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Dawn's picture

AV Sequential Pacing to Ventricular Tachycardia

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. The pacemaker is pacing the right ventricle, so you will see a wide QRS with a leftward axis, as the impulse spreads up and leftward toward the left ventricle.   The V Tach portion is, of course, limited to the precordial leads, so we cannot plot the frontal plane axis.  But, it meets many of the accepted criteria for ventricular tachycardia, including:  very wide QRS, negative QRS in Lead V6, absence of RBBB or LBBB pattern.   For more on recognizing V Tach in a WCT, go to Ask the Expert at this LINK.    

This is also a very good example of how the interpretation by the machine can be wrong.  Always read the ECG yourself!

Dawn's picture

Wide Complex Tachycardia: V Tach

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:

* Monophasic upright QRS in V1  (does not have RBBB pattern of rsR')

* Extreme left axis deviation (II, III, and aVF are negative, I, aVL, and aVR are poisitive)

* V6 is negative

 

For a more thorough discussion of the ECG signs of V Tach, go to Jason Roediger's Ask the Expert page discussion on the topic:

http://www.ekgguru.com/node/157

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