ECG of the Week - 6th May 2013 - Interpretation

I don't have any clinical information on this case unfortunately but it looks like an interesting ECG :-)

Rate:

• Overall rate 60 bpm

Rhythm:

• Irregular - likely regularly irregular
• Pattern of 2 sinus complexes followed by 2 ventricular complexes

Axis:

• Indeterminate

Intervals:

• Sinus complexes
• PR - Normal ( 160ms)
• QRS - Prolonged (120ms)
• QT - 400ms (QTc Bazette ~ 430 ms)

• Ventricular complexes
• QRS - Prolonged (180ms)
• QT - 480ms 

Segments:

• ST Elevation V2-4 of sinus complexes discordant to QRS
• Discordant ST & T wave changes of ventricular complexes

Additional:

• Notching in terminal portion of 1st ventricular complexes 
• Best seen in lead II
• Corresponds to atrial activity at a rate of 55 bpm
• Regularly irregular atrial activity in pattern of 3 complexes then pause
• Poor R wave progression

Interpretation:

• Sinus rhythm
• Intraventricular conduction delay
• Regular coupled ventricular ectopics

Without more clinical information it's hard to comment further on the likely causes for this ECG appearance but some potential culprits are:

• Ischaemia
• Electrolyte / acid base disturbance
• Drugs
• esp. digoxin
• Environmental e.g. hypothermia

VAQ Corner

For those planning to sit the ACEM Fellowship, or any of our other interested readers.
 I don't know anything about the real case so I've made up the clinical details for this question.

A 76 yr old female presents to your ED following a collapse at home. 
She complains of feeling dizzy and lethargic for the last 2 days.
She has a history of IHD, CCF, and hypertension.
She is on multiple medications but can not recall them.
Observations: BP 85/45 RR 16 Sats 95% RA GCS 14 (M=6 V=5 E=3)

a) Describe & interpret the ECG (50%)
b) Outline your management (50%)


I won't directly be answering our VAQ corner questions on the blog, unless it's a 100% describe and interpret. These questions are designed to give people the oppurtunity to think about the ECG with some clinical context, especially when I don't have a real case to attach to, and also to provide a chance to do some VAQ practice. 
If people would like to submit some answers I will happily added them to our posts, just email them to me here.

References / Further Reading

Life in the Fast Lane

• PVC's here

Textbook

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