ECG Guru - Instructor Resources - Sinus tachycardia https://www.ecgguru.com/ecg/sinus-tachycardia en Narrow-complex Tachycardia In An Infant https://www.ecgguru.com/ecg/narrow-complex-tachycardia-infant <div class="field field-name-field-ecg field-type-image field-label-hidden"><div class="field-items"><div class="field-item even"><a href="/ecg/narrow-complex-tachycardia-infant"><img typeof="foaf:Image" src="https://www.ecgguru.com/sites/default/files/Peds100.jpg" width="1800" height="1227" alt="" /></a></div></div></div><div class="field field-name-field-ecg-interpretation field-type-text-long field-label-hidden"><div class="field-items"><div class="field-item even"><p class="MsoNormal"><strong><span style="font-size: 16.0pt; line-height: 107%; color: #00b050;">The patient:<span style="mso-spacerun: yes;">&nbsp; </span></span></strong><span style="font-size: 12.0pt; line-height: 107%;">This ECG was obtained from a two-month-old girl who was a patient in the Emergency Department.<span style="mso-spacerun: yes;">&nbsp; </span>She had a fever due to a respiratory infection and was dehydrated. She was alert, active, and irritable.</span></p><p class="MsoNormal"><strong><span style="font-size: 16.0pt; line-height: 107%; color: #00b050;">The ECG:<span style="mso-spacerun: yes;">&nbsp; </span></span></strong><span style="font-size: 12.0pt; line-height: 107%; color: black; mso-themecolor: text1;">There is a narrow-complex tachycardia at a rate of 194 bpm.<span style="mso-spacerun: yes;">&nbsp; </span>This is faster than the normal range for a two-month-old, which is about 80-160 bpm.<span style="mso-spacerun: yes;">&nbsp; </span>The intervals are all within normal range.<span style="mso-spacerun: yes;">&nbsp; </span>The frontal plane axis, at 145 degrees, is rightward, which is normal for this age. There are prominent, narrow Q waves in the inferior wall leads (II, III, and aVF) and in the left lateral leads (V4, V5, and V6).<span style="mso-spacerun: yes;">&nbsp; </span>There are no Q waves in the high lateral leads (I and aVL).<span style="mso-spacerun: yes;">&nbsp; </span>This is a normal pattern for this age group.<span style="mso-spacerun: yes;">&nbsp;&nbsp; </span><a href="http://www.sciencedirect.com/science/article/pii/B9781416037743100280">www.sciencedirect.com/science/article/pii/B9781416037743100280</a></span></p><p class="MsoNormal"><span style="font-size: 12.0pt; line-height: 107%; color: black; mso-themecolor: text1;">The evaluation of this ECG must be preceded by a thorough evaluation of the patient.<span style="mso-spacerun: yes;">&nbsp; </span>SINUS TACHYCARDIA would be expected in the setting of fever, dehydration, hypoxia, pain or other discomfort. Should the rate fail to gradually return to a normal range after treatment, we would have to consider a reentrant supraventricular tachycardia. Reentrant tachycardias have a SUDDEN ONSET and SUDDEN TERMINATION.</span></p><p class="MsoNormal"><span style="font-size: 12.0pt; line-height: 107%; color: black; mso-themecolor: text1;">Unfortunately, we do not have follow up on the patient.</span></p></div></div></div><div class="field field-name-field-rate-this-content field-type-fivestar field-label-above"><div class="field-label">Rate this content:&nbsp;</div><div class="field-items"><div class="field-item even"><form class="fivestar-widget" action="/taxonomy/term/67/feed" method="post" id="fivestar-custom-widget" accept-charset="UTF-8"><div><div class="clearfix fivestar-average-text fivestar-average-stars fivestar-form-item fivestar-hearts"><div class="form-item form-type-fivestar form-item-vote"> <div class="form-item form-type-select form-item-vote"> <select id="edit-vote--2" name="vote" class="form-select"><option value="-">Select rating</option><option value="20">Give Narrow-complex Tachycardia In An Infant 1/5</option><option value="40">Give Narrow-complex Tachycardia In An Infant 2/5</option><option value="60">Give Narrow-complex Tachycardia In An Infant 3/5</option><option value="80" selected="selected">Give Narrow-complex Tachycardia In An Infant 4/5</option><option value="100">Give Narrow-complex Tachycardia In An Infant 5/5</option></select> <div class="description"><div class="fivestar-summary fivestar-summary-average-count"><span class="average-rating">Average: <span >3.4</span></span> <span class="total-votes">(<span >7</span> votes)</span></div></div> </div> </div> </div><input class="fivestar-submit form-submit" type="submit" id="edit-fivestar-submit" name="op" value="Rate" /><input type="hidden" name="form_build_id" value="form-3Xp7eyEuB48tY6V56XMZrkMFRk_oaJg5vkDSsmCll2k" /> <input type="hidden" name="form_id" value="fivestar_custom_widget" /> </div></form></div></div></div><div class="field field-name-field-taxonomy field-type-taxonomy-term-reference field-label-above"><div class="field-label">Related Terms:&nbsp;</div><div class="field-items"><div class="field-item even"><a