EKG Interpretation

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We as Emergency Physicians are confronted with EKGs everyday. In the setting of extreme tachycardia it is very important to know what you are dealing with because certain medication interventions may yield disaster. How do you interpret this particular EKG and what management would you consider? I’m going to seek out Cardiology and ask for their interpretation to follow some of your reads. Let the discussion begin!

Just click on the image for a zoom-in view:

EKG Tachycardia 1

5 Comments

  • alvarezzy

    whenever i see these patients, main question for me is not whether this is vtac or afib with aberrancy or svt.
    main thing is: is the patient stable or unstable. what’s the BP? is there a pulse? is the patient mentating well? is the patient having chest pain? or any other signs of hypoperfusion. Do I have a resident who wants to try shocking the patient (in a more controlled environment other than during a “medical notification” cardiac arrest)
    Otherwise, if stable and have time, few of meds available, and my go to is lidocaine, amio or procainamide. I actually use lidocaine more often than amio and very rarely (like once), procainamide.

    PS. I try to get a picture of the monitor screen before I do maneuvers so long as the patient is relatively stable for bragging rights to Dr. Cassidy =)

  • Jacobi_Chiefs

    Having just taught ACLS at Jacobi I feel like an expert. HAHA!

    Anyways, first thing is patient stable or unstable?
    Unstable: synchronized cardioversion (defibrillation if wide and irregular)
    Stable: wide or narrow? Narrow you can do vagal maneuvers, adenosine and if no luck nodal blockers. If wide and regular still can use adenosine. If wide and irregular I would use procainamide (only one safe to use in wpw).

    a.yoon

  • siuf

    It’s v tach; based on very-wide QRS and axis criteria.

    On the screen, it looks regular, but it’s hard to tell sometimes. If it’s not regular, then never mind.

    • alvarezzy

      agree with siuf.. i actually sat down and tried figuring out the reading when i first saw this for academic purposes…. just going by what uptodate has on wide complex tachycardia (wtc), i think this is vtac.

      1. axis: no man’s land. down in I and down in avF.
      2. rbbb pattern in v1, v2: A monophasic R or biphasic qR complex in lead V1 favors VT
      3. rbbb pattern: An rS complex (R wave smaller than S wave) in lead V6 favors VT. In contrast, an Rs complex (R wave larger than S wave) in lead V6 favors SVT.
      4. then there’s the brugada criteria, and i gave up..

      i think it’s important to know that there are criteria in reading wct. as any alluded to, it all really boils down to whether the patient is stable or unstable, and the management is easier if you look at it from that perspective.

      amal mattu gave a nice lecture a few years ago at acep on the use of adenosine in wct. he cautions that adenosine breaks vtac on small percentages of patients, so just because “it breaks” doesn’t mean it’s SVT. These patients should get a formal EP study.

      This is from emrap June 2011:
      * 80‐85% of all wide‐complex tachycardias are ventricular tachycardia
      • Always assume it is VTach before anything else; you must prove any alternative diagnosis, not assume
      • In developed countries, the leading cause of a bundle branch block is coronary artery disease
      • If a wide‐complex tachycardia converts to sinus rhythm with a BBB, you must be absolutely sure the QRS morphology is the same; if it is, it may be safe to assume it was SVT with a BBB
      * If any change in QRS morphology, you must assume it is VTach

      LA

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