faster than most…

the case.

a 34 year old man presents to ED with chest pain & palpitations. His symptoms came on suddenly whilst doing light exercises at the gym.

He has a past medical history of hypercholesterolaemia (on treatment) & reports occasional use of amphetamines. On arrival to the ED he is agitated & diaphoretic with a systolic blood pressure of  78 mmHg.

This is his initial 12-lead ECG…

[DDET Describe & interpret his ECG…]

Standard rate & calibration.
Incomplete ECG [V1, V3-4 & V6 missing]

• Rate.
  • ~250/min
• Rhythm.
  • Regular QRS.
  • No P-waves.
• Axis.
  • Left axis deviation.
• Intervals.
  • PR ~ n/a.
  • QRS ~ 120msec [monomorphic]
  • QTc ~ 490 msec
• Segments.
  • QRS:T wave discordance
• Other.
  • possible Fusion beat [red-circles]
  • QRS alternans.
  • Notching of every 2nd QRS [blue circles].
    • ?retrograde P waves with 2:1 AV block
    • ?feature of QRS alternans

Interpretation.
Ventricular tachycardia with unusually fast rate, ?ventricular flutter.

annotated ECG

[/DDET]

[DDET A little more on this before we progress…]

Ventricular Flutter.

• Thought to be an ‘extreme VT’.
• Rates typically exceed 200 bpm, but often 250-300 /min !!
• Associated with rapid haemodynamic compromise and progression to ventricular fibrillation

Appearance.

• Continuous sine wave configuration.
• No distinction between QRS complex, T waves or ST segments.

A tip from the LITFL crew: “the ECG looks identical when viewed upside down” !!

You be the judge …

[/DDET]

[DDET What is your approach to this patient ?]

He clearly has an unstable, broad-complex tachycardia & needs cardioversion as soon as possible.

• Resuscitation area with full cardiorespiratory monitoring [ECG, NIBP, pulse oximetry & quantitative waveform capnography]
• Defibrillator pads placed
• Sedation: cautious use to avoid hypotension
  • In this case he received 50micrograms of fentanyl & 50mg of propofol.
• Synchronised DC cardioversion at 200 joules.
• He successfully cardioverts on the first attempt (thankfully…) & his haemodynamics approach normality !!

Below are his repeat ECGs…

[/DDET]

[DDET ECG number 2…]

ECG taken immediately post-DC cardioversion.

• Sinus rhythm [Beats 3, 4 & 5] with left-ventricular ectopy [RBBB-appearance] & idioventricular rhythm.
• Marked STE in lead aVR with widespread STD
  • ?post-reversion changes
  • ?acute coronary syndrome [LMCA vs triple vessel vs proximal LAD]

[/DDET]

[DDET ECG number 3…]

ECG taken ~ 12 minutes post-DC cardioversion

• Sinus rhythm with further idioventricular rhythm.
• Ventricular couplets present [last two complexes on ECG]
  • Are these couplets significant ? Are they a cause or effect of his tachydysrhythmia ?!? (see reference 5)
• ST-segment changes have improved, but not resolved completely…

Ask yourself: would you be transporting this guy to the cath-lab with these ECGs ??

[/DDET]

[DDET The case continues…]

So our guy is taken to the Cath-lab soon after arrival to the ED….

Coronary angiogram: Normal.

Electrophysiology study: Easily inducible VT. No inducible atrial flutter.

Cardiac MRI: Biventricular dilatation & hypokinesis with inflammatory changes consistent with myopericarditis [?post-viral, ?2* to amphetamines]. An alternate diagnosis of cardiac sarcoid is suggested…

He was discharged home 5 days after the initial presentation following insertion of an AICD …..

[/DDET]

[DDET References]

1. Chan TC, Brady WJ, Harrigan RA, Ornato JP, Rosen P. ECG in Emergency Medicine and Acute Care. Elsevier Mosby 2005.
2. Durham, D., & Worthley, L. I. G. (2002). Cardiac arrhythmias: diagnosis and management. The tachycardias. Critical care and resuscitation : journal of the Australasian Academy of Critical Care Medicine, 4(1), 35–53.
3. Hudson, K. B., Brady, W. J., Chan, T. C., Pollack, M., & Harrigan, R. A. (2003). Electrocardiographic manifestations: ventricular tachycardia. The Journal of Emergency Medicine, 25(3), 303–314. doi:10.1016/S0736-4679(03)00207-5
4. Gurevitz, O., Viskin, S., Glikson, M., Ballman, K. V., Rosales, A. G., Shen, W.-K., et al. (2004). Long-term prognosis of inducible ventricular flutter: not an innocent finding. American Heart Journal, 147(4), 649–654. doi:10.1016/j.ahj.2003.11.012
5. Omar, A. R., Lee, L. C., Seow, S. C., Teo, S. G., & Poh, K. K. (2011). Managing ventricular ectopics: are ventricular ectopic beats just an annoyance? Singapore medical journal, 52(10), 707–13– quiz 714.
6. Life in the Fast Lane – Ventricular Flutter
7. thebluntdissection – broad, fast & regular…

[/DDET]

[DDET Special thanks…]

…. to Ed Burns & Adam Lee for their assistance in reviewing these ECGs !!

[/DDET]