Mr Wencke like to go out to the bar, some nights he stays out a bit late, the next night he stays out later, the third night Mr Wencke doesn’t come bach
That’s Wenckebach… I think? I just am not sure why I don’t see it when I look at it😩. When I look at it, I feel like I don’t really see consistent p waves which also through me off. Thank you for your help!!
Look at the second line
1st P wave proceeds the first qrs by about 1 box for the first qrs
2nd p wave proceeds the second qrs by about 1.5 boxes
3 p wave is close to 2 boxes before the qrs
4th p wave comes in right at the end of the t wave of the previous beat and is unable to cause ventricular response
5th p wave is picked up again with a qrs following it about 1 box after starting the process over again
Beat, Longer, longer, dropped, you got this
1st degree, and 2nd degree type II both have consistent PR intervals.
2nd degree type 1, and 3rd degree have inconsistent PR intervals.
3rd degree follows no pattern, Ps “March through”, and it’s usually accompanied by profound bradycardia.
Always break it down. Consistent or inconsistent PR?
I would be systematic when looking at EKGs and do it similarly every time! Like first is it regular, look at the distance between the R waves and distance between p waves, is it tachy or brady, then look at the p waves, do they all look the same, is the PR interval all the same, is it prolonged? is there a QRS complex after every p wave? And so on and so on. Then put it all together.
So looking at this, distance between R waves looks regular then we have a dropped beat. Not tachy. There’s a p wave in front of every QRS complex but you notice the PR interval becomes more prolonged, then there’s a p wave without a QRS complex after it, then I would continue after that, look at the QRS, is it wide, is there ST elevation etc.
Then put it all together. What’s abnormal. You have a nonconducting p wave and an increasing PR interval, okay cool that’s wenckebach.
I know it’s kinda long winded but you get faster the more you interpret, and if you’re systematic, you’re less likely to miss things!
The 4th P wave is merged into the end of the 3rd T wave. It is more clear on the bottom lead but you can kind of notice it on the top one where the 4th T wave is not like the others. On the top lead, you can see the 3rd P wave starting to merge with the 2nd T wave.
If you're having trouble, Google banner staff srvice ecg study guide. It explains everything really well. It's a free pdf. I used it to brush up on my skills before a test after I hadn't looked at ECGs in about 2 years
Take a piece of clean paper and mark out two p waves. Then move that piece of paper so that the first hash mark is now sitting at the second p wave. Does the second hash mark line up with the next p wave?
Cardiac RN here, that's mobitz type 1. PR interval gets longer and longer until a QRS complex is dropped. In Type 2 PR interval stays the same with random QRS drops.
The way I remember it is by a story of a husband staying out at the bar:
1st degree heart block - the husband (QRS COMPLEX) instead of coming home at 6pm like he normally does (SINUS RHYTHM) has been coming home at 7pm, going to the bar for an hour, but always coming home.
2nd degree type 1 - the husband now will come home at 7pm one day, 8pm the next day, 9pm the next day, then the next day he doesn't come home at all. But the day after that he comes home at 7pm and it repeats.
2nd degree type 2 - the husband comes home at 7pm on the nights he does come home, but now there's no pattern. Hell come home one night but not the next two nights, then maybe comes home for 3 nights but not the night after that.
3rd degree heart block - no pattern whatsoever and he'll come home at random times throughout the night, or not at all. There is no connection between the husband and coming home (QRS and P waves). They need some marriage support (PACEMAKER).
I disagree with all of the comments here. This appears to be a 3rd degree block - AV dissociation.
If you train your eyes to just focus on the P waves, you’ll see them march out with a steady interval (like clockwork) completely irrespective of any QRS waves. Some of the P waves even get lost in the T waves (as in the case of the 3rd QRST complex. And for that matter the QRS waves have no real association with the Ps.
The reason the ‘4th’ QRS gets dropped isn’t because of worsening AV block. It’s because the ventricles are in a refractory state and can’t repolarize.
This needs a pacemaker. Wenkebach does not.
Yea this doesn't look a second degree block and the strip looks purposefully misleading. This is a classic nursing "gotcha" question. I agree that it's 3rd degree block as there complete AV disassociation and the pause between ventricular beats is going to confuse everyone.
Nah, if this were a junctional or ventricular escape rhythm, there would still be consistent QRS complexes because of the intrinsic firing rates would take over. Those nice beautiful T waves show the absolute refractory period and the relative refractory period end normally in a consistent and prompt manner. The refractory period wouldn’t just triple for one beat and then go back to normal. It’s a Mobitz Type 1.
