Click to enlarge |
- 156 bpm
- Regular
- Atrial activity very difficult to see
- Potential P wave visible in lead I just after T wave
- Very low voltage
- Not always appreciable
- Normal
- QRS - Normal
- Inferior ST depression
- T waves broad in leads II, III, aVF, V3-6
Interpretation:
Challenging ECG in terms of the rhythm, three possible DDx:
- Sinus tachycardia
- Atrial tachycardia
- Atrial flutter 2:1 block
Below is the rhythm strip with some of the possible atrial complexes highlights with a red square.
Click to enlarge |
- Alter paper speed, gain and rhythm strip lead
- Use a Lewis lead configuration
- Treat the patient - Sx treatment, seek and treat potential causes, consider adenosine
Lewis Lead
The Lewis lead configuration was first described in 1931 and uses a modified lead placement to assist in the identification of atrial activity.
You can read more about the Lewis lead and how to perform it in the links below:
- Bakker AL, Nijkerk G, Groenemeijer BE, Waalewijn RA, Koomen EM, Braam RL, Wellens HJ.The Lewis lead: making recognition of P waves easy during wide QRS complex tachycardia.Circulation. 2009 Jun 23;119(24):e592-3.
- EMCritWee - The Lewis Lead
- Dr Smith's ECG Blog - Wide Complex Tachycardia: Lewis Leads Do Not Differentiate VT from SVT with Aberrancy
Life in the Fast Lane
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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