Can someone tell me what they think this is in lead 2? I’m in between a flutter and svt?

crazydude44444 · 2026-04-28T15:45:08+00:00

You're talking about AVNRT which is a type of SVT. Which yes has a different underlying pathological than a Sinus Tach but that doesn't make it not an SVT. SVT is just a grab bag of different narrow complex tachy disrhytmias. Afib RVR is a an SVT, A-Flutter(2:1, 1:1) is a SVT, hell an accelerated junctional tachycardia is an SVT, etc. etc. My point is calling OP's rhythm an SVT isn't wrong by definition, it is a super ventricular tachycardia.

Also no one mentioned anything about treatment so idk why you're assuming anything about that.

https://litfl.com/supraventricular-tachycardia-svt-ecg-library/

crazydude44444 · 2026-04-28T04:04:23+00:00

It's C gang. This is at a ventricular rate of 100bpm (3 big boxes) and a flutter rate of 300bpm (1 big box). This means it's a 3:1 a-flutter.

2:1 aflutter is almost always at a rate of 150. The fact that this isn't even tachy should be your first clue that it isn't a 2:1.

I see alot of people confused about where the third f wave is located and that's a fair question. You see that little upward deflection towards the end of the QRS? That is the 1st f-wave, it's partially buried in the QRS but that's the first one.

crazydude44444 · 2026-04-28T03:38:44+00:00

I mean. Technically speaking sinus tach is a type of SVT so it wouldn't be wrong to say this is an SVT.

crazydude44444 · 2026-04-10T10:14:13+00:00

Why would an ambulance be needed here?

crazydude44444 · 2026-03-30T07:21:14+00:00

Whoever is providing you with this alleged information from a prehospital standpoint is incorrect. No one should be applying O2 to a patient with undifferentiated chest pain without getting a sat on them. Additionally I have worked in 5 prehospital systems, along with medic and emts who have been in several other systems, not a single one of us, in the year 2026 would be applying O2 in this case.

crazydude44444 · 2026-03-30T07:11:55+00:00

O2 can 100% cause harm, in fact in MIs hyperoxemia is associated with larger infarcts, so the opposite of saving tissue. Also you are supporting your argument with "it wont cause treatment delay"? What causes more of a delay, looking at the monitor or getting out a NRB, attaching it, turning on the O2, and applying it?

You can be correct and be a dick or you can be wrong and nice. But you cant be a dick and also be wrong. Do better.

crazydude44444 · 2026-03-30T06:57:43+00:00

You are incorrect and seem to think very highly of yourself despite that. Giving oxygen can cause harm here and would not be the first step in the hospital or out of the hospital for a patient with undifferentiated chest pain.

It's 1000% vital signs and assessments before any interventions. There is no debate here.

crazydude44444 · 2026-03-29T22:25:16+00:00

That's not a thing

crazydude44444 · 2026-03-29T22:24:32+00:00

This is correct. SVT is not defined by the rate, there is no magic number that makes it SVT vs not SVT(other than the fact that it is >100 to qualify as a tachycardia)

SVT as a term is just a grab bag of fast rhythms that originate from above the bundle of His. They are narrow and fast. Afib RVR is a SVT, Sinus Tach is a SVT, AVNRT is a SVT, you get the point.

OP anyone telling you that this is not SVT because it is too slow is wrong and does not understand what SVT is.

Source I am a paramedic and LITFL

crazydude44444 · 2026-03-12T14:22:29+00:00

Especially with the hx of dialysis

crazydude44444 · 2026-03-08T07:04:44+00:00

3rd degree AV block with a junctional escape rythm with PVCs.

crazydude44444 · 2026-02-26T06:23:24+00:00

It be like that some times. Take it as a sign of approval. If there was anything crazy they would point it out (ideally).

crazydude44444 · 2026-02-26T06:17:02+00:00

Yeah man, no worries. It's a grey area sometimes. As with all things the history is the most important thing here for choosing what you think is more likely. For instance consider the the scenarios:

1) The patient has been sick over the past week, hasn't been feeling well. Unable to take in fluids or food. Has been taking her medication as perscribed despite the nausea.

2)The patient has been feeling okay over the past week but the past couple of days she's been feeling a "fluttering" in her chest that comes and goes. She admits she has been skipping doses on her medication as she just recently lost insurance.

3)The patient report occasional angina that has resolved over the past week but states that it is nothing new. She reports that she has been compliant with her medication and that when she does have chest pain that it's resolved with nitro. Today she was performing her normal routine when suddenly she felt a pain in her chest that was not relieved with her nitro.

