Comments for EMS 12-Lead

Comment on 50 year old male CC: Chest Pressure – Discussion by Michael Henry

Michael Henry — Thu, 23 Feb 2012 02:03:03 +0000

The 12 lead at the PCI center shows some borderline elevation in lead I. This can be indicative of pericarditis especially with the history or strep. A better tracing prehospitally would have been more beneficial however the nature of the job can make it very difficult.

Comment on Axis Determination – Part VI by thomas

thomas — Thu, 23 Feb 2012 01:29:21 +0000

Hey i found it very useful ! Thanks

Comment on 63 year old female CC: Chest Pressure by Brad J.

Brad J. — Wed, 22 Feb 2012 22:28:47 +0000

Afib is irregularly irregular, but how well can you really see the pattern with a rate of 200+? Honest question and not saying anyone is wrong.

Comment on 63 year old female CC: Chest Pressure by Aaron Johnston

Aaron Johnston — Wed, 22 Feb 2012 22:10:58 +0000

@ Dr. Smith
That's an interesting thought, that we are seeing V-tach followed by a-fib with RVR as a seperate rhythm. Maybe I am trying too hard for a single diagnosis in my analysis.
Any comment on the treatment here? I am always very nervous to engage in an extended series of medications when cardioversion is on the table..
Aaron

Comment on 63 year old female CC: Chest Pressure by Chris

Chris — Wed, 22 Feb 2012 22:05:07 +0000

I think it’s WPW.
First and second ECG are FBI: Fast, Broad and Irregulair.
Positive concordance precodiaal. Only responding on cardioversion.
So this must be an a.p. conduction.
For a-flutter i think there are no signs.
Post cardioversion ECG i see in V1- V3 a slighty slurred upstroke of R-wave
and still positive concordance. Compare with old ECG if recorded.
Consider an a.p. located left posterior septal

Comment on 63 year old female CC: Chest Pressure by Stephen Smith

Stephen Smith — Wed, 22 Feb 2012 21:54:51 +0000

Atrial flutter with variable block should be REGULARLY irregular and this is not. The only way I can explain this rhythm is to invoke 2 problems: a slightly irregular monomorphic VT AND atrial fib with RVR and narrow complex (seen at the end of the first 12-lead). It is not irregular enough for atrial fib and not bizarre enough for WPW with atrial fib. That's my two cents.

Comment on 63 year old female CC: Chest Pressure by Brad J

Brad J — Wed, 22 Feb 2012 21:01:41 +0000

@ Arnel, short QTc? Can you explain your reasoning on this bc if anything they appear to be elongated.

Comment on 63 year old female CC: Chest Pressure by Brad J.

Brad J. — Wed, 22 Feb 2012 20:45:05 +0000

@ Aaron, very good explanation to your thoughts. As you can see above I’m also leaning towards an atrial rhythm, but I’m thinking more afib than anything. I also considered A-flutter, but don’t see any flutter waves at all (I know it’s too fast to see flutter waves). I’m honestly not seeing any signs of WPW though even with post conversion…. One thing I noticed now that I didn’t originally notice is that there are flat T waves in AVL and V1. Also in the limb leads I notice longer gradual building T waves which would also indicate hypokalemia. Just a thought….

Comment on 63 year old female CC: Chest Pressure by Arnel C

Arnel C — Wed, 22 Feb 2012 20:31:59 +0000

1. VT - positive concordance
2. short QTc
3. Acquired vs congenital. Probable acquired short QTc. Thinking of hypercalcemia.

Comment on 63 year old female CC: Chest Pressure by Aaron Johnston

Aaron Johnston — Wed, 22 Feb 2012 20:20:06 +0000

Great ECG set.
On the first ECG I see mainly a wide complex monomorphic irregular tachycardia. Then on the rhythm strip just under V6 the rhythm narrows, and now we see a rapid, possibly regular rhythm (difficult without calipers) without identifable p waves and with a very long QTc.
The second ECG is entirely the monomorphic irregular wide complex tachycardia, probably with even wider QRS.
The third ECG is sinus, now normal QTc and possibly some very subtle inferior ischemia.
I don't think it is incorrect to look at either of the first 2 ECGs and think 'V-TACH!', but I think there are some clues that this is not what is going on:
First, on the first ECG there is revision to a narrow complex rhythm that has the same rate and (ir)regularity as the previous wide complex rhythm.
Second, I do not see any fusion beats.
Third, I do not see any retrograde p waves.
Fourth, the rhythm is markedly irregular which would be surprising for a fast ventricular tachycardia.
Next is the question of an abberent conduction pathway, ie. is this afib with WPW. Again on the first strip we see the conversion of wide to narrow without any significant slowing of the rate. If this conversion was due to alternating conduction down an accessory pathway and the sinus pathway I would expect to see the rate slow a bit as the conversion occurs. We do not see this.
Finally, the complete lack of response to a cornucopia of antidysrhythmic medications. This always makes me think about a-flutter, a rhythm refractory to many of our medical machinations. It is possible that what we are seeing in ECG 1 and 2 is actually a-flutter with variable block causing the irregularity. A set of calipers and calculating the intervals is really the best way to differentiate this from a-fib.
Overall I think this is a-flutter with variable block (vs a-fib) and a rate related bundle branch block. The post conversion ECG possible shows some subtle new inferior changes but I would probably do another ECG 10 minutes later and see if these resolved (ie. if they were due to rate related ischemia).