ECG of the Week - 19th November 2012 - Interpretation

This ECG is from a 49 year old with chest pain.

 

 

Click to enlarge

 

 

Initial 3 Complexes

Rate:

• ~65-68

Rhythm:

• Regular

Axis:

• Normal

Intervals:

• PR - Normal (~160ms)
• QRS - Normal (100ms)
• QT - 400ms (QTc Bazette ~420-430 ms)

Segments:

• ST Depression I, II, III

Additional:

• P Wave Inversion Lead I

Interpretation:

• Ectopic Atrial Rythm with ischaemic features

Subsequent ECG

• Ventricular Ectopic with 'R-onT' phenomenon
• Polymorphic VT --> VF

Interpretation:

• Acute myocardial ischaemia / infarction causing polymorphic VT / VF

 What happened next ?

• CPR
• Received 4 x 200J shocks
• 150mg iv amiodarone
• 100 mg iv lignocaine

Subsequent ROSC was achieved after < 10 minutes. 

Post ROSC ECG showed antero-lateral ST elevation.

The patient underwent inter-hospital transfer for PCI.

PCI revealed a proximal LAD lesion with 90% occlusion, which was stented.
Echo showed

• Normal LV size with anterior, septal and apical akinesis and overall moderate systolic impairment
• Probable LV apical thrombus
• Normal right ventricular size and apical akinesis and overall mild systolic impairment.

The patient was subsequently discharged on warfarin, anti-platelet therapy, ACE inhibitor, beta-blocker, and a statin.

Things to think about

• The role of early revascularisation with thrombolysis prior to inter-hospital transfer
• The role of lignocaine in shock refractory VT/VF
• Several International Guidelines on ALS are linked to below and the recommendations on the use of lignocaine vary between guidelines

References / Further Reading

 

International Resuscitation Guidelines

• Australian Resuscitation Council Guidelines here
• UK Resuscitation Council Guidelines here
• American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science 2010 Edition here

Textbook

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