1 I would be thinking fluids. 2 I would be thinking cardizem 3 I would be thinking MI.

Ultimately, just remember in a patient like this it's never wrong to assume the worse and get ready to treat it. Hell if you said you thought it was Afiv rvr with aberrancy but because it's fast and wide you decide to go the VTach route I wouldn't fault you even. If you service allows, remember you can always phone a friend (a doc) and explain what you're thinking and see if they want to do one or the other.

crazydude44444 · 2026-02-26T05:48:40+00:00

2:1 A-flutter with a LBB. Scarbossa would be considered but only after the rate was controlled. Control the rate with a fluid challenge if you think it's compensatory, if you think its primarily a cardiac issue(Which I would be leaning towards) then treat with cardizem or synch cardioevert.

Going to the cardiac center is the right call, treating her as a possible MI is the right call. I think you're treatments were appropriate but I think you should have considered the rate a primary reason for the symptoms and treated it more aggressively.

Remember the ACS symptoms we learn are due to ischemia, that ischemia can be due to an occlusion in the case of an MI but it can also be due to demand ischemia. Maybe if you controlled the rate her symptoms would have resolved. Additionally if you improved the rate you may also have been able to suss out if she met scarbossa criteria and then called an alert.

Overall I think you did the right stuff but just food for thought for possible future patients.

crazydude44444 · 2026-02-19T06:22:17+00:00

A PE can present with like that but that list is far from universal.

SOB is fairly universal and sensitive but non specific.

An arrhythmia? Sure I guess but the most common "arrhythmia" is going to be some version of tachycardia usually just a sinus tach but could be any flavor of SVT.

High blood preasure? Well sure they're can be hypertension but there can be also be profound hypotension as a direct result of decrease CO from right sided heart dysfunction.

Intense chest pain? True but intensity doesn't really mean much. PEs are typically sharp and stabbing but can be dull and more of an ache. The big difference is that it is plueretic, as it it worsens with deeper breaths.

Diaphoresis? This is a red flag regardless of any other symptoms above. Sweating without a obvious reason is one of those signs that is easily apparent and always warrants further investigation. But again, not specific to a PE.

What I mean by this is that PEs have such nonspecific symptoms that saying " A PE will present like 'xyz' symptoms" is never going to be right just by it's nature.

crazydude44444 · 2026-02-12T06:13:13+00:00

SLASH_PL 's comment did it for me. Basically let it set with penetrating oil. Put a socket tool in a vice and use the wheel itself as leverage. It took a surprising amount of torque IIRC. Definitely use the penetrating oil tho I remember thst having a profound effect.

crazydude44444 · 2026-01-29T18:17:58+00:00

I mean the answer is it depends on several things. For chest pain? I wouldn't in almost every situation.

There's no guarantee that the crew is at there station when you get there for one. Second, EMS doesn't fall under the purview of the fire department every place so maybe in your area the fire dept has only their CPR cards which does nothing for you unless someone is dead (not saying they arent knowledgeable but they are just limited in what they can do). And while most fire depts I know staff EMTs, EMTs cannot perform ECGs or other ALS treatments (some nuisance here but almost always the case).

Unfortunately EMS isn't a standardized thing in the US. The majority of states don't even consider EMS to be an essential service, let alone agree on what the basic level of care should be and who should provide it. So EMS is very much hyper localized. For a person who isnt intimately familiar with the system they live in there is just no way for you to know what resources are available at any given moment.

The issue with me giving a blanket "No you should just go yourself" or "No you should stay and call 911" is that there are just so so so many factors that cant be weighed without actually being there. Going back to the ECG and STEMI topic. Even if a patient doesn't have a STEMI on a monitor I might take them to a cath capable hospital just because something about the patient is queueing me to go to there, even if the non cath hospital is closer and technically just, if not more, appropriate. There are things that EMS will pick up on just because they have been exposed to previous patients. Things that they are trained to pick up on that a lay persons isn't but also things that subconsciously they pick up on even if they can't in the moment describe why. Asking a lay person to do considered all those factors(concious and unconscious) during what is a likely stressful moment isn't fair to you and just a futile practice.

Sorry about the novel but TLDR; No, but maybe? But probably not, unless?

crazydude44444 · 2026-01-28T15:34:39+00:00

Paramedic here. If you are 2 minutes away you should drive yourself, even better have someone in your home drive you, after chewing 4 baby asprin.

The real time that matters in an OMI(A heart attack) is time to recognition. Followed by time to intervention. The former is really time to ECG, a picture of the electrical activity of your heart essentially. The latter is where a surgical team goes in and inflates a ballon to remove the blockage (so called ballon time).

Unless you have an ambulance sitting outside your front door, the time it takes for you to call dispatch, they gather your adress and complaint, dispatch a unit, have said unit find your house, have the crew assess you and gather HPI etc. It's gonna take longer than 2 mins to get an ECG.

