faster than most…

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 …..

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…

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