ECG Guru - Instructor Resources - WCT https://www.ecgguru.com/ecg/wct en Wide Complex Tachycardia https://www.ecgguru.com/ecg/wide-complex-tachycardia-4 <div class="field field-name-field-ecg field-type-image field-label-hidden"><div class="field-items"><div class="field-item even"><a href="/ecg/wide-complex-tachycardia-4"><img typeof="foaf:Image" src="https://www.ecgguru.com/sites/default/files/WCT%201034.jpg" width="1800" height="667" alt="" /></a></div><div class="field-item odd"><a href="/ecg/wide-complex-tachycardia-4"><img typeof="foaf:Image" src="https://www.ecgguru.com/sites/default/files/LBBB%201041%20cropped.jpg" width="1800" height="648" alt="" /></a></div></div></div><div class="field field-name-field-ecg-interpretation field-type-text-long field-label-hidden"><div class="field-items"><div class="field-item even"><p class="MsoNormal"><strong><span style="color: #00b050;">The Patient</span></strong><span style="color: #00b050;"><span style="mso-spacerun: yes;">&nbsp;&nbsp; </span></span>A 64-year-old woman has called 911 because she has chest discomfort radiating to her left arm, palpitations, weakness, and a headache.<span style="mso-spacerun: yes;">&nbsp; </span>She had a valve replacement (we do not know which valve) two weeks ago and has a healing incision over her sternum.<span style="mso-spacerun: yes;">&nbsp; </span>She is found sitting in a chair, pale, cool, and diaphoretic. Her blood pressure is 94/palp.<span style="mso-spacerun: yes;">&nbsp; </span>Her pulse rate is 196 bpm and weak. She is afebrile.</p><p class="MsoNormal"><strong><span style="color: #00b050;">ECG #1<span style="mso-spacerun: yes;">&nbsp;&nbsp; </span></span></strong>This ECG shows a <strong>wide-complex tachycardia</strong> at 196 bpm.<span style="mso-spacerun: yes;">&nbsp; </span>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.<span style="mso-spacerun: yes;">&nbsp; </span>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. <span style="mso-spacerun: yes;">&nbsp;</span>An abrupt onset of the rhythm would point to a diagnosis of a reentrant rhythm, either ventricular tachycardia (VT) or paroxysmal supraventricular tachycardia (PSVT).<span style="mso-spacerun: yes;">&nbsp; </span></p><p class="MsoNormal">There is an important rule in emergency medical care:<span style="mso-spacerun: yes;">&nbsp; </span>a wide-complex tachycardia should be <strong>treated as</strong> <strong>VT until and unless it is proven to be something else</strong>.<span style="mso-spacerun: yes;">&nbsp; </span>The most likely alternate interpretation is PSVT with aberrant conduction, which usually takes the form of <strong>left or right bundle branch block</strong>. 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.<span style="mso-spacerun: yes;">&nbsp; </span>This protocol serves both possibilities, VT and PSVT, well.<span style="mso-spacerun: yes;">&nbsp; </span>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.</p><p class="MsoNormal">An interesting finding of this ECG is that the pattern for <strong>LEFT BUNDLE BRANCH BLOCK</strong> is present.<span style="mso-spacerun: yes;">&nbsp; </span>The criteria for LBBB is:<span style="mso-spacerun: yes;">&nbsp; </span>supraventricular rhythm, wide QRS, negative QRS in V1 and positive QRS in Leads I and V6.<span style="mso-spacerun: yes;">&nbsp; </span>Without visible P waves, we cannot prove that this is a supraventricular rhythm, but this looks like LBBB.<span style="mso-spacerun: yes;">&nbsp; </span>There are ST changes that we normally associate with LBBB – <strong>discordant ST segments</strong>. That is, there is ST elevation in leads with negative QRS complexes and ST depression in leads with positive ST segments. For further information regarding evaluating ST segments for M.I. when there are discordant ST changes, I would refer you to <a href="https://journalfeed.org/article-a-day/2019/enhancing-sgarbossa-criteria-for-stemi">Dr. Steven Smith’s, et al, modification of Sgarbossa’s Criteria.</a></p><p class="MsoNormal"><strong><span style="color: #00b050;">ECG #2</span></strong><span style="color: #00b050;"><span style="mso-spacerun: yes;">&nbsp;&nbsp; </span></span>Approximately 7 minutes later, the rhythm converted to sinus rhythm at 100 bpm.<span style="mso-spacerun: yes;">&nbsp; </span>When the rate changed, P waves became quite obvious, and the QRS complexes did not change.<span style="mso-spacerun: yes;">&nbsp; </span>She now has <strong>sinus rhythm with LEFT BUNDLE BRANCH BLOCK</strong>, proving that the faster rhythm was also LBBB, rather than VT.