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

• SVT vs VT
• LBBB
• Sgarbossa Criteria
• Atrial tachycardia
• Atrial Flutter

Textbook

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