You will see this problem quite a bit. With a HR around 150, always make sure you are not missing flutter with wide complex tachycardia (could have baseline BBB). Even if you do not see the flutter wave, look for them with your calipers. Measure the R-R interval with the calipers; place them on the ECG grid lines; take half of that measurement and start looking for bumps along the T-wave for the flutter wave. If you see a clear P-wave, try to march out the flutter waves with the calipers from above measurement. Hope this makes sense, can catch it more than a few times if you look for Flutter whenever you see a HR of 150.
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As you rightly suggested, it is the high index of suspicion which helps us bring out the features of atrial flutter. 150 is the rate for which you have to suspect atrial flutter with 2:1 conduction as 300 is a typical flutter rate. In an actual clinical case, carotid sinus massage may decrease the ventricular rate by slowing the AV conduction so that flutter waves may become more evident on the monitor.
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