<span style="mso-spacerun: yes;">&nbsp; </span>She also meets voltage criteria for left ventricular hypertrophy, which causes ST changes similar to those caused by LBBB. <span style="mso-spacerun: yes;">&nbsp;</span>At the time of conversion, her BP became 130/P and her skin regained normal color and temperature, without diaphoresis.<span style="mso-spacerun: yes;">&nbsp; </span>Her subjective symptoms improved.<span style="mso-spacerun: yes;">&nbsp; </span>She was maintained on the Amiodarone drip for the short transport to the hospital.&nbsp; It is possible that this is a rate-dependent bundle branch block, as the sinus rate is around 100 bpm, and the rhythm would need to be reevaluated when she regains a slower rate.</p><p class="MsoNormal">This case is a good endorsement for initial treatment protocols for wide-complex tachycardia that are effective for both VT and PSVT.</p></div></div></div><div class="field field-name-field-rate-this-content field-type-fivestar field-label-above"><div class="field-label">Rate this content:&nbsp;</div><div class="field-items"><div class="field-item even"><form class="fivestar-widget" action="/taxonomy/term/727/feed" method="post" id="fivestar-custom-widget" accept-charset="UTF-8"><div><div class="clearfix fivestar-average-text fivestar-average-stars fivestar-form-item fivestar-hearts"><div class="form-item form-type-fivestar form-item-vote"> <div class="form-item form-type-select form-item-vote"> <select id="edit-vote--2" name="vote" class="form-select"><option value="-">Select rating</option><option value="20">Give Wide Complex Tachycardia 1/5</option><option value="40">Give Wide Complex Tachycardia 2/5</option><option value="60">Give Wide Complex Tachycardia 3/5</option><option value="80" selected="selected">Give Wide Complex Tachycardia 4/5</option><option value="100">Give Wide Complex Tachycardia 5/5</option></select> <div class="description"><div class="fivestar-summary fivestar-summary-average-count"><span class="average-rating">Average: <span >3.2</span></span> <span class="total-votes">(<span >57</span> votes)</span></div></div> </div> </div> </div><input class="fivestar-submit form-submit" type="submit" id="edit-fivestar-submit" name="op" value="Rate" /><input type="hidden" name="form_build_id" value="form-NCwAkpvQj0jTe5fawrKppCwcUbx0_kjCbiI_MmdkYOk" /> <input type="hidden" name="form_id" value="fivestar_custom_widget" /> </div></form></div></div></div><div class="field field-name-field-taxonomy field-type-taxonomy-term-reference field-label-above"><div class="field-label">Related Terms:&nbsp;</div><div class="field-items"><div class="field-item even"><a href="/ecg/wide-complex-tachycardia" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Wide complex tachycardia</a></div><div class="field-item odd"><a href="/ecg/wct" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">WCT</a></div><div class="field-item even"><a href="/ecg/left-bundle-branch-block-0" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Left bundle branch block</a></div><div class="field-item odd"><a href="/ecg/lbbb" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">LBBB</a></div></div></div><ul class="links inline"><li class="addtoany first last"><span><span class="a2a_kit a2a_target addtoany_list" id="da2a_1"> <a class="a2a_dd addtoany_share_save" href="https://www.addtoany.com/share#url=https%3A%2F%2Fwww.ecgguru.com%2Fecg%2Fwide-complex-tachycardia-4&amp;title=Wide%20Complex%20Tachycardia"><img src="/sites/all/modules/addtoany/images/share_save_256_24.png" width="256" height="24" alt="Share"/></a> </span> <script type="text/javascript"> <!--//--><![CDATA[//><!-- if(window.da2a)da2a.script_load(); //--><!]]> </script></span></li> </ul> Fri, 09 Oct 2020 20:30:14 +0000 Dawn 792 at https://www.ecgguru.com https://www.ecgguru.com/ecg/wide-complex-tachycardia-4#comments Wide Complex Tachycardia https://www.ecgguru.com/ecg/wide-complex-tachycardia-3 <div class="field field-name-field-ecg field-type-image field-label-hidden"><div class="field-items"><div class="field-item even"><a href="/ecg/wide-complex-tachycardia-3"><img typeof="foaf:Image" src="https://www.ecgguru.com/sites/default/files/WCT121%20JL_0.jpg" width="1808" height="1012" alt="" /></a></div></div></div><div class="field field-name-field-ecg-interpretation field-type-text-long field-label-hidden"><div class="field-items"><div class="field-item even"><p class="MsoNormal"><strong><span style="color: #00b050;">The Patient:</span></strong><span style="color: #00b050;"><span style="mso-spacerun: yes;">&nbsp;&nbsp; </span></span>The details of this patient’s complaints and presentation are lost, but we know he was a 66-year-old man who was being treated in the Emergency Department. His rhythm went from sinus tachycardia with non-respiratory sinus arrhythmia to multi-focal atrial tachycardia (MAT) to wide-complex tachycardia. The WCT lasted a few minutes and spontaneously converted to an irregular sinus rhythm.