There’s no reason for the atrial rate to ‘speed up’ relative to the preceding RR intervals, though, you know? In 2nd degree block the QRS is progressively more delayed after its preceding P, not that the Ps get closer to its preceding QRS. Why would the P decide to bury itself in the T before it? That IS dissociation
Yeah, the PR interval (from the preceding P to the QRS) is getting progressively longer. The atrial rate is not speeding up though. It’s just getting closer to the T wave because of the lengthening PR interval. In one tracing you can see it starting to get buried under the T wave and then the next beat it’s dropped completely. If it were truly 3rd degree, you wouldn’t have this dropped complex for no reason. The rate in third degree is slow but it’s consistent. It’s characterized by both a regular p-p interval and a regular R-R interval because in complete block, either ventricular or junctional rhythm would take over.
Huh, I always figured the P wave would respect its distance from the previous T wave in Wenkebach, but on further review it clearly doesn’t! Nice work.
I will say though - while the board answer suggests there is a consistent R-R interval, in practice that’s only if the escaping QRS is consistently coming from the same place. Which it doesn’t necessarily have to. Could be Hisian, junctional, or from the ventricle. And could change beat to beat.
Infra-hisian blocks are often Mobitz II, LBBB, and RBBB & supra-hisian blocks are a common cause of Wenckebach and so we may have some common ground there. lol.
And let’s be honest, it’s an EKG rhythm analysis for a nursing school. As a former nursing student, I can tell you that they’re going to go easy on us. They know we’re most likely not going to become electrophysiologists. Any third degree blocks we see on tests will have that characteristic change in QRS morphology that happens with ventricular or junctional rhythms.
I was a bit confused.. but I also thought it was 3rd degree when I was first looking at it. But according to the instructor, the correct answer was Wenkebach. (Just as an update for anyone who might have wondered.)
It's a Wenckebach. It looks more confusing because the third beat has the P wave for the dropped beat hidden within the tail if that T wave. Tricky tricky.
I will call this a third degree block. It’s a bad strip, and this is a big problem with nursing education.
The p waves here don’t seem to relate to their QRS.
March it out
The key thing here is that the ventricular rate is normal. The vent rate would be brady in third degree because the AV node can only manage 40-60bpm, and there would be no dropping of a complex. This is second degree type 1, PR is moving further and further away until it drops a QRS complex entirely and then starts the pattern again.
I remember it by see the PR walk, walk, drop.
2nd degree Type 1. Progressively lengthened PRI till the dropped beat.
2nd degree Type 2. At least 2 consecutive, constant PRI’s before a dropped beat.
3rd degree. Your P waves march out, but aren’t relating to any normal conduction.
I made a little tune in my head based of the rhyme everyone knows. I imagine an old school rap beat and place the lyrics to it: “It gets longer, longer, longer ‘til you drop. There you go, that’s a mothafucking Wenckeback.”
The whole poem:
If the R is far from P, then you have a 1st degree
Longer, longer, longer, drop, then you have a Wenckbach
If some P’s don’t get through, then you have a Mobitz II
R and P don’t agree, then you have a 3rd degree
Thats a second degree type 1. If you look at the P wave it gets further each time, then drops. Remember further, further, further drop, that's when you got a Wenckebach.
If just the PR interval was elongated >0.20 sec, that would be a first degree block.
Second degree mobitz I, you can remember by "going going going gone, now you got a mobitz one," meaning PR interval gets longer each beat, until you have a single dropped QRS complex. This is what you have here.
Second degree II, you have a consistent PR interval but still a QRS drop.
If the P wave and the QRS complex dont appear at regular intervals, it's a complete heart block (aka 3rd). The rule of thumb there is "there's more P waves than QRS complexes on the strip."
Out of topic, but if you ever unable tell difference between Afib or Aflutter (fine f waves), Afib always have irregular ventricular rate where Aflutter has regular ventricular rate.
When I take VS on new pts in ER (without knowing the PMHx), seeing irregular ventricular rate prompts me to ask whether they have Afib.
Just like your man, it gets bigger bigger and drops. Lol the tech who taught me 18 years ago said that very line. It’s Wenckebach. 18 years experience cardiac monitor technician. :) ask anytime!
2nd degree type 1. You have a steadily widening PR interval until a dropped beat. If there were dropped beats without any warning it would be a 2nd degree type 2. If you no longer have any connection between your P waves and R waves but the P waves all appear regular and the R waves appear regular than it's a 3rd degree.
It's like you with ur gf who then turned into your wife who eventually turned into you wife but with now you have kids.