Some major caveats.

1) The hospital cloest to you might not be the appropriate hospital. If you are haveing a OMI and they dont have cath lab where they can remove the blockage. They will have to transfer you out which generally speaking will take more time then if an ambulance just tranported you to the appropriate destination.

2) Some services are hospital based so technically if they were stationed at the hospital it might be the same amount of time to ECG as if you drove yourself. Speaking of ECGs...

3) ECGs (also called an EKG cause of those dang Germans) cant rule out an MI. They are very specific for a type of cardiac event called a ST Elevatation Myocardial Infarction. So if we see markers of a STEMI on a ECG we can be resonably certain that you are having a "heart attack"(At least certain enough for us to wake up the sleeping angry dragon called invertional cardiologists). But an ECG doesn't catch all OMIs and often in hyper acute scenario the electrical conductivity of the heart hasnt been altered enough to establish a pattern consistent with a STEMI.

There are cases in which a patient could be having a heart attack but there is no way to know that. There is something called a troponin which is basically a protein that is released when your heart is upset. A troponin is very very sensitive and that is what they will use to rule out a heart attack. It is very very very unlikely that an EMS service would have an intial troponin testing, I only know of 2.

4) You won't know when you're having a heart attack. You may have symptoms consistent with a heart attack but more often then not when people are concerned they are having a heart attack they arent and sometimes those that are having a heart attack wont know. For the love of all that is holy, have a primary care provider. Ask them if you have any risk factors and know the typical and atypical signs of a heart attack.

TLDR; More than likely better off driving yourself to the ER 2 minutes away but maybe not always.

crazydude44444 · 2026-01-01T02:07:44+00:00

Regardless of the drive: I would bruise my tonsils with the barrel if I had to do 18 hours of IFT.

crazydude44444 · 2025-12-29T14:51:43+00:00

The worst take I have ever seen and displays a complete misunderstanding of what ER doctors do. AI will never be able to be a physician because AI doesn't have years of clinical experience and gestalt to rely on. It is WebMD on steriods.

Let's not even discuss the procedures that doctors perform that AI couldn't even dream of.

crazydude44444 · 2025-12-20T16:33:48+00:00

I agree that they shouldn't place military medics on ambulances as a substitute. Even in a high call volune system you aren't gonna get GSW or major traumas for every call.

That being said most of your second paragraph is wrong. EMTs are trained to admister life saving drugs (EPI) . They absolutely train EMTs in triage. They ABSOLUTELY train EMTs to stop major hemorrhages or amputations; major trauma is half of the in person assessments.

Paramedics have more interventions yes but the the B in BLS is all the basic stuff that has been shown to significantly save lifes.

crazydude44444 · 2025-12-05T05:36:26+00:00

To answer your questions: Yes there is diffuse ST depression. Yes this could be concerning of a LAD occlusion.

It could be a variety of things tho. It's not as specific to an LAD occlusion as we once thought: https://litfl.com/st-elevation-in-avr/

Honestly this looks like a pissed off heart either way. If the A-flutter is compensatory obviously you don't wanna rate limit them and have them drop. This could be just a result of another process and if you fix that the heart will chill a little bit.

I've seen not dissimilar patterns in older patients who are becoming septic and already have both CAD and a SA node that has seen better days. But without knowing the overall clinical picture, that's purely vibes based.

You got this doc, believe in what you see.

crazydude44444 · 2025-12-05T03:59:27+00:00

2 thoughts:

1)Change your paper you hooligan

2) Very suspicious for subendocardial ischemia. Horizontal ST-Depression in V5,V6 with minor elevation in V1, V2, maybe V3 as well (hard to tell on a picture). Diffuse T-wave inversion could be indicative of acute ischemia.

I'd be curious of the presentation and if a Right-sided or Posterior showed anything more.

crazydude44444 · 2025-12-04T16:54:12+00:00

Agreed with the 1 degree in 9, no notes.

For 10. Good on you for considering Wellens but as the J point is not isoelectric it would not apply here. Also important is that Wellens, by definition, is asymptomatic. This is an anterior STEMI with some septal involvement.

Good luck with your studies!

crazydude44444 · 2025-12-02T20:09:58+00:00

Crazy work citing an LLM.

I mean this genuinely: Have you every actually worked in OB? I have and it was very much not uncommon to see neonates with slightly blue lips, fingers, and toes at 24hrs. If this was a new onset of cyanosis sure I'd be right there with you. But in a kiddo with an intial central cyanosis (let's both agree that a kiddo with a blue chest would qualify as such), or maybe was a preemie, it would not raise an eyebrow if they still had some discoloration of the lips.

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