in not being as regular as junctional escape rhythms usually are. And, it is in ECG #3 that we an accelerated junctional rhythm (at least for the first 5 beats!).

 

We know all 7 beats in ECG #1 are junctional because of the AV dissociation that we see with P waves too near the QRS for the last 4 beats to conduct. So we can only guess why we don't see any sinus P waves in the beginning of ECG #1.

 

I suspect ECG #2 gives us the answer. First 2 beats are sinus — and then no sinus P wave until beat #3 — therefore, most probably there is an underlying sinus arrhythmia that on occasion slows down enough that junctional escape beats occur ( = beat #3 in ECG #2). The the junctional rhythm speeds up — and for beats #5,6,7 we now see retrograde P waves (GREEN arrows). What I will guess (and illustrate in my laddergram) — is that conduction from the AV node to the atria takes the SAME amount of time as does conduction from the AV node to the ventricles for beats #3 and 4 — but when the junctional rhythm speeds up (for beats #5,6,7 and for beats #1-thru-5 in ECG #3) — the AV node is not able to conduct as well, such that conduction back to the atria now takes longer and we then see retrograde (GREEN arrow) P waves!

 

But in ECG #3 — beat #6 is a PVC which does not conduct retrograde — such that the SA node has a little more time to recover, and sinus rhythm returns at a fast enough rate to maintain control of the rhythm.

 

BOTTOM LINE — We have a combination of things = Sinus brady with arrhythmia + an irregular junctional escape rhythm that at times becomes accelerated. This is not a "normal" response — so we need to look for potential factors that might be causing intermittent accelerated junctional escape (ie, illicit drugs? alcohol? stress? anxiety? fear? who knows? — but perhaps there is some clue in the history?).

 

So — IF you figure anything potential causative factors — let me know so I can include it in my write-up. If not, it's OK — as the rhythm strips alone are of value for a blog post.

Amelia — I will be happy to acknowledge you. Please tell me the city and country you'd like me to list after your name — OR — if you prefer, I can keep this case as being sent by an anonymous source.

 

It may be a little while before I publish this — but in any case, I'll let you know. In the meantime — I hope the above helps you in the management of this patient! 

 

From Amelia:

Thank you very much for the explanations!! Actually this case is of my boss, and the colleague who works with my boss was so interested about it and she asked me to share it with you. She is much interested in ECG. I forwarded her all the explanations. We thank you very much! Unfortunately because it is not my personal case, you can publish it with anonymous, it will be perfect like this. We found no causative factors in the patien’s history, no illicit substances, no alcohol but she is indeed more anxious because she lives with the idea that she has a heart problem. We tried to calm her down but her mother doesn’t help her at all.