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. The most likely alternate interpretation is PSVT with aberrant conduction, which usually takes the form of left or right bundle branch block. There is an important rule in emergency medical care: a wide-complex tachycardia should be treated as VT until and unless it is proven to be something else. An abrupt onset of the rhythm would point to a diagnosis of a reentrant rhythm, either ventricular tachycardia (VT) or paroxysmal supraventricular tachycardia (PSVT). 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. The rate is too fast to appreciate whether there are P waves present. 132 seconds in duration, per the ECG machine. She is afebrile.ĮCG #1 This ECG shows a wide-complex tachycardia at 196 bpm. She is found sitting in a chair, pale, cool, and diaphoretic. She had a valve replacement (we do not know which valve) two weeks ago and has a healing incision over her sternum. The Patient A 64-year-old woman has called 911 because she has chest discomfort radiating to her left arm, palpitations, weakness, and a headache. Read more about Left Bundle Branch Block.This ECG meets the criteria for LEFT BUNDLE BRANCH BLOCK. Because there is sinus rhythm, we know the delay in conduction is due to interventricular conduction delay, and not to ventricular rhythm. The QRS complexes, as mentioned, are wide. ( ) ECG criteria are not highly accurate for detecting atrial enlargement, and abnormal findings should be confirmed by anatomic measurement. This meets the ECG criteria for LEFT ATRIAL ENLARGEMENT, or preferably, LEFT ATRIAL ABNORMALITY. In V1, the P waves are biphasic, with the terminal negative portion greater than 40 ms duration (red lines). The P waves are broad, > 110 ms in Lead II (red lines in close up) and bifid, with greater than 40 ms between the two peaks in Lead II (blue lines). There are P waves present, and so the rhythm is SINUS BRADYCARDIA. We do not know the patient’s medications or baseline rate. The ECG The first feature that might capture your attention is the wider-than-normal QRS complex, which is 160 ms (.16 seconds). This ECG is taken from an elderly man with heart failure. Read more about Rate-related Left Bundle Branch Block.The pause after the PAC allows the left bundle branch to repolarize, conducting one single beat normally. This indicates that the LBB is refractory at this time. The 12-LEAD ECG has essentially the same rate and rhythm, except all the beats in the first ¾ of the ECG are conducted aberrantly, in a LEFT BUNDLE BRANCH BLOCK pattern. It is hard to determine mechanism of aberrant conduction when we have only a ten-second rhythm strip. Aberrant conduction often occurs due to a faster heart rate, but the only clue here is the intermittent conduction disturbance seems to disappear when the rate slows very slightly. These wider QRS complexes represent aberrant conduction with LBBB occurring intermittently. Most of the QRS complexes are normal width, but the 2 nd, 5 th, and 8 th are slightly wide at 130 ms, or. There are regular P waves present, all followed by QRS complexes. The rate is around 107 bpm, with an R to R interval of approximately 543 ms in the earlier, regular portion. The RHYTHM STRIP shows a tachycardiac rhythm that slows very slightly toward the end. The ECG: There are a rhythm strip with two leads, II and III, and also a standard 12-lead ECG. He appeared tired and slightly confused, and was normotensive. His chief complaint, as reported by caregivers, was lethargy, fever, and a declining mental status. The patient: This ECG is from an 87-year-old man who was transported to the Emergency Department by paramedics. In A Patient With Left Bundle Branch Block These are possibly pathological Q waves, likely from a past anterior-septal M.I. The QRS complexes transition at V4 from negative to positive, but Leads V1 – V3 have no initial r waves. The frontal plane axis is within normal limits, but toward the right, at 87 degrees. (Supraventricular rhythm, wide QRS, upright QRS in Leads I and V6, negative QRS in V1). The criteria for left bundle branch block are met. If you see a P wave in Leads I and II, they are also present in Lead III. P waves are not visualized well in all leads, so remember that the three channels of this ECG are run simultaneously. The ECG: There is normal sinus rhythm with a rate of 90 bpm. He was not considered to be a candidate for valve surgery. Long-standing history of triple vessel disease, severe aortic stenosis, hypertension, thrombocytopenia. The Patient: A 64-year-old man complaining of chest pain and shortness of breath for 20 minutes.
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