These two ECGs are from a 77-year-old woman who was complaining of palpitations and mild shortness of breath. She stated a history of atrial fibrillation. She was alert, with a systolic BP over 120. At the hospital, she was found to have cardiomyopathy, resulting in global hypokinesis. She also had significant coronary artery narrowing in her left main, left anterior descending, and circumflex, which were treated with coronary artery bypass graft surgery.
Wide complex tachycardia
This ECG was taken from a patient who was complaining of palpitations and tachycardia, but who was hemodynamically stable, with no history of heart disease. It is an example of RIGHT VENTRICULAR OUTFLOW TRACT TACHYCARDIA, a type of idiopathic ventricular tachycardia. The ECG signs of RVOT are: wide QRS complex, left bundle branch block pattern (QRS negative in V1 and positive in Leads I and V6), heart rate over 100 bpm, rightward or inferior axis (LBBB usually has a normal to leftward axis), AV dissociation.
Wide-QRS rhythms can be difficult to diagnose from the ECG alone. This difficulty is compounded when the rate is fast, as it can be hard to determine if P waves are present before the QRSs, or dissociated, or absent.
This ECG and rhythm strip were donated to the ECG Guru by Ryan Cihowiak. We don't have clinical information on the patient, unfortunately. It is a great example, however, of how difficult WCT can be to diagnose.
This is a good example of atrial fibrillation with left bundle branch block. You get two ECGs with this one, because the patient presented to EMS with a fast heart rate, and the rate was slowed with the drug diltiazem. We do not have any other patient information, unfortunately.
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 wide complex tachycardia has an initial rate of 129/min. It is difficult to discern if P waves are present, although the ECG machine does give us a PR interval. The ECG meets most of the criteria for left bundle branch block: wide QRS, negative QRS in V1, positive QRS in Lead I and V6.The axis is leftward, which is common in LBBB. However, it is difficult to say for certain that this is a supraventricular rhythm. Later, however, the patient's rate slowed (see top strip), revealing P waves. When the rate slowed, the left bundle branch block pattern remained.
This ECG was donated to the ECG Guru by Dr. Arnel Carmona, one of our favorite Gurus. You will not often see such a great example of this. We are very grateful to Dr. Carmona for his contribution to learning. Dr. Carmona's new blog is EZG - ECG for beginners and enthusiasts.
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:
This ECG was submitted by Sebastian Garay, EMT-P and ECG Guru (and ECG Guru Member sebmedic). It is a very interesting case of wide complex tachycardia in a patient with Wolff-Parkinson-White.
This is a good example of wide complex tachycardia that must be evaluated for V Tach vs supraventricular rhythm with left BBB.
There is an irregular rhythm. When the rate is fast, it is important to look at a longer strip, as sometimes fast rates will cause the rhythm to look regular. We know that monomorphic V Tach is not irregular, so that tells us that we are looking at atrial fibrillation.
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