</p><p class="MsoNormal"><strong><span style="color: #00b050;">Wide-complex tachycardia:<span style="mso-spacerun: yes;">&nbsp; </span>Ventricular tachycardia or aberrantly-conducted supraventricular tachycardia?<span style="mso-spacerun: yes;">&nbsp; </span></span></strong>When confronted with a wide-complex tachycardia, it can be very difficult to determine whether the rhythm is ventricular or supraventricular with aberrant conduction, such as bundle branch block. The patient’s history and presentation may offer clues.<span style="mso-spacerun: yes;">&nbsp; </span>It is very important, if the patient’s hemodynamic status is at all compromised (they are “symptomatic”), the WCT should be treated as VENTRICULAR TACHYCARDIA until proven otherwise. <span style="mso-spacerun: yes;">&nbsp;</span></p><p class="MsoNormal">There have been many lists made of the ECG features that favor a diagnosis of ventricular tachycardia. Here are two such lists:<span style="mso-spacerun: yes;">&nbsp; </span><a href="https://litfl.coom/vt-versus-svt-ecg-library/">Life In The Fast Lane</a>, and <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4040878/">National Institute of Health</a>.</p><p class="MsoNormal"><strong><span style="color: #00b050;">The ECG:<span style="mso-spacerun: yes;">&nbsp; </span></span></strong>This ECG shows a regular, fast, wide-QRS rhythm.<span style="mso-spacerun: yes;">&nbsp; </span>The rate is 233 bpm.<span style="mso-spacerun: yes;">&nbsp; </span>It had a sudden onset and sudden offset (not shown on this ECG), and the rhythm lasted about 3-5 minutes. The patient felt the change in rate, but did not become hypotensive or unstable.<span style="mso-spacerun: yes;">&nbsp; </span>Some features that relate directly to the most commonly-referenced VT vs. SVT charts are:</p><p class="MsoListParagraphCxSpFirst" style="text-indent: -.25in; mso-list: l0 level1 lfo1;"><!--[if !supportLists]--><span style="mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin;"><span style="mso-list: Ignore;">1)<span style="font: 7.0pt 'Times New Roman';">&nbsp;&nbsp;&nbsp;&nbsp; </span></span></span><!--[endif]-->The morphology of the QRS complexes in this ECG is indicative of <a href="https://www.ecgguru.com/ecg/left-bundle-branch-block-and-artifact">left bundle branch block</a>. V1 has a wide, negative, monomorphic QRS. Leads I and V6 have wide, positive QRSs. Aberrant conduction often takes a LBBB or RBBB pattern.</p><p class="MsoListParagraphCxSpMiddle" style="text-indent: -.25in; mso-list: l0 level1 lfo1;"><!--[if !supportLists]--><span style="mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin;"><span style="mso-list: Ignore;">2)<span style="font: 7.0pt 'Times New Roman';">&nbsp;&nbsp;&nbsp;&nbsp; </span></span></span><!--[endif]-->The QRS is difficult to measure due to unclear start and stop points in all leads, but the overall width appears to be about 120 ms (.12 sec).<span style="mso-spacerun: yes;">&nbsp; </span>VT tends to have very wide QRS complexes, greater than 160 ms.</p><p class="MsoListParagraphCxSpMiddle" style="text-indent: -.25in; mso-list: l0 level1 lfo1;"><!--[if !supportLists]--><span style="mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin;"><span style="mso-list: Ignore;">3)<span style="font: 7.0pt 'Times New Roman';">&nbsp;&nbsp;&nbsp;&nbsp; </span></span></span><!--[endif]-->This ECG’s axis is about -30 degrees, and aVR is negative. This indicates an axis just a little to the left, within normal range.<span style="mso-spacerun: yes;">&nbsp; </span>An extremely abnormal axis, between <span style="text-decoration: underline;">+</span>180 degrees and -90 degrees (called Northwest axis) almost always indicates VT. Both SVT and VT can have normal axes.</p><p class="MsoListParagraphCxSpMiddle" style="text-indent: -.25in; mso-list: l0 level1 lfo1;"><!--[if !supportLists]--><span style="mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin;"><span style="mso-list: Ignore;">4)<span style="font: 7.0pt 'Times New Roman';">&nbsp;&nbsp;&nbsp;&nbsp; </span></span></span><!