Saturday, 17 January 2015

ECG of the Week - 12th January 2015 - Interpretation

This ECG is from a 74 yr old female. I don't have any more clinical information on the case unfortunately.
Check out the comments on our original case here.


Click to enlarge


Rate:

  • Ventricular rate ~136 bpm
  • Atrial rate ~ 270 bpm
Rhythm:
  • Regular atrial & ventricular activity
  • Atrial activity best seen in leads I & V1 
    • Notching in terminal portion of QRS and also in isoelectric segment
Atrial activity highlighted in leads I & V1
Click to enlarge
Axis:
  • LAD
Intervals:
  • QRS - Prolonged (140ms)
  • QT - 310ms
Segments:

  • Appropriate ST segment & T wave discordance
  • Sgarbossa Negative
Additional:
  • Typical LBBB Morphology
Interpretation:
  • Regular Wide Complex Tachycardia
  • Evidence of 2:1 conduction 
    • Likely atrial tachycardia or atrial flutter
  • LBBB Morphology
    • DDx - Native, rate related or aberrancy
What would we want to ask our patient ?

The first thing to establish is whether we have time to take a full and detailed history. Clinical instability, e.g. hypotension, mandate urgent resuscitation and rhythm control.
But if we time for a 'chat' there are a number of things to establish in this patient including:
  • Are they symptomatic ?
    • Do they have palpitations ?
    • Do they have - chest pain, dysponea, syncope or pre-syncope ?
  • Do we have a cause ?
    • Concurrent or recent illness ?
    • Has this happened before ?
    • Do they have a chronic dysrhythmia ?
    • Do they have a cardiac history ?
  • What are we going to do about it ?
    • Do we have an accurate onset time ?
    • Are they on long term anti-coagulation - warfarin, NOAC etc ?
    • What do they want us to do ?
  • Do we anticipate sedation / DCCV difficulties ?
    • Previous episodes and outcome
    • Previous sedation or GA
    • Fasting status
  • What is the long term plan ?
    • Consider co-morbidities ?
    • Social circumstance ?
    • Patient / NOK wishes ?
Management Options

Without knowing more about our patient it's difficult to establish the best management but broad consideration are:

  • Rate vs Rhythm Control
  • Correction of any underlying / precipitating condition e.g. infection, electrolyte abnormality, ischaemia etc.
  • Anti-coagulation
  • Long-term management / prevention

References / Further Reading

Life in the Fast Lane


Textbook
  • Chan TC, Brady WJ, Harrigan RA, Ornato JP, Rosen P. ECG in Emergency Medicine and Acute Care. Elsevier Mosby 2005.