Rate: yikes, err 40 bpm vent rate, no appreciable atrial rate Regularity: regular P-waves: none appreciated PRi: nonexistent QRSd: wide-wide @ 200 ms BBB: V1+ (qR it looks), RBBB Axis: indeterminate frontal axis, ventral Z-axis QTi: normal (< 1/2 R-R) T-waves: hard to interpret if appropriately discordant in most leads, but they tower over many of the QRS complexes ST-segments: elevated/depressed in multiple leads
DDx: - Extensive MI (from thumbnail that's what I thought) - Hyperkalemia (rate, lack of atrial activity, bizarre appearance all point in favor)
Depending on presentation will plot the course, a decent choice if you're not sure is probably calcium. Pacing won't be effective in HyperK+ without it.
Hopefully haven't double posted. Having commenting problems.
What would I do? Google and Wiki causes of QRS widening.
On a more serious note - ABC's If patient is clinically stable, take a history to establish underlying aetiology. In particular medication and whether there is any use of TCA or intentional drug ingestion.
Ask for help from Dr Larkin.
ABG/VBG to quickly exclude hyperkalaemia and assess UEC as well as acid-base balance (provided one hasn't haemolysed he darn sample)
Treatment would depend on the underlying aetiology and patient's clinical status.
Buy a coffee from T5 after referring onward to the appropriate inpatient team!
Thanks for the input this ECG seems to have generated more comment than usual.
I would love to give you more information on this case but I actually don't have any info other than the ECG 'punchline'. I don't know any past medical history or the circumstances of the presentation.
We look at a great number of ECGs every day without any, or very little, clinical context. This highlights the need for a systematic approach to ECG interpretation and formulation of a list of differentials. These can then be refined following history, examination, other investigation results, and they also allow us to prioritise workload, investigations, and treatment.
Kevy, hope your buying the coffee after dragging me in to help :-)
Rate: yikes, err 40 bpm vent rate, no appreciable atrial rate
ReplyDeleteRegularity: regular
P-waves: none appreciated
PRi: nonexistent
QRSd: wide-wide @ 200 ms
BBB: V1+ (qR it looks), RBBB
Axis: indeterminate frontal axis, ventral Z-axis
QTi: normal (< 1/2 R-R)
T-waves: hard to interpret if appropriately discordant in most leads, but they tower over many of the QRS complexes
ST-segments: elevated/depressed in multiple leads
DDx:
- Extensive MI (from thumbnail that's what I thought)
- Hyperkalemia (rate, lack of atrial activity, bizarre appearance all point in favor)
Depending on presentation will plot the course, a decent choice if you're not sure is probably calcium. Pacing won't be effective in HyperK+ without it.
Labs and echo too.
Very neat ECG!
Agreed... Would be helpful to know some history to lean one way or another.
ReplyDeleteHopefully haven't double posted. Having commenting problems.
ReplyDeleteWhat would I do? Google and Wiki causes of QRS widening.
On a more serious note -
ABC's
If patient is clinically stable, take a history to establish underlying aetiology. In particular medication and whether there is any use of TCA or intentional drug ingestion.
Ask for help from Dr Larkin.
ABG/VBG to quickly exclude hyperkalaemia and assess UEC as well as acid-base balance (provided one hasn't haemolysed he darn sample)
Treatment would depend on the underlying aetiology and patient's clinical status.
Buy a coffee from T5 after referring onward to the appropriate inpatient team!
And also assess if patient needs pacing.
ReplyDeleteHi guys,
ReplyDeleteThanks for the input this ECG seems to have generated more comment than usual.
I would love to give you more information on this case but I actually don't have any info other than the ECG 'punchline'. I don't know any past medical history or the circumstances of the presentation.
We look at a great number of ECGs every day without any, or very little, clinical context. This highlights the need for a systematic approach to ECG interpretation and formulation of a list of differentials. These can then be refined following history, examination, other investigation results, and they also allow us to prioritise workload, investigations, and treatment.
Kevy, hope your buying the coffee after dragging me in to help :-)
John