--[endif]-->The precordial leads V2 through V6 have RS patterns. <span style="mso-spacerun: yes;">&nbsp;</span>Any precordial lead havig an RS pattern favors the diagnosis of SVT. <span style="mso-spacerun: yes;">&nbsp;</span></p><p class="MsoListParagraphCxSpMiddle" style="text-indent: -.25in; mso-list: l0 level1 lfo1;"><!--[if !supportLists]--><span style="mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin;"><span style="mso-list: Ignore;">5)<span style="font: 7.0pt 'Times New Roman';">&nbsp;&nbsp;&nbsp;&nbsp; </span></span></span><!--[endif]-->The precordial leads transition from negative in V1 to positive in V6, with a somewhat late transition in V5.<span style="mso-spacerun: yes;">&nbsp; </span>Precordial concordance (all precordial QRS complexes in the same direction) favors the diagnosis of VT.<span style="mso-spacerun: yes;">&nbsp; </span>A negative QRS in V6 also favors the diagnosis of VT.</p><p class="MsoListParagraphCxSpLast" style="text-indent: -.25in; mso-list: l0 level1 lfo1;"><!--[if !supportLists]--><span style="mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin;"><span style="mso-list: Ignore;">6)<span style="font: 7.0pt 'Times New Roman';">&nbsp;&nbsp;&nbsp;&nbsp; </span></span></span><!--[endif]-->I see no AV dissociation (P waves that are not associated with the QRS complexes).<span style="mso-spacerun: yes;">&nbsp; </span>If present, AV dissociation guarantees a diagnosis of VT.</p><p class="MsoNormal">While the actual differentiation between SVT and VT can be much more complicated than this, I feel that this patient has a very good chance of having SVT with LBBB that is probably rate-related.<span style="mso-spacerun: yes;">&nbsp; </span>His rhythm spontaneously converted to an irregular sinus rhythm.<span style="mso-spacerun: yes;">&nbsp; </span>If this tachycardia recurs or persists, an electrophysiological study could be needed to find the cause and confirm the diagnosis.</p><p class="MsoNormal">I would love to know what you think about this rhythm.<span style="mso-spacerun: yes;">&nbsp; </span>In the Basic Rhythms section, I will post a strip of his multifocal atrial tachycardia.</p></div></div></div><div class="field field-name-field-rate-this-content field-type-fivestar field-label-above"><div class="field-label">Rate this content:&nbsp;</div><div class="field-items"><div class="field-item even"><form class="fivestar-widget" action="/taxonomy/term/727/feed" method="post" id="fivestar-custom-widget--2" accept-charset="UTF-8"><div><div class="clearfix fivestar-average-text fivestar-average-stars fivestar-form-item fivestar-hearts"><div class="form-item form-type-fivestar form-item-vote"> <div class="form-item form-type-select form-item-vote"> <select id="edit-vote--4" name="vote" class="form-select"><option value="-">Select rating</option><option value="20">Give Wide Complex Tachycardia 1/5</option><option value="40">Give Wide Complex Tachycardia 2/5</option><option value="60" selected="selected">Give Wide Complex Tachycardia 3/5</option><option value="80">Give Wide Complex Tachycardia 4/5</option><option value="100">Give Wide Complex Tachycardia 5/5</option></select> <div class="description"><div class="fivestar-summary fivestar-summary-average-count"><span class="average-rating">Average: <span >3</span></span> <span class="total-votes">(<span >21</span> votes)</span></div></div> </div> </div> </div><input class="fivestar-submit form-submit" type="submit" id="edit-fivestar-submit--2" name="op" value="Rate" /><input type="hidden" name="form_build_id" value="form-PmncAalu7nc9Nk6YM0F4aKCFzHCBUrI4G98VY6n2Xfw" /> <input type="hidden" name="form_id" value="fivestar_custom_widget" /> </div></form></div></div></div><div class="field field-name-field-taxonomy field-type-taxonomy-term-reference field-label-above"><div class="field-label">Related Terms:&nbsp;</div><div class="field-items"><div class="field-item even"><a href="/ecg/wide-complex-tachycardia" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Wide complex tachycardia</a></div><div class="field-item odd"><a href="/ecg/wct" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">WCT</a></div><div class="field-item even"><a href="/ecg/left-bundle-branch-block-0" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Left bundle branch block</a></div><div class="field-item odd"><a href="/ecg/lbbb" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">LBBB</a></div><div class="field-item even"><a href="/ecg/ventricular-tachycardia" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Ventricular tachycardia</a></div><div class="field-item odd"><a href="/ecg/vt" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">VT</a></div></div></div><ul