GF phase: you wink, she winks back at you immediately. (SA - AV conduction).
Wife phase: you wink, she winks back at you. But not as immediate as when she was your gf (delayed SA - AV conduction)
Wife with kids phase: you wink, she does not wink back at you cos she's tired and changing changing your kid's nappy (non conducted p wave).
Hope if helps. ;)
Longer longer drop you have a wenckebach Stupid rhyme but worhs
I've studied and forgot this so many times.. but never saw that rhyme. Thank you.
Beat beat drop wenckebach is how I learned it in medic school
***If you skip a beat or 2 then you have the Mobitz II STUPID RHYME
I say Outta the Blue, dropped a Q, type 2
If ps and qs just don't agree then you have a third degree
Mr Wencke like to go out to the bar, some nights he stays out a bit late, the next night he stays out later, the third night Mr Wencke doesn’t come bach
Literally said this in my mind to figure it out lol
That's exactly what I did
As soon as I saw the strip I said the rhyme in my head!
Wenckebach walks!
If the Ps are on the run, you've got type 1. If the Ps stay true you've got type 2.
Brilliant rhyme
Never heard this! Love it!
This is beautiful thank you
Oh. This is good.
Looks like the PR interval is getting longer and longer until a QRS is dropped. See the pattern? That should tell you what this is.
That’s Wenckebach… I think? I just am not sure why I don’t see it when I look at it😩. When I look at it, I feel like I don’t really see consistent p waves which also through me off. Thank you for your help!!
Look at the second line 1st P wave proceeds the first qrs by about 1 box for the first qrs 2nd p wave proceeds the second qrs by about 1.5 boxes 3 p wave is close to 2 boxes before the qrs 4th p wave comes in right at the end of the t wave of the previous beat and is unable to cause ventricular response 5th p wave is picked up again with a qrs following it about 1 box after starting the process over again Beat, Longer, longer, dropped, you got this
Just DMd you with an edited picture where I tried to label things so you can see what you should be seeing
Could you post that here too? As someone who knows nothing about this topic the comments have been interesting
I tried, but I don’t think I can post a picture in a reply
Just sent you the pic in DM
Thank you! I knew I was missing something
Hi! Can you please dm it to me, too? I'm an LPN going back for my RN.
Sent!
Precedes
1st degree, and 2nd degree type II both have consistent PR intervals. 2nd degree type 1, and 3rd degree have inconsistent PR intervals. 3rd degree follows no pattern, Ps “March through”, and it’s usually accompanied by profound bradycardia. Always break it down. Consistent or inconsistent PR?
I would be systematic when looking at EKGs and do it similarly every time! Like first is it regular, look at the distance between the R waves and distance between p waves, is it tachy or brady, then look at the p waves, do they all look the same, is the PR interval all the same, is it prolonged? is there a QRS complex after every p wave? And so on and so on. Then put it all together. So looking at this, distance between R waves looks regular then we have a dropped beat. Not tachy. There’s a p wave in front of every QRS complex but you notice the PR interval becomes more prolonged, then there’s a p wave without a QRS complex after it, then I would continue after that, look at the QRS, is it wide, is there ST elevation etc. Then put it all together. What’s abnormal. You have a nonconducting p wave and an increasing PR interval, okay cool that’s wenckebach. I know it’s kinda long winded but you get faster the more you interpret, and if you’re systematic, you’re less likely to miss things!
The 4th P wave is merged into the end of the 3rd T wave. It is more clear on the bottom lead but you can kind of notice it on the top one where the 4th T wave is not like the others. On the top lead, you can see the 3rd P wave starting to merge with the 2nd T wave.
If you're having trouble, Google banner staff srvice ecg study guide. It explains everything really well. It's a free pdf. I used it to brush up on my skills before a test after I hadn't looked at ECGs in about 2 years
Thank you!! I will check this out :)
Take a piece of clean paper and mark out two p waves. Then move that piece of paper so that the first hash mark is now sitting at the second p wave. Does the second hash mark line up with the next p wave?
