Saturday, 4 April 2015

ECG of the Week - 30th March 2015 - Interpretation

This ECG is from an 80 yr old male who presented to the Emergency Department feeling generally unwell for the preceding 10 hours ! He denied chest pain, dysponea or syncope. He had a history of paroxysmal atrial fibrillation and had a single chamber PPM in-situ for bradycardia. Vital signs were within normal limits.
Check out the comments form our original post here.



Click to enlarge
Sorry about the image quality my scanner is broken so I had to take a picture with my phone !

Rate:
  • ~192 bpm
Rhythm:
  • Regular
  • AV Dissociation
    • Notching in upstroke of some QRS complexes and notching in T wave of complex 21
    • Could be Josephson's Sign rather than dissociation
Axis:
  • Right axis deviation
Intervals:
  • QRS - Prolonged (120-140ms)
  • QT - 280-320ms
Additional:

  • Positive precordial concordance
  • All QRS complexes in leads V1-6 are positive
  • Discordant ST segment and T wave changes
  • Nil fusion or capture beats


Interpretation:

  • Broad Complex Tachycardia
  • Multiple features support VT as listed above plus patients age

What happened ?

The patient was successfully DC cardioverted. 
His post-cardioversion ECG is below.

Click to enlarge
Post-cardioversion we can see a regular ventricular paced rhythm with LBBB morphology consistent with RV pacing and expected discordant ST / T wave changes (Sgarbossa negative). Note the absence of native atrial or ventricular activity.

DC Cardioversion when PPM/AICD is present

Australian Resuscitation Guideline 11.4 makes reference to pad/paddle placement in patients with ICD/PPM in situ.

Click to enlarge

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.