A paramedic crew responded to the office of a local physician. A 61-year-old male presented with a one-week history of chest pain and shortness of breath.
This ECG is from a man who was experiencing palpitations and light-headedness with near-syncope. On first look, you will see a wide-complex tachycardia (WTC) with a rate around 240 per minute. It is difficult to assess for the presence of P waves because of the rate and the baseline artifact.
This ECG was obtained from a 45-year-old man who was experiencing palpitations and lightheadedness, which he originally attributed to anxiety. There are short, but frequent periods of ventricular tachycardia, which are self-limiting. This is called "NON-SUSTAINED VENTRICULAR TACHYCARDIA". The underlying rhythm is sinus, with a remarkably long PR interval, and at least one episode of failure of the P wave to conduct, making "second-degree AV block, Type II" a possibility. It is difficult to thoroughly evaluate the underlying rhythm because it is not seen very often in this ECG.
This wide-complex tachycardia is ventricular tachycardia. Along with the wide QRS and the fast rate, features which favor a diagnosis of VT over BBB include: backwards (extreme right) QRS axis, negative QRS in V6, and an apparently monophasic QRS in V1, as opposed to the rSR' pattern of right bundle branch block.
Remember, ALL wide-QRS t
This ECG was donated to the ECG Guru by Brent Dubois, and was originally published on the FaceBook page, Paramedic Tips & Tricks. We published it to this site three years ago, but believe it should be shown again, as it is somewhat rare to catch a good-quality 12-Lead ECG of an implanted cardioverter-defibrillator pacemaer using overdrive pacing to terminate a ventricular tachycardia. Most of our examples have been rhythm strips.
This ECG was taken from a patient who was complaining of palpitations and tachycardia, but who was hemodynamically stable, with no history of heart disease. It is an example of RIGHT VENTRICULAR OUTFLOW TRACT TACHYCARDIA, a type of idiopathic ventricular tachycardia. The ECG signs of RVOT are: wide QRS complex, left bundle branch block pattern (QRS negative in V1 and positive in Leads I and V6), heart rate over 100 bpm, rightward or inferior axis (LBBB usually has a normal to leftward axis), AV dissociation.
Wide-QRS rhythms can be difficult to diagnose from the ECG alone. This difficulty is compounded when the rate is fast, as it can be hard to determine if P waves are present before the QRSs, or dissociated, or absent.
This ECG and rhythm strip were donated to the ECG Guru by Ryan Cihowiak. We don't have clinical information on the patient, unfortunately. It is a great example, however, of how difficult WCT can be to diagnose.
These two strips are from one patient who was electrically cardioverted twice in a few minutes. The original reason for the cardioversion was Torsades de Pointes, a type of polymorphic ventricular tachycardia associated with a long QT interval. For more information about TDP, go to this LINK. It is a bit difficult to comment on the patient's post-cardioversion rhythm, because so little of it is shown. It appears to be sinus, with a wide QRS.
Continuing our series from the patient with acute AWMI, donated by Jenda Enis Štros, a new dysrhythmia has appeared. The patient was taken to the cath lab, and a thrombus was removed from the stent. We now see a wide-complex tachycardia. The morphology (shape and configuration) of the QRS has changed considerably from the previous ECGs, so we know this is idioventricular in origin.
Years ago, I was tasked with introducing 12-lead ECG interpretation to firefighter/paramedics who had been using ECG for rhythm monitoring for years. Some were eager to add to their skills, others - not so much. The feeling was, we have been doing just fine as we are. When finally convinced that they could interpret STEMI with a 12-lead, many were content to use the 12-lead ECG only for that.
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