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Instructors' Collection ECG: Wide Complex Tachycardia

The Patient:   A 78-year-old woman called emergency responders because she had palpitations. She was alert and oriented.  Her BP was reported as being “stable”.  We do not have information about her past medical history.  We will update this post if we receive information about her outcome. 

ECG Number 1, 11:57 a.m.:  There is a wide-complex tachycardia at a rate of about 230 bpm.  The QRS is .15 seconds (150 ms).  The QRS frontal plane axis is leftward. P waves are not readily seen, but the computer gives a P axis and PRI.  The PRI given is taken from Lead II, which, along with V5, does have P waves. In the other leads, the P waves are buried in preceding T waves.  This photo shows an ECG that is not lying flat, so it is difficult to line up the complexes.  Normally, it helps to look at the leads above or below to determine where waves begin and end, as all three channels are run simultaneously. The QRS complexes have a “typical” left bundle branch block morphology, with an rS complex in V1 and a monophasic R wave in Leads I and V6.  The T waves are “discordant”, they are in the opposite direction from the QRS complexes, which is typical of LBBB. 

ECG Number 2, 12:05 p.m.:   This is a rhythm strip recording a synchronized shock at 100 joules, resulting in conversion of the WCT to a narrow complex, irregular rhythm.  It appears that there is a P wave before every narrow QRS, but artifact prevents proper evaluation. 

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An Interesting Holter Strip

Here you can see a long rhythm strip from a Holter ECG, written at 25 mm/s. On the left, a sinus bradyarrhythmia can be seen first, followed by an atrial tachycardia. After a few beats this changes back into a sinus bradyarrhythmia. Then follows a short VT over 3 beats, after 1 sinus node beat then a ventricular couplet. Sinus bradyarrhythmia again at the end.

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Atrial Fibrillation With Rate-related Left Bundle Branch Block

For a better overview, the leads aVL and V2-V4 are not shown in this ECG. The basic rhythm is atrial fibrillation (no P waves or flutter waves visible, but fibrillation waves). When the conduction rate drops, the QRS complexes are narrow. Faster conduction results in wide QRS complexes with LBBB morphology. This is an example of phase 3 (acceleration dependant) LBBB.

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New Book From Dr. Jerry Jones

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ECG Glossary from Dr. Ken Grauer

Are you looking for a comprehensive ECG glossary that goes beyond simply defining words? Dr. Ken Grauer, who is the ECG Guru's Consulting Expert, has a Glossary available on his website that explains the terms.  Instructors and students alike will benefit from having this glossary readily available.  The glossary is exerpted from his e-Publication, "A 1st Book On ECGs - 2014", available on Amazon.

Coronary Arteries Anterior View Labeled

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Anterior view of coronary arteries

This is an original illustration by Dawn Altman.  It is free for your use in an educational setting.  For other uses, please contact Dawn at [email protected].

 

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ECG HISTORY:     ECG was first put into clinical use in the early 1900s.  In 1909, it helped diagnose an arrhythmia.  A year later, indications of a heart attack were noted.

 

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