What are these wide complexes? If unclear by explanation, the laddergram helps to understand.

An 18 y.o. female who presented for chest pain. Patient reports productive cough and headache x 4 days. She notes persistent sternal chest pain worse at night and waking her from sleep. She also notes intermittent abdominal pain, describing as a " tightness " ." Sinus arrhythmia with variable right bundle origin PVCs "Is this accurate?No.This is sinus bradycardia with a slightly accelerated right ventricular escape, such that sometimes:1.  the sinus beat is conducted before any ventricular escape (beats 7)2.  the ventricular beat starts at almost the exact same time as the P-wave, and the P-wave therefore does not conduct (beats 6 and 9)3. the ventricular beat occurs very shortly after the P-wave such that the P-wave does not conduct (beats 2, 3, 5)4. The ventricular beat fuses to varying degrees with the conducted beat (beats 1, 3, 4, 8)This is AV dissociation (not NOT AV block).Her bedside echo was normal and troponins were negative in the ED.See Dr. Grauer ' s extensive discussion below for more detail.This is not pathologic, and not worrisome.If you see a patient with such a rhythm, simply walk them around on a monitor to increase the sinus rate.  Then the sinus will usurp the ventricular escape and the ECG will normalize at a faster rate.  If not, there is then a problem.The patient was referred for Holter and it was normal.===================================MY Comment by KEN GRAUER, MD (2/20/2020):===================================There ar...

Source: Dr. Smith's ECG Blog - February 19, 2020 Category: Cardiology Authors: Steve Smith Source Type: blogs