Name that ECG: 51 year old male

Welcome to another exciting installment of Name that ECG. Remember, your job is to interpret the ECG to its fullest; we'll leave the treatment for somebody else!

51 year old male, palpitations.

Name that ECG: 51 year old male

 

Rhythm:

  • Rate?
  • Regularity?
  • P-waves?
  • PR interval? Associated?
  • QRS width?

Bonus points:

  • Axis?
  • QTc?
  • ST/T-wave changes?

What are your differentials?

Posts which include any permutation of the phrase "treat the patient not the monitor" will be deleted and their author fed to trauma hungry EMT students.

9 Comments

  • VinceD says:

    Regular wide-complex tachycardia at a rate of 185 bpm.

    No signs of atrial activity. Leads I and V5/V6 raise the possibility of atrial flutter, but that is unlikey with this rate and morphology.

    Axis is right around 90 degrees.

    LBBB morphology in V1 but I, aVL, and V6 are atypical. QRS interval is around 200ms.

    QTc is not grossly abnormal.

    This is V-Tach
    ————————————-
    Pointing towards VT:
    Wide and fast.
    Atypical morphology.
    QRS duration > 160ms.
    Loss of QRS/T-wave differentiation
    Slurred S-wave in V1 w/ R-to-nadir interval > 60ms.
    R-wave peak time in lead II > 50ms.
    LBBB w/ inferior axis typical of right ventricular outflow tract VT.

  • matt c says:

    No right axis.
    No upright complex in V1.
    No downward complex in V6.

    May not meet VT criteria.

  • Floyd says:

    The axis is decent and i really cannot certainly rule in v-tach. I know the old saying is that wide and fast is v-tach until proven otherwise, but would it be appropriate to treat with a trial of adenosine if patient is stable. Could this be svt/lbb abberancy? Vince could you explain your process in detail of being certain this is v-tach for those who arent too smart like me. Also could that be st elevation in aVL? Honestly all i see is negetive concordance in all precordials except for v-5&v-6(or atleast I think), and a good axis.

  • KB says:

    Agree with regular wide-complex tachycardia at a rate of 185 bpm.

    Diff: Vtach, Sinus tach w BBB, SVT.

    My diagnosis: Vtach. Would shock or CV depending on pulse.

  • Darren says:

    Regular wide complex tachycardia, rate 170-190 range.  Unifocal in nature.  No evidence of P waves or other atrial activity present.  QRS width appears approximately 170 ms.  Axis close to 90 degrees.  ST segment changes difficult to see due to the rhythm; nothing pops out. 
    There is no P-QRS dissociation to look for.  The axis is high normal to possibly slight right, not falling into the ERAD criteria.  However, note the slurring of the downstroke in V1 and V2.  In addition, V6 appears negative to me.  I see no evidence of an accessory pathway either.  Based on these findings, I would be comfortable calling VT.

  • Zack says:

    Rate~180-200bpm/monomorphic. Rhythm DDx: AVRT w/ antidromic conduction(because of wide QRS and high rate), SVT w/ aberrancy 2nd to WPW(possible deltas), RVOT VT(because of inferior axis and LBBB pattern). Looks like there might be p-waves visible and mostly buried within the QRS. Possible delta waves present which would contribute to the widening of the QRS complexes. PR-interval: buried in QRS.  QRS:~200ms. Axis: inferior axis. ST: hard to tell, but the antereoseptal leads look elevated>5mm. Tx=procainamide or sync cardioversion depending on pt presentation. 

  • RyanTee says:

    Rate is extremely fast !!!!!  The QRS is definitely very wide( about 5 small squares = 0.20s) which favours VT, SVT cannot be ruled out also..No extreme axis here but the QRS pattern certainly doesnt resemble any BBB…Using my favoured Sasaki, there is no monomorphic R wave indicating apical impulse, but R to S nadir is 3 small squares = 0.12 s and the initial r wave is about 0.04s..My diagnosis would be Vtach..

  • Andrew Przepioski says:

    In real life, I would treat this as vtach until proven as otherwise. I'd agree with a trial of adenosine. I'm just having fun posting up what I think I see.
    My friend showed me this, and my initial impression was "this doesn't look like what vtach normally looks like". Something looks off to me…. He introduced Sasaki's rule to me and I tried using it, but it was really hard figuring out what was what in this.
    At first, I thought lead I looked crazy, like vfib (and I am not suggesting this 12-lead is vfib), then noticed that I, V5, and V6 looked the most normal so I decided to start using those as references to the rest of the 12-lead.

    Rate is 167-187. Complex #3 to #4, it's 167 (1,500/9 small boxes). #6 to either #5 or #7 is 8 boxes, about 187. If you use the 6 second rule (first 6 seconds of the 12-lead), I counted about 15 complexes. That would be about 150.
    Axis, lead I has the smallest amplitude. The mean QRS is likely perpindicular to this so it's either going about straight up or straight down. The inferior leads look positive to me (based on where the start and end of the complexes are using lead I), aVR looks biphasic, aVL looks negative. I'd say the mean QRS vector is around +90 degree to +120 degree so probably some right axis deviation.
    Lead I, the complexes aren't even 1 big box actually. It's about 140 ms. I see T -> R -> S -> T -> R -> S, etc.
    Looks like there is some R-wave progression in the precordial leads which would favor SVT… I can't see RBBB or LBBB which favors VT…
    I cannot stress enough that I would treat this as VT until proven otherwise in real life, I don't trust myself enough, but for this scenario, I am gonna call it SVT with aberrancy because of my initial gut feeling "it doesn't look like vtach to me" and some of the findings that goes against VT.
    The QT is 260 ms (looking at the start of the 5th complex). Using Bazzett's formula. If the rate was 150, the QTc would be 411 ms. If it was as high as 187, it would be 459 ms. Not too bad.

  • Andrew Przepioski says:

    Well, I was just fooling around with saying it's SVT earlier.. This was very confusing to me, and I spent a lot of time trying to look up things and get other people opinions. I personally think that I described RVOT VT earlier, and that's what I am going to say.

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