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 Differential Diagnosis

  • First-degree AB block
  • Atrial flutter
  • Mobitz type 2
  • Ventricular bigeminy
  • Ventricular trigeminy

 

 

Diagnosis

This patient was diagnosed with ventricular bigeminy.

The ECG reveals a regular rate. There are P waves with a PR interval of 126, with normal being 120-200 so this is not first-degree AV block. The rhythm is regular, and there are no flutter (saw tooth) waves, so this is not atrial flutter. Wenckebach type 1 has a gradual lengthening of the PR interval until there is a dropped beat (a P without a QRS following) and is not occurring in this ECG. Mobitz type 2 is an intermittently dropped QRS segment (without the gradual lengthening of the PR interval), but this is not occurring on this ECG, either. Ventricular bigeminy is a ventricular beat occurring every other beat; this rhythm is present on this ECG. Ventricular trigeminy is a ventricular beat every third beat.

Learnings/what to look for:

  • Ventricular bigeminy is diagnosed when there is a ventricular depolarization occurring every other beat
  • The ventricular beat is a wide QRS complex (appearance similar/identical to a PVC)
  • These beats may occur from a sympathomimetic stimulus (eg, meds, caffeine, cocaine), alcohol, beta agonists, theophylline, electrolyte abnormality, acidosis, or ischemia.

Pearls for Urgent Care Management and Considerations for Transfer

  • Inquire about signs of acute coronary syndrome, such as chest discomfort, shortness of breath, diaphoresis, weakness, or dizziness, as well as hemodynamic instability such as tachycardia, hypotension, dizziness, or confusion
  • Compare to an old ECG
  • Consider checking electrolytes in patients who are at risk for abnormalities, such as patients on diuretics, or those with dehydration, prolonged vomiting/diarrhea, or with renal failure. Review the med list for antiarrhythmics, as many may also have a proarrhythmic potential

If there is concern for ischemia, transfer to the ED for emergent evaluation

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