The patient:  This ECG is from an 87-year-old man who was transported to the Emergency Department by paramedics. His chief complaint, as reported by caregivers, was lethargy, fever, and a declining mental status.  He appeared tired and slightly confused, and was normotensive.

The ECG:  There are a rhythm strip with two leads, II and III, and also a standard 12-lead ECG. The RHYTHM STRIP shows a tachycardiac rhythm that slows very slightly toward the end.  The rate is around 107 bpm, with an R to R interval of approximately 543 ms in the earlier, regular portion.  There are regular P waves present, all followed by QRS complexes.  Most of the QRS complexes are normal width, but the 2^nd, 5^th, and 8^th are slightly wide at 130 ms, or .13 seconds.

These wider QRS complexes represent aberrant conduction with LBBB occurring intermittently.  Aberrant conduction often occurs due to a faster heart rate, but the only clue here is the intermittent conduction disturbance seems to disappear when the rate slows very slightly.  It is hard to determine mechanism of aberrant conduction when we have only a ten-second rhythm strip.

The 12-LEAD ECG  has essentially the same rate and rhythm, except all the beats in the first ¾ of the ECG are conducted aberrantly, in a LEFT BUNDLE BRANCH BLOCK pattern.  This indicates that the LBB is refractory at this time.  Beat No. 15 is premature (PAC).  The pause after the PAC allows the left bundle branch to repolarize, conducting one single beat normally.

The Patient   A 64-year-old woman has called 911 because she has chest discomfort radiating to her left arm, palpitations, weakness, and a headache.  She had a valve replacement (we do not know which valve) two weeks ago and has a healing incision over her sternum.  She is found sitting in a chair, pale, cool, and diaphoretic. Her blood pressure is 94/palp.  Her pulse rate is 196 bpm and weak. She is afebrile.

ECG #1   This ECG shows a wide-complex tachycardia at 196 bpm.  The QRS complexes are .132 seconds in duration, per the ECG machine. The rate is too fast to appreciate whether there are P waves present.  We did not see the onset of the tachycardia, but with a rate this fast and regular, it is most likely a reentrant rhythm, rather than sinus tachycardia.  An abrupt onset of the rhythm would point to a diagnosis of a reentrant rhythm, either ventricular tachycardia (VT) or paroxysmal supraventricular tachycardia (PSVT). 

There is an important rule in emergency medical care:  a wide-complex tachycardia should be treated as VT until and unless it is proven to be something else.  The most likely alternate interpretation is PSVT with aberrant conduction, which usually takes the form of left or right bundle branch block. Fortunately, the paramedics on this call have a protocol for treating WCT that includes electrical cardioversion for the unstable patient, and amiodarone for the stable patient.  This protocol serves both possibilities, VT and PSVT, well.  The patient’s perfusion status and BP made her borderline in this determination, but she was alert and oriented, so the paramedics opted for administering the amiodarone while they prepared to electrically cardiovert.

The Patient:  This ECG was taken from a 73-year-old man with a history of heart failure with preserved ejection fraction, severe left ventricular hypertrophy, Type II diabetes, and stage 4 chronic kidney disease.  He also suffered deep vein thrombosis and is on anticoagulation.  He has a recent diagnosis of IgA myeloma.  He presented with a complaint of nausea and vomiting and was found to have a worsening of acute kidney infection.  There was suspicion of renal and cardiac amyloidosis, but the patient refused biopsy to confirm this.  He was started on chemotherapy for multiple myeloma and will be followed as an outpatient.

The ECG:  The rhythm is sinus at around 60 bpm, although the rate varies a little at the beginning of the strip.  The QRS complex is wide at .12 seconds, or 120 ms., representing interventricular conduction delay (IVCD).  The PR interval is .32 seconds, or 320 ms. This constitutes first-degree AV block.  There is left axis deviation in the frontal plane and poor R wave progression in the horizontal plane.