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<\/a><\/p>\nFirst Glance:<\/strong><\/p>\n From across the room it looks like a regular wide complex tachycardia at ~150bpm.<\/p>\n Discussion:<\/strong><\/p>\n The first thing that springs to mind is whether this is VT. Sure- 150bpm is a fair rate for VT, and we do have regular but unusual-appearing QRS complexes \u00a0(more like rsr’S’ complexes) that are over 120ms, and we do have an unusual axis for what the machine claims is lead II. However- it doesn’t feel obvious. I see regular positive deflections before the large S waves that look like atrial depolarizations with a PR interval of ~110-120 ms. These are most apparent in the first few beats of the strip, and the last 11 beats.<\/p>\n You could argue that those positive deflections are not atrial waves, but actually part of the T wave. I can not definitively say that is not the case from this strip, but it seemed unlikely due to the morphology. If those were<\/em> T waves, then it is possible that the unusual morphology of the QRS is actually due to retrograde P waves superimposed on the start of the QRS as would be seen in a junctional tachycardia. Again- can’t rule it out.<\/p>\n Further circumstantial evidence that those positive deflections are atrial waves are that the atrial axis is appropriate for lead II.<\/p>\n Look at another strip from the same patient, and see if it changes your mind: Here we can see the same strip, but with two identical beats that look like PVCs. Now I am less confident still that this is not VT. Look at the supposed P waves tracking through in magenta. Let us call these the ‘X’ waves for now. There is a normal X wave before<\/em> every QRS, but you could also say there is a normal X wave after<\/em> every QRS. That’s no help.<\/p>\n But with this new strip we can now see that these alternative beats have broken up the rhythm. Just before the wide ?ectopic beat there is a normal-appearing X wave. If this was sinus tach and the X waves were P waves, then this would make sense. The atria are just humming along like normal, and a PVC just fired in early.<\/p>\n However, when we look after<\/em> the ectopic beat, we do not see a normal X wave before the next QRS (we would expect a positive ‘X’ spike where the orange triangles are if these are P waves). Does this mean the X waves are T waves? This would push us more towards junctional tachycardia with aberrancy, or VT.<\/p>\n Or wait, if you consider that this is a tachycardia at 150 bpm, should we be considering that constant imitator of all arrhythmias: atrial flutter? what if the X waves are flutter waves, and the unusual morphology seen in the QRS complex is actually due to a 2:1 flutter wave\/QRS superimposition? If we track out the X waves as if this was flutter we see this:<\/p>\n Final Impression?<\/strong><\/p>\n Regular wide-complex rhythm at 150 bpm with a couple monomorphic likely ventricular beats.<\/p>\n Management implications:<\/strong><\/p>\n Compare to prior EKGs to see old morphology. Check lead placement.\u00a0Attention to a really pristine 12L with a clean baseline would probably crack this case. Adenosine might reveal the underlying atrial rhythm, and synced shocks would be indicated if this was a new rhythm in a hemodynamically unstable patient.<\/p>\n \u00a0The Take-home Point:<\/strong><\/p>\n Often you can not make a firm rhythm\u00a0interpretation\u00a0on 15 seconds of tele monitoring. Surprise!<\/p>\n <\/p>\n <\/p>\n wide complex tachycardia First Glance: From across the room it looks like a regular wide complex tachycardia at ~150bpm. Discussion: The first thing that springs to mind is whether this is VT. Sure- 150bpm is a fair rate for VT, and we do have regular but unusual-appearing QRS complexes \u00a0(more like rsr’S’ complexes) that are …read more<\/a><\/p>\n","protected":false},"author":1,"featured_media":0,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[2],"tags":[5],"class_list":["post-95","post","type-post","status-publish","format-standard","hentry","category-cases","tag-3star"],"_links":{"self":[{"href":"https:\/\/www.electricant.net\/ekg\/wp-json\/wp\/v2\/posts\/95","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/www.electricant.net\/ekg\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/www.electricant.net\/ekg\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/www.electricant.net\/ekg\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/www.electricant.net\/ekg\/wp-json\/wp\/v2\/comments?post=95"}],"version-history":[{"count":22,"href":"https:\/\/www.electricant.net\/ekg\/wp-json\/wp\/v2\/posts\/95\/revisions"}],"predecessor-version":[{"id":1729,"href":"https:\/\/www.electricant.net\/ekg\/wp-json\/wp\/v2\/posts\/95\/revisions\/1729"}],"wp:attachment":[{"href":"https:\/\/www.electricant.net\/ekg\/wp-json\/wp\/v2\/media?parent=95"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/www.electricant.net\/ekg\/wp-json\/wp\/v2\/categories?post=95"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/www.electricant.net\/ekg\/wp-json\/wp\/v2\/tags?post=95"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}<\/p>\n
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\nWhile it is impossible to be definitive with this strip, I can convince myself that the slightly-higher-than-300 bpm X waves continue through the ectopic beat and continue with no pause in the underlying X rhythm. It’s a possibility, then. So much uncertainty!!<\/p>\n\u00a0<\/em>Three star strip. Devious stuff.<\/em><\/p>\n—> see the next strip<\/a><\/h1>\n","protected":false},"excerpt":{"rendered":"