class="links inline"><li class="addtoany first last"><span><span class="a2a_kit a2a_target addtoany_list" id="da2a_2"> <a class="a2a_dd addtoany_share_save" href="https://www.addtoany.com/share#url=https%3A%2F%2Fwww.ecgguru.com%2Fecg%2Fwide-complex-tachycardia-3&amp;title=Wide%20Complex%20Tachycardia"><img src="/sites/all/modules/addtoany/images/share_save_256_24.png" width="256" height="24" alt="Share"/></a> </span> </span></li> </ul> Fri, 01 May 2020 22:19:23 +0000 Dawn 783 at https://www.ecgguru.com https://www.ecgguru.com/ecg/wide-complex-tachycardia-3#comments ECG Basics: Ventricular Tachycardia https://www.ecgguru.com/ecg/ecg-basics-ventricular-tachycardia-0 <div class="field field-name-field-ecg field-type-image field-label-hidden"><div class="field-items"><div class="field-item even"><a href="/ecg/ecg-basics-ventricular-tachycardia-0"><img typeof="foaf:Image" src="https://www.ecgguru.com/sites/default/files/165%20V%20Tach.jpg" width="1938" height="338" alt="" /></a></div></div></div><div class="field field-name-field-ecg-interpretation field-type-text-long field-label-hidden"><div class="field-items"><div class="field-item even"><p>V tach is identified by:&nbsp; wide QRS complexes (&gt;.12 seconds), rate faster than 100 bpm.&nbsp; In MONOMORPHIC V tach, all QRS complexes look alike.&nbsp; There are other mechanisms of wide-complex tachycardia, but they can be difficult to differentiate from a single rhythm strip.&nbsp; All WCT should be treated as V tach until proven otherwise.</p></div></div></div><div class="field field-name-field-rate-this-content field-type-fivestar field-label-above"><div class="field-label">Rate this content:&nbsp;</div><div class="field-items"><div class="field-item even"><form class="fivestar-widget" action="/taxonomy/term/727/feed" method="post" id="fivestar-custom-widget--3" accept-charset="UTF-8"><div><div class="clearfix fivestar-average-text fivestar-average-stars fivestar-form-item fivestar-hearts"><div class="form-item form-type-fivestar form-item-vote"> <div class="form-item form-type-select form-item-vote"> <select id="edit-vote--6" name="vote" class="form-select"><option value="-">Select rating</option><option value="20">Give ECG Basics: Ventricular Tachycardia 1/5</option><option value="40">Give ECG Basics: Ventricular Tachycardia 2/5</option><option value="60">Give ECG Basics: Ventricular Tachycardia 3/5</option><option value="80" selected="selected">Give ECG Basics: Ventricular Tachycardia 4/5</option><option value="100">Give ECG Basics: Ventricular Tachycardia 5/5</option></select> <div class="description"><div class="fivestar-summary fivestar-summary-average-count"><span class="average-rating">Average: <span >4</span></span> <span class="total-votes">(<span >2</span> votes)</span></div></div> </div> </div> </div><input class="fivestar-submit form-submit" type="submit" id="edit-fivestar-submit--3" name="op" value="Rate" /><input type="hidden" name="form_build_id" value="form-bOjCfJ5klR_--OWCJMwaUq44dzMTMfv_IrKT-DFO8Hw" /> <input type="hidden" name="form_id" value="fivestar_custom_widget" /> </div></form></div></div></div><div class="field field-name-field-taxonomy field-type-taxonomy-term-reference field-label-above"><div class="field-label">Related Terms:&nbsp;</div><div class="field-items"><div class="field-item even"><a href="/ecg/wide-complex-tachycardia-0" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Wide-complex tachycardia</a></div><div class="field-item odd"><a href="/ecg/wct" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">WCT</a></div><div class="field-item even"><a href="/ecg/ventricular-tachycardia" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Ventricular tachycardia</a></div><div class="field-item odd"><a href="/ecg/vt" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">VT</a></div><div class="field-item even"><a href="/ecg/rhythm-strip" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Rhythm strip</a></div><div class="field-item odd"><a href="/ecg/ecg-basics" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">ECG Basics</a></div><div class="field-item even"><a href="/ecg/basic-ecg" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Basic ECG</a></div></div></div><ul class="links inline"><li class="addtoany first last"><span><span class="a2a_kit a2a_target addtoany_list" id="da2a_3"> <a class="a2a_dd addtoany_share_save" href="https://www.addtoany.com/share#url=https%3A%2F%2Fwww.ecgguru.com%2Fecg%2Fecg-basics-ventricular-tachycardia-0&amp;title=ECG%20Basics%3A%20%20Ventricular%20Tachycardia"><img