Rate: ~70 bpm Regularity: regular P-waves: Inverted in I, upright in II/III. PRi: ~180ms, associated 1:1. QRSd: Narrow, ~100ms QTc: normal (<1/2 RR) P Axis: Rightward, left atrial focus or lead misplacement QRS Axis: Normal ST/T-waves: downsloping ST-segments w/ ST-depression consistent with ischemia Rhythm: ectopic atrial rhythm (or sinus rhythm with lead misplacement)
Right two-thirds:
Early coupled PVC (+aVR) initiating PMVT devolving into primary VF. Not calling TdP due to normal QTc prior to initiation. Given ST/T-wave changes and patient complaint we should consider an ischemic cause of this event.
Dx: ectopic atrial rhythm with PVC initiating PMVT/VF due to ischemia (ACS).
Rx: defibrillation, consider an antiarrhythmic. Confirm lead placement once arrhythmias are taken care of.
my post vanished, or perhaps I did not submit it properly few days ago... anyway.... once again.
initally I,II,III regular rythm ~ 70/min. However P wave inversion in I is against Sinus Rythm Criteria. Therefore either incorrectly placed leads (right-left arm) or less likely but possible dextrocardia. So check the leads to exclude technical error and listen to the heart :) P mitrale in III, but again lets check the leads! Then polymorphic looking VT, which suggests Torsade de Pointes with ventricular rate ~ 300/min. QT does not look overtly prolonged, so wldn't expect a long QTc. Chest pain and polymorphic VT, still ACS high on my list, especially with those ST depressions in I,II. Also low Mg? Hypomagnesemia/ hypokalemia? I would give 2g of Magnesium anyway. Patient by definition is unstable (as per ALS) because has chest pain, so electricity 200J.... and call Cardiology :)
Had a patient once who was given amiodarone for TdP by Physicans. (after Mg of course:)
I'll cover the left third first.
ReplyDeleteRate: ~70 bpm
Regularity: regular
P-waves: Inverted in I, upright in II/III.
PRi: ~180ms, associated 1:1.
QRSd: Narrow, ~100ms
QTc: normal (<1/2 RR)
P Axis: Rightward, left atrial focus or lead misplacement
QRS Axis: Normal
ST/T-waves: downsloping ST-segments w/ ST-depression consistent with ischemia
Rhythm: ectopic atrial rhythm (or sinus rhythm with lead misplacement)
Right two-thirds:
Early coupled PVC (+aVR) initiating PMVT devolving into primary VF. Not calling TdP due to normal QTc prior to initiation. Given ST/T-wave changes and patient complaint we should consider an ischemic cause of this event.
Dx: ectopic atrial rhythm with PVC initiating PMVT/VF due to ischemia (ACS).
Rx: defibrillation, consider an antiarrhythmic. Confirm lead placement once arrhythmias are taken care of.
my post vanished, or perhaps I did not submit it properly few days ago... anyway.... once again.
ReplyDeleteinitally I,II,III regular rythm ~ 70/min. However P wave inversion in I is against Sinus Rythm Criteria. Therefore either incorrectly placed leads (right-left arm) or less likely but possible dextrocardia. So check the leads to exclude technical error and listen to the heart :)
P mitrale in III, but again lets check the leads! Then polymorphic looking VT, which suggests Torsade de Pointes with ventricular rate ~ 300/min. QT does not look overtly prolonged, so wldn't expect a long QTc.
Chest pain and polymorphic VT, still ACS high on my list, especially with those ST depressions in I,II. Also low Mg?
Hypomagnesemia/ hypokalemia? I would give 2g of Magnesium anyway. Patient by definition is unstable (as per ALS) because has chest pain, so electricity 200J.... and call Cardiology :)
Had a patient once who was given amiodarone for TdP by Physicans. (after Mg of course:)