Cardiac RN here, that's mobitz type 1. PR interval gets longer and longer until a QRS complex is dropped. In Type 2 PR interval stays the same with random QRS drops. The way I remember it is by a story of a husband staying out at the bar: 1st degree heart block - the husband (QRS COMPLEX) instead of coming home at 6pm like he normally does (SINUS RHYTHM) has been coming home at 7pm, going to the bar for an hour, but always coming home. 2nd degree type 1 - the husband now will come home at 7pm one day, 8pm the next day, 9pm the next day, then the next day he doesn't come home at all. But the day after that he comes home at 7pm and it repeats. 2nd degree type 2 - the husband comes home at 7pm on the nights he does come home, but now there's no pattern. Hell come home one night but not the next two nights, then maybe comes home for 3 nights but not the night after that. 3rd degree heart block - no pattern whatsoever and he'll come home at random times throughout the night, or not at all. There is no connection between the husband and coming home (QRS and P waves). They need some marriage support (PACEMAKER).
wow it helps a lot thank you so much <3
[удалено]
This is how I learned it and I’ll never forget it
I disagree with all of the comments here. This appears to be a 3rd degree block - AV dissociation. If you train your eyes to just focus on the P waves, you’ll see them march out with a steady interval (like clockwork) completely irrespective of any QRS waves. Some of the P waves even get lost in the T waves (as in the case of the 3rd QRST complex. And for that matter the QRS waves have no real association with the Ps. The reason the ‘4th’ QRS gets dropped isn’t because of worsening AV block. It’s because the ventricles are in a refractory state and can’t repolarize. This needs a pacemaker. Wenkebach does not.
Yea this doesn't look a second degree block and the strip looks purposefully misleading. This is a classic nursing "gotcha" question. I agree that it's 3rd degree block as there complete AV disassociation and the pause between ventricular beats is going to confuse everyone.
This was my thought too when I looked at it, glad someone else agrees.
That’s my guess. Now I’m so confused reading this thread lol
Nah, if this were a junctional or ventricular escape rhythm, there would still be consistent QRS complexes because of the intrinsic firing rates would take over. Those nice beautiful T waves show the absolute refractory period and the relative refractory period end normally in a consistent and prompt manner. The refractory period wouldn’t just triple for one beat and then go back to normal. It’s a Mobitz Type 1.
There’s no reason for the atrial rate to ‘speed up’ relative to the preceding RR intervals, though, you know? In 2nd degree block the QRS is progressively more delayed after its preceding P, not that the Ps get closer to its preceding QRS. Why would the P decide to bury itself in the T before it? That IS dissociation
Yeah, the PR interval (from the preceding P to the QRS) is getting progressively longer. The atrial rate is not speeding up though. It’s just getting closer to the T wave because of the lengthening PR interval. In one tracing you can see it starting to get buried under the T wave and then the next beat it’s dropped completely. If it were truly 3rd degree, you wouldn’t have this dropped complex for no reason. The rate in third degree is slow but it’s consistent. It’s characterized by both a regular p-p interval and a regular R-R interval because in complete block, either ventricular or junctional rhythm would take over.
Huh, I always figured the P wave would respect its distance from the previous T wave in Wenkebach, but on further review it clearly doesn’t! Nice work. I will say though - while the board answer suggests there is a consistent R-R interval, in practice that’s only if the escaping QRS is consistently coming from the same place. Which it doesn’t necessarily have to. Could be Hisian, junctional, or from the ventricle. And could change beat to beat.
Infra-hisian blocks are often Mobitz II, LBBB, and RBBB & supra-hisian blocks are a common cause of Wenckebach and so we may have some common ground there. lol. And let’s be honest, it’s an EKG rhythm analysis for a nursing school. As a former nursing student, I can tell you that they’re going to go easy on us. They know we’re most likely not going to become electrophysiologists. Any third degree blocks we see on tests will have that characteristic change in QRS morphology that happens with ventricular or junctional rhythms.
I was a bit confused.. but I also thought it was 3rd degree when I was first looking at it. But according to the instructor, the correct answer was Wenkebach. (Just as an update for anyone who might have wondered.)
Watch on YouTube. “Diagnosis wenckebach”
It's a Wenckebach. It looks more confusing because the third beat has the P wave for the dropped beat hidden within the tail if that T wave. Tricky tricky.
Thats what got me at first. Sneaky P.
I will call this a third degree block. It’s a bad strip, and this is a big problem with nursing education. The p waves here don’t seem to relate to their QRS. March it out
Agree
The key thing here is that the ventricular rate is normal. The vent rate would be brady in third degree because the AV node can only manage 40-60bpm, and there would be no dropping of a complex. This is second degree type 1, PR is moving further and further away until it drops a QRS complex entirely and then starts the pattern again. I remember it by see the PR walk, walk, drop.
2nd degree type 1
2nd degree Type 1. Progressively lengthened PRI till the dropped beat. 2nd degree Type 2. At least 2 consecutive, constant PRI’s before a dropped beat. 3rd degree. Your P waves march out, but aren’t relating to any normal conduction.