src="/sites/all/modules/addtoany/images/share_save_256_24.png" width="256" height="24" alt="Share"/></a> </span> </span></li> </ul> Wed, 20 Dec 2017 21:00:14 +0000 Dawn 749 at https://www.ecgguru.com https://www.ecgguru.com/ecg/ecg-basics-ventricular-tachycardia-0#comments Ventricular Tachycardia In A Patient With Myopathy https://www.ecgguru.com/ecg/ventricular-tachycardia-patient-myopathy <div class="field field-name-field-ecg field-type-image field-label-hidden"><div class="field-items"><div class="field-item even"><a href="/ecg/ventricular-tachycardia-patient-myopathy"><img typeof="foaf:Image" src="https://www.ecgguru.com/sites/default/files/VT.png" width="1800" height="734" alt="" /></a></div><div class="field-item odd"><a href="/ecg/ventricular-tachycardia-patient-myopathy"><img typeof="foaf:Image" src="https://www.ecgguru.com/sites/default/files/RVOT.jpg" width="1800" height="605" alt="" /></a></div></div></div><div class="field field-name-field-ecg-interpretation field-type-text-long field-label-hidden"><div class="field-items"><div class="field-item even"><p class="MsoNormal">These two ECGs are from a 77-year-old woman who was complaining of palpitations and mild shortness of breath.&nbsp; She stated a history of atrial fibrillation.&nbsp; She was alert, with a systolic BP over 120.&nbsp; At the hospital, she was found to have cardiomyopathy, resulting in global hypokinesis. She also had significant coronary artery narrowing in her left main, left anterior descending, and circumflex, which were treated with coronary artery bypass graft surgery.</p><p class="MsoNormal"><strong><span style="font-size: 12.0pt; line-height: 107%;">The first ECG </span></strong>was taken on arrival of the EMS crew at the patient’s home.&nbsp; It shows ventricular tachycardia, rate 226 bpm,&nbsp;<strong>All WCTs should be considered to be ventricular tachycardia until proven otherwise.&nbsp;&nbsp;</strong><span style="font-size: 13.008px;">While WCT can sometimes be difficult to definitively diagnose in the field, this ECG has many features which favor the diagnosis of VT, including:</span></p><p class="MsoListParagraphCxSpFirst" style="text-indent: -.25in; mso-list: l1 level1 lfo1;"><!--[if !supportLists]--><span style="font-family: Symbol; mso-fareast-font-family: Symbol; mso-bidi-font-family: Symbol;">·<span style="font-variant-numeric: normal; font-stretch: normal; font-size: 7pt; line-height: normal; font-family: 'Times New Roman';">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </span></span><!--[endif]-->An extremely wide QRS (I measure .24 sec., the machine measures .368 sec.).</p><p class="MsoListParagraphCxSpMiddle" style="text-indent: -.25in; mso-list: l1 level1 lfo1;"><!--[if !supportLists]--><span style="font-family: Symbol; mso-fareast-font-family: Symbol; mso-bidi-font-family: Symbol;">·<span style="font-variant-numeric: normal; font-stretch: normal; font-size: 7pt; line-height: normal; font-family: 'Times New Roman';">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </span></span><!--[endif]-->An extreme left axis deviation (aVF is all negative).</p><p class="MsoListParagraphCxSpMiddle" style="text-indent: -.25in; mso-list: l1 level1 lfo1;"><!--[if !supportLists]--><span style="font-family: Symbol; mso-fareast-font-family: Symbol; mso-bidi-font-family: Symbol;">·<span style="font-variant-numeric: normal; font-stretch: normal; font-size: 7pt; line-height: normal; font-family: 'Times New Roman';">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </span></span><!--[endif]-->Absence of either RBBB or LBBB pattern, with a&nbsp; completely negative QRS in V6.&nbsp; This all negative V6 places the liklihood of the rhythm being VT to about 100%.</p><p class="MsoListParagraphCxSpMiddle" style="text-indent: -.25in; mso-list: l1 level1 lfo1;"><!--[if !supportLists]--><span style="font-family: Symbol; mso-fareast-font-family: Symbol; mso-bidi-font-family: Symbol;">·<span style="font-variant-numeric: normal; font-stretch: normal; font-size: 7pt; line-height: normal; font-family: 'Times New Roman';">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </span></span><!--[endif]-->No obvious P waves (although the machine gives a P wave axis and a PR interval).</p><p class="MsoListParagraphCxSpMiddle" style="text-indent: -.25in; mso-list: l1 level1 lfo1;"><!--[if !supportLists]--><span style="font-family: Symbol; mso-fareast-font-family: Symbol; mso-bidi-font-family: Symbol;">·<span style="font-variant-numeric: normal; font-stretch: normal; font-size: 7pt; line-height: normal; font-family: 'Times New Roman';">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </span></span><!