Wednesday, 31 October 2012

ECG of the Week - 29th October 2012 - Interpretation


This ECG is from an 83 year old male patient.
Presented with shortness of breath.




Click to enlarge
 
 
Rate:
  • ~155
Rhythm:
  • Regular
  • ? Flutter waves - best seen in precordial leads esp. V3 rate ~300bpm
Axis:
  • LAD (-66 deg)
Intervals:
  • QRS - Prolonged (160-200ms)
  • QT - 360ms (QTc Bazette ~ 270 ms)
Segments:
  • ST Depression V2-4, II
  • T Inversion V1-3, I, aVL, aVR
 
Additional:
 
  • RBBB Morphology with discordant ST changes
  • 3rd & 19th Complexes morpholoigcally different ? Fusion
  • Nil Concordence

Interpretation:
 
  • Broad Complex Tachycardia
  • Differentials:
    • Ventricular Tachycardia
    • SVT with aberrant conduction (pre-existing or rate related)
    • SVT in setting of pre-excitation
  • Right Bundle Branch Block Morphology
  • Left Axis Deviation

  • Our diagnosis is:
  • Atrial Flutter 2:1 Block with either pre-existing RBBB or rate-related RBBB
  • Bifasicular block
 
Further links on differentiating broad complex tachydysrhythmias and types of broad complex tachydysrhythmias can be found below.

What happened ?
  • Old notes revealed a Hx of Paroxysmal Atrial Fibrillation and a pre-existing RBBB (same morphology as this ECG)
  • Pt reviewed by cardiology
  • Initially Tx with adensosine with no response
  • Underwent DC cardioversion
  • Resultant rate controlled Atrial Fibrillation
  • Tx oral amiodarone.
  • ECHO
    • Dilated LV
    • Extensive akinese of infero-posterior and lateral walls
    • Severe MR
    • Mild Pulmonary Hypertension
    • Hypokinetic Right Ventricle
    • Mod - Severe systolic impairment.

References / Further Reading
 
Life in the Fast Lane
 
  • SVT vs VT here
  • Ventricular Tachycardia here
  • Fasicular VT here
ECGpedia.org
  • Approach to Wide Complex Tachycardia here
Textbook
  • Chan TC, Brady WJ, Harrigan RA, Ornato JP, Rosen P. ECG in Emergency Medicine and Acute Care. Elsevier Mosby 2005.