A paramedic crew responded to the office of a local physician. A 61-year-old male presented with a one-week history of chest pain and shortness of breath.
This series of ECG rhythm strips shows a paroxysmal supraventricular tachycardia successfully treated with adenosine. The patient was complaining of a rapid heart rate and palpitations, but was hemodynamically stable. It is not known whether any parasympathetic stimulation, such as a Valsalva maneuver or carotid sinus massage, was used initially.
These two strips are from one patient who was electrically cardioverted twice in a few minutes. The original reason for the cardioversion was Torsades de Pointes, a type of polymorphic ventricular tachycardia associated with a long QT interval. For more information about TDP, go to this LINK. It is a bit difficult to comment on the patient's post-cardioversion rhythm, because so little of it is shown. It appears to be sinus, with a wide QRS.
Years ago, I was tasked with introducing 12-lead ECG interpretation to firefighter/paramedics who had been using ECG for rhythm monitoring for years. Some were eager to add to their skills, others - not so much. The feeling was, we have been doing just fine as we are. When finally convinced that they could interpret STEMI with a 12-lead, many were content to use the 12-lead ECG only for that.
An example of ventricular tachycardia in Lead II. This patient's rate is about 190/min. V Tach will have the following criteria: Rate greater than 100/min, QRS duration greater than .12 sec. (120 ms), and no P wave associated with the QRS.
It can be difficult to distinguish V Tach from other wide-complex tachycardias without a 12-lead ECG, but all wide-complex tachycardias should be treated as V Tach until proven otherwise, as V Tach is a potentially lethal dysrhythmia. V Tach can cause a severe reduction in cardiac output which can lead to V Fib and death.
This ECG shows a wide-complex tachycardia with a rate of 137/minute. No patient information is available other than what is on the ECG. Here, we will comment for the BASIC LEVEL learner, and allow the ECG Gurus out there to add INTERMEDIATE and ADVANCED level comments.
This is a good example of ventricular tachycardia with PRECORDIAL CONCORDANCE. The QRS complexes in the chest, or precordial, leads all point downward. When the precordial leads are all negative or all positive in a wide-complex tachycardia, there is virtually a 100% chance that the WCT is ventricular tachycardia. This ECG shows many characteristics of VT, including the extreme "backwards" axis: aVR is positive and II, III, and aVF are negative. Lead I is almost equiphasic. Also, the lack of a clear BBB pattern and a negative V6 are strongly suggest
A 66 year old man is complaining of palpitations and chest pain which radiated to his left arm and neck, which lasted 20 minutes, then went away. Paramedics found him in V Tach. His BP was 120/80 and his pulse 120/min. He converted to a narrow-complex rhythm while being given amiodarone, but became nauseated. He returned to V Tach, and his symptoms disappeared. This patient had an implanted defibrillator, which never went off. How do we know this is V Tach?
This is an interesting ECG for showing students AV sequential pacing and also ventricular tachycardia. The unusual thing about this ECG is that the V Tach starts at the time the machine begins recording the precordial leads. This particular ECG machine shows a slight "gap" at the lead change, so we don't see the actual start of the V Tach. Both rhythms have wide QRS complexes.
This wide complex tachycardia occurred in a 91 year old man with a history of atrial fibrillation. He complained of "fluttering" in his chest, and denied chest pain or other problems. While the paramedic attempted to start an I.V., he spontaneously converted to atrial fibrillation with left BBB, and PVCs. Once he converted, his symptoms abated. Remember, all wide complex tachycardias (WCT) should be treated as V Tach in the field, as this is by far the most common WTC and the most dangerous.
Some of the ECG clues that this WTC is ventricular tachycardia are:
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