--[endif]-->No RS complexes seen in the precordial leads (V1-V6).</p><p class="MsoListParagraphCxSpMiddle" style="text-indent: -.25in; mso-list: l1 level1 lfo1;"><span style="font-family: Symbol; mso-fareast-font-family: Symbol; mso-bidi-font-family: Symbol;">·<span style="font-variant-numeric: normal; font-stretch: normal; font-size: 7pt; line-height: normal; font-family: 'Times New Roman';">&nbsp; &nbsp;</span></span><span style="font-family: Symbol; mso-fareast-font-family: Symbol; mso-bidi-font-family: Symbol;"><span style="font-variant-numeric: normal; font-stretch: normal; font-size: 7pt; line-height: normal; font-family: 'Times New Roman';">&nbsp; &nbsp;</span></span></p><p class="MsoListParagraphCxSpMiddle" style="text-indent: -.25in; mso-list: l1 level1 lfo1;"><strong style="text-indent: -0.25in; font-size: 13.008px;"><span style="font-size: 12.0pt; line-height: 107%;">The second ECG </span></strong><span style="text-indent: -0.25in; font-size: 13.008px;">was taken three minutes later, with no change in the patient’s symptoms.&nbsp; (The age is different because a different crew took the tracing, but it was confirmed to be from the same patient.) The heart rate is now 239 bpm, and she still has a wide-complex tachycardia.&nbsp; The morphology of the QRS complexes has changed.&nbsp; This now has the pattern of r</span><span style="text-indent: -0.25in; font-size: 13.008px;">ight ventricular outflow tract ventricular tachycardia (RVOT).</span><strong style="text-indent: -0.25in; font-size: 13.008px;"> &nbsp;</strong><span style="text-indent: -0.25in; font-size: 13.008px;">RVOT</span><strong style="text-indent: -0.25in; font-size: 13.008px;"> </strong><span style="text-indent: -0.25in; font-size: 13.008px;">originates from the area around the outflow tract of the RV, or from the tricuspid annulus.&nbsp;</span><span style="font-size: 13.008px;">&nbsp;</span></p><p class="MsoNormal">Characteristics of RVOT include:</p><p class="MsoListParagraphCxSpFirst" style="text-indent: -.25in; mso-list: l0 level1 lfo2;"><!--[if !supportLists]--><span style="font-family: Symbol; mso-fareast-font-family: Symbol; mso-bidi-font-family: Symbol;">·<span style="font-variant-numeric: normal; font-stretch: normal; font-size: 7pt; line-height: normal; font-family: 'Times New Roman';">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </span></span><!--[endif]-->Heart rate &gt; 100 bpm</p><p class="MsoListParagraphCxSpMiddle" style="text-indent: -.25in; mso-list: l0 level1 lfo2;"><!--[if !supportLists]--><span style="font-family: Symbol; mso-fareast-font-family: Symbol; mso-bidi-font-family: Symbol;">·<span style="font-variant-numeric: normal; font-stretch: normal; font-size: 7pt; line-height: normal; font-family: 'Times New Roman';">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </span></span><!--[endif]-->Atrioventricular dissociation</p><p class="MsoListParagraphCxSpMiddle" style="text-indent: -.25in; mso-list: l0 level1 lfo2;"><!--[if !supportLists]--><span style="font-family: Symbol; mso-fareast-font-family: Symbol; mso-bidi-font-family: Symbol;">·<span style="font-variant-numeric: normal; font-stretch: normal; font-size: 7pt; line-height: normal; font-family: 'Times New Roman';">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </span></span><!--[endif]-->QRS width &gt; .12 seconds.</p><p class="MsoListParagraphCxSpMiddle" style="text-indent: -.25in; mso-list: l0 level1 lfo2;"><!--[if !supportLists]--><span style="font-family: Symbol; mso-fareast-font-family: Symbol; mso-bidi-font-family: Symbol;">·<span style="font-variant-numeric: normal; font-stretch: normal; font-size: 7pt; line-height: normal; font-family: 'Times New Roman';">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </span></span><!--[endif]-->Left bundle branch block morphology</p><p class="MsoListParagraphCxSpLast" style="text-indent: -.25in; mso-list: l0 level1 lfo2;"><!--[if !supportLists]--><span style="font-family: Symbol; mso-fareast-font-family: Symbol; mso-bidi-font-family: Symbol;">·<span style="font-variant-numeric: normal; font-stretch: normal; font-size: 7pt; line-height: normal; font-family: 'Times New Roman';">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </span></span><!--[endif]-->Inferior / rightward axis (around +90 degrees)</p><p class="MsoListParagraphCxSpLast" style="text-indent: -.25in; mso-list: l0 level1 lfo2;"><span style="text-indent: -0.25in; font-size: 13.008px;">RVOT often responds to adenosine.