13 yr old girl was transferred to ICU for atrial flutter. Patient is muscle tremors and is neurologically obtunded, thought to be secondary to severe, systemic vasculitis. Figure 1 is an EKG strip from bedside monitor on the floor. Pulse oximeter trace is present in the strip as well.
In order to clarify the diagnosis, Doppler was performed with the cursor placed between mitral valve and aortic valve.
1) What is the diagnosis?
Sinus rhythm. Muscle tremors causing fib-flutter pattern. In EKG: Hallmark of atrial fibrillation is irregularly-irregular ventricular rate (which is absent here). Also, pulse ox trace is regular and is normal, beat-to-beat. In Doppler trace: There is 1:1 relationship between mitral inflow and aortic outflow.
2) How would you manage this?
Just get out of the way and let them manage the obtunded state and muscle tremors.
(Click on the image to enlarge)
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