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…
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
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 …
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…
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]
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 ??
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 …..
- Chan TC, Brady WJ, Harrigan RA, Ornato JP, Rosen P. ECG in Emergency Medicine and Acute Care. Elsevier Mosby 2005.
- 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.
- 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
- 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
- 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.
- Life in the Fast Lane – Ventricular Flutter
- thebluntdissection – broad, fast & regular…
…. to Ed Burns & Adam Lee for their assistance in reviewing these ECGs !!
Great case as always Chris. One question- synchronized cardioversion at 200 J. I would have started at 100. Your thoughts?
Thanks Victoria.
This was a case that was ‘handed down’ to me, so I can’t speak for the actual decision made at the time. I can only imagine they wanted a ‘better chance’ at success given his clinical state !!
GREAT case Chris! Given the patient’s relatively young age (34) for a wide tachycardia as fast as this (I get ~ 260/minute (as 1/4 the rate ~ 65/min) – I included AFlutter in my initial differential of a rhythm that you obviously need to consider as VT until proven otherwise. I take EP report of “no inducible AFlutter” as support that your EP cardiologists thought the same. Post-conversion tracings showing LOTS of ST depression initially AND lots of PVCs (with some of the PVCs on ECG #3 having the same lateral upright and inferior all negative configuration) lead me away from AFlutter – but I do think that should at least be considered in the initial differential diagnosis given the regular WCT (Wide-Complex Tachycardia) at 260/minute – in which case WPW with 1:1 AV conduction could be the cause. All that said – these are academic issues in the emergency situation because immediate cardioversion is the definite intervention of choice on presentation with this rhythm (systolic BP = 78 mmHg). Almost regardless of what this rhythm is – EP referral for full eval and consideration of need for an ICD will be needed (WCTs this wide, this “ugly” and this fast are unlikely to be a more benign form of VT – and if it was AFlutter, then ablation should be strongly considered). As to amount of energy for emergency cardioversion – data are scarce (my impression when I’ve researched this) – with “best” answer being use “enough energy to successfully cardiovert the patient”. Simple AFlutter generally needs less energy (50-100J). Simple monomorphic VT may respond to 100J – but if you are concerned, probable little morbidity from starting at 200J which may be favored when you anticipate potential for not responding (as might be the case here – given the exceedingly rapid rate …).
Ken, as always, thank you for your comments !!
Brilliant point regarding the DDx for A.flutter with 1:1 conduction.
Cheers, Chris.
Will be passing this case along to my paramedic class. Most interesting!