</span></p><p class="MsoNormal">RVOT usually occurs in the absence of structural heart disease, or occasionally in the setting of arrhythmogenic right ventricular dysplasia/cardiomyopathy.&nbsp; This patient certainly was found to have serious heart disease, making the diagnosis of idiopathic RVOT unlikely, and adenosine not recommended.&nbsp;</p><p class="MsoNormal">Myopathy as severe as this patient’s frequently causes ventricular ectopy and ventricular tachycardia, which can add to the severe cardiac output issues the patient faces.<span style="font-size: 13.008px;">&nbsp;</span></p><p class="MsoNormal">References: <a href="http://ecg-interpretation.blogspot.com/2012/01/ecg-interpretation-review-35-sct-vt.html/">http://ecg-interpretation.blogspot.com/2012/01/ecg-interpretation-review-35-sct-vt.html/</a> ; <a href="https://lifeinthefastlane.com/collections/">https://lifeinthefastlane.com/collections/</a> ;&nbsp; <a href="https://stanfordhealthcare.org/medical-conditions/blood-heart-circulation/ventricular-tachycardia/types/right-ventricular-outflow-tract-tachycardia.html">https://stanfordhealthcare.org/medical-conditions/blood-heart-circulation/ventricular-tachycardia/types/right-ventricular-outflow-tract-tachycardia.html</a></p></div></div></div><div class="field field-name-field-rate-this-content field-type-fivestar field-label-above"><div class="field-label">Rate this content:&nbsp;</div><div class="field-items"><div class="field-item even"><form class="fivestar-widget" action="/taxonomy/term/727/feed" method="post" id="fivestar-custom-widget--4" accept-charset="UTF-8"><div><div class="clearfix fivestar-average-text fivestar-average-stars fivestar-form-item fivestar-hearts"><div class="form-item form-type-fivestar form-item-vote"> <div class="form-item form-type-select form-item-vote"> <select id="edit-vote--8" name="vote" class="form-select"><option value="-">Select rating</option><option value="20">Give Ventricular Tachycardia In A Patient With Myopathy 1/5</option><option value="40">Give Ventricular Tachycardia In A Patient With Myopathy 2/5</option><option value="60">Give Ventricular Tachycardia In A Patient With Myopathy 3/5</option><option value="80" selected="selected">Give Ventricular Tachycardia In A Patient With Myopathy 4/5</option><option value="100">Give Ventricular Tachycardia In A Patient With Myopathy 5/5</option></select> <div class="description"><div class="fivestar-summary fivestar-summary-average-count"><span class="average-rating">Average: <span >3.2</span></span> <span class="total-votes">(<span >5</span> votes)</span></div></div> </div> </div> </div><input class="fivestar-submit form-submit" type="submit" id="edit-fivestar-submit--4" name="op" value="Rate" /><input type="hidden" name="form_build_id" value="form-JdRA96Of-kmI6M4Cn06zAj0x2VK4otng7zTt_AQGAn0" /> <input type="hidden" name="form_id" value="fivestar_custom_widget" /> </div></form></div></div></div><div class="field field-name-field-taxonomy field-type-taxonomy-term-reference field-label-above"><div class="field-label">Related Terms:&nbsp;</div><div class="field-items"><div class="field-item even"><a href="/ecg/ventricular-tachycardia" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Ventricular tachycardia</a></div><div class="field-item odd"><a href="/ecg/vt" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">VT</a></div><div class="field-item even"><a href="/ecg/rvot" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">RVOT</a></div><div class="field-item odd"><a href="/ecg/right-ventricular-outflow-tract-tachycardia" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Right ventricular outflow tract tachycardia</a></div><div class="field-item even"><a href="/ecg/wide-complex-tachycardia" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Wide complex tachycardia</a></div><div class="field-item odd"><a href="/ecg/wct" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">WCT</a></div></div></div><ul class="links inline"><li class="addtoany first last"><span><span class="a2a_kit a2a_target addtoany_list" id="da2a_4"> <a class="a2a_dd addtoany_share_save" href="https://www.addtoany.com/share#url=https%3A%2F%2Fwww.ecgguru.com%2Fecg%2Fventricular-tachycardia-patient-myopathy&amp;title=Ventricular%20Tachycardia%20In%20A%20Patient%20With%20Myopathy"><img src="/sites/all/modules/addtoany/images/share_save_256_24.png" width="256" height="24" alt="Share"/></a> </span> </span></li> </ul> Wed, 20 Dec 2017 05:15:44 +0000 Dawn 748 at https://www.ecgguru.com https://www.ecgguru.com/ecg/ventricular-tachycardia-patient-myopathy#comments