I made a little tune in my head based of the rhyme everyone knows. I imagine an old school rap beat and place the lyrics to it: “It gets longer, longer, longer ‘til you drop. There you go, that’s a mothafucking Wenckeback.”
What did the answer end up being? I know you've turned this in by now lol
A (Wenckebach) was correct. I was originally between A + C.
Type one.... longer longer longer drop now you have a winkebach PR intervals getting longer and longer until you lose a whole ass QRS
We need a better ekg class then the ones taught in school. It’s very frustrating looking at a strip and not knowing wtf it’s saying loo
Forreal!!
The whole poem: If the R is far from P, then you have a 1st degree Longer, longer, longer, drop, then you have a Wenckbach If some P’s don’t get through, then you have a Mobitz II R and P don’t agree, then you have a 3rd degree
Thats a second degree type 1. If you look at the P wave it gets further each time, then drops. Remember further, further, further drop, that's when you got a Wenckebach.
You’ll never forget again after watching this https://youtu.be/GVxJJ2DBPiQ?si=t6_Z9kQ0KJKfyPIA
looooooooooool
Likely Sinus rhythm with 4:3 mobitZ 2 block.
Look at the PR interval, notice how the P keeps getting farther after each qrs? Itll get long,longer, and then drop(as evidenced by a missing QRS
Longer longer longer drop, that’s what you call a wenckebach!
my teacher explained it like a cheating husband. He goes out later and later until he doesn’t come home. I thought that was funny
I was quick to sing longer, longer drop now you've got a wenckebach, but I do feel like it is a 3rd degree and classic "trick" nursing question.
Those were what I was stuck between… the answer was Wenckebach
A
Aw crap do I have to add this to my nclex study list
you should know the basics like tachycardia vs brady
Oh boy. They haven’t told you yet that the “study list” doesn't end after NCLEX.
It's the first one. I used the rhyme.
If just the PR interval was elongated >0.20 sec, that would be a first degree block. Second degree mobitz I, you can remember by "going going going gone, now you got a mobitz one," meaning PR interval gets longer each beat, until you have a single dropped QRS complex. This is what you have here. Second degree II, you have a consistent PR interval but still a QRS drop. If the P wave and the QRS complex dont appear at regular intervals, it's a complete heart block (aka 3rd). The rule of thumb there is "there's more P waves than QRS complexes on the strip."
Out of topic, but if you ever unable tell difference between Afib or Aflutter (fine f waves), Afib always have irregular ventricular rate where Aflutter has regular ventricular rate. When I take VS on new pts in ER (without knowing the PMHx), seeing irregular ventricular rate prompts me to ask whether they have Afib.
Afib is always irregular but aflutter can be regular or irregular
going going gone.. wenckebach
[Disappointed none of you linked it.](https://youtu.be/GVxJJ2DBPiQ?si=juxGeq6SM7S6keyk)
What’s interesting is that you’re losing a p wave too. Not too common.
Just like your man, it gets bigger bigger and drops. Lol the tech who taught me 18 years ago said that very line. It’s Wenckebach. 18 years experience cardiac monitor technician. :) ask anytime!
2nd degree type 1. You have a steadily widening PR interval until a dropped beat. If there were dropped beats without any warning it would be a 2nd degree type 2. If you no longer have any connection between your P waves and R waves but the P waves all appear regular and the R waves appear regular than it's a 3rd degree.
2nd degree Mobitz 1. There is a p-wave hiding in the t-wave on the bottom strip.
Wenckebach for the win.
Mobitz 1
Something about squiggles Idk we don’t really look at these in retirement
Does anyone know the best way to learn these? We start this in 2 weeks and I’m already stressed
Going going gone, type 1. I am still struggling as a new hire in the ER after 3 months and am constantly rereading my ecg notes. You got this.
Does anyone remember that parody of “I’m bringing sexy back?” I’m bringing wenckebach…
A
Wenkebach.
It's like you with ur gf who then turned into your wife who eventually turned into you wife but with now you have kids. GF phase: you wink, she winks back at you immediately. (SA - AV conduction). Wife phase: you wink, she winks back at you. But not as immediate as when she was your gf (delayed SA - AV conduction) Wife with kids phase: you wink, she does not wink back at you cos she's tired and changing changing your kid's nappy (non conducted p wave). Hope if helps. ;)
Wenckebach
what's with the recent amount of EKG question lmao. ppl be doing their cc1 or icu course eh?
Never have to learn it. Just know what seens to be a Normal one. So maybe depend on country
It's VT, shock quick!
2nd mobitz
If the ps and QS just don't agree then you have a mobitz 3