The initial rhythm on paramedic arrival was VF, initial DC cardioversion resulted in PEA with ROSC following iv adrenaline. A further episode of pre-hospital VF responded to DC cardioversion.
On arrival to the Emergency Department the patient is intubated, starting to make voluntary movements, with eye opening to stimuli. Vital signs: BP 98/67, BSL 8.2, Temp 36.8
Check out the comments on this case here.
The initial ECG is below:
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| Click to enlarge |
Rate:
- Atrial rate ~72 bpm
- Ventricular rate 30 bpm
- Complete heart block
- Ventricular escape rhythm
- Normal
- QRS - Prolonged (140ms)
- QT - 660ms
- ST Elevation leads V2-3
- Nil ST depression
Additional:
- Right bundle branch block
- Deep T Inversion leads II, III, aVF, V1-6
- Terminal positive deflection leads V2-6
Interpretation:
- Post arrest ECG
- Complete heart block
- Marked T-wave inversion with differentials including:
- Ischaemia / Infarction
- Raised ICP
- 'Rollercoaster T-wave' and QT prolongation
- Check out this excellent case of the same by Amal Mattu here
- Cardiomyopathy
- Acid/base or electrolyte disturbance
- ? Related to DC cardioversion this can cause voltage and ST segment changes but I don't know if it causes T-wave changes
What happened ?
The patient was kept intubated and sedated. Transcutaneous pacing was commenced and iv adrenaline infusion commenced to maintain BP / MAP. Cardiology services were urgently contacted and transvenous pacing was commenced and the patient transferred for angiography and CT head.
We will continue this case next week with another ECG and the clinical conclusion of the case.
References / Further Reading
Life in the Fast Lane
Emergency ECG Video of the Week - Amal Mattu
Textbook
- Chan TC, Brady WJ, Harrigan RA, Ornato JP, Rosen P. ECG in Emergency Medicine and Acute Care. Elsevier Mosby 2005.
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