href="/ecg/sinus-tachycardia" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Sinus tachycardia</a></div><div class="field-item odd"><a href="/ecg/paroxysmal-supraventricular-tachycardia" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Paroxysmal supraventricular tachycardia</a></div><div class="field-item even"><a href="/ecg/pediatric-ecg" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Pediatric ECG</a></div><div class="field-item odd"><a href="/ecg/q-waves" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Q waves</a></div><div class="field-item even"><a href="/ecg/right-axis-deviation" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Right axis deviation</a></div></div></div><ul class="links inline"><li class="addtoany first last"><span><span class="a2a_kit a2a_target addtoany_list" id="da2a_1"> <a class="a2a_dd addtoany_share_save" href="https://www.addtoany.com/share#url=https%3A%2F%2Fwww.ecgguru.com%2Fecg%2Fnarrow-complex-tachycardia-infant&amp;title=%20Narrow-complex%20Tachycardia%20In%20An%20Infant"><img src="/sites/all/modules/addtoany/images/share_save_256_24.png" width="256" height="24" alt="Share"/></a> </span> <script type="text/javascript"> <!--//--><![CDATA[//><!-- if(window.da2a)da2a.script_load(); //--><!]]> </script></span></li> </ul> Tue, 26 Oct 2021 20:20:58 +0000 Dawn 808 at https://www.ecgguru.com https://www.ecgguru.com/ecg/narrow-complex-tachycardia-infant#comments Sinus Tachycardia https://www.ecgguru.com/ecg/sinus-tachycardia-0 <div class="field field-name-field-ecg field-type-image field-label-hidden"><div class="field-items"><div class="field-item even"><a href="/ecg/sinus-tachycardia-0"><img typeof="foaf:Image" src="https://www.ecgguru.com/sites/default/files/Sinus100.jpg" width="1800" height="1210" alt="" /></a></div></div></div><div class="field field-name-field-ecg-interpretation field-type-text-long field-label-hidden"><div class="field-items"><div class="field-item even"><p class="MsoNormal">This ECG is from a collection of tracings that, sadly, have no patient information.<span style="mso-spacerun: yes;">&nbsp; </span>It is interesting nonetheless, and we would love to hear your thoughts on it.</p><p class="MsoNormal"><strong style="mso-bidi-font-weight: normal;"><span style="color: #00b050;">ECG Findings:<span style="mso-spacerun: yes;">&nbsp; </span></span>The rhythm </strong>is sinus tachycardia, at a rate of 120 bpm.<span style="mso-spacerun: yes;">&nbsp; </span>The QRS is narrow at .08 seconds (82 ms).<span style="mso-spacerun: yes;">&nbsp; </span>While the <strong style="mso-bidi-font-weight: normal;">PR interval</strong> is normal, at .14 seconds (140 ms), the <strong style="mso-bidi-font-weight: normal;">PR segment</strong> is very short. The PR segment is the line between the end of the P wave to the beginning of the QRS complex.<span style="mso-spacerun: yes;">&nbsp; </span>This can indicate the presence of an accessory pathway that bypasses the AV node, or of faster conduction within the AV node. The P waves in the inferior leads II, III, and aVF barely meet voltage criteria for right atrial enlargement, <span style="mso-spacerun: yes;">&nbsp;</span>but the P waves in V1 do not have the usual prominent positive deflection one would expect with RAE.<span style="mso-spacerun: yes;">&nbsp; </span>Even with the short PR segment, the segment appears to be elevated in the inferior leads, without any reciprocal PR depression.<span style="mso-spacerun: yes;">&nbsp; </span>The PR segment is where atrial repolarization occurs (the atrial “T” wave). There are many conditions that can elevate or depress PR segments, and without a patient story here, we can’t guess at the cause.<span style="mso-spacerun: yes;">&nbsp; </span>If you are an instructor, this would be a good ECG to illustrate why we use the TP segment to determine the “isoelectric line”, rather than the PR segment.</p><p class="MsoNormal">The inferior <strong style="mso-bidi-font-weight: normal;">ST segments</strong> are very flat, which is not normal, while the rest of the ST segments display the normal concave up “smile” shape.<span style="mso-spacerun: yes;">&nbsp; </span>Serial ECGs would no doubt be helpful here, to recognize changes in the ST segments.</p><p class="MsoNormal"><strong style="mso-bidi-font-weight: normal;"><span style="color: #00b050;">Bottom Line</span></strong><span style="color: #00b050;">: </span><span style="mso-spacerun: yes;">&nbsp;</span>It would be much easier to make a determination about the causes of these subtle changes if we had patient information.<span style="mso-spacerun: yes;">&nbsp; </span>However, this ECG is still valuable as an exercise in measuring intervals, and as an example of short PR segment. It is also a good example of a fairly fast sinus tachycardia.<span style="mso-spacerun: yes;">&nbsp; </span>We would love to hear our visitors’ thoughts on this tracing.</p></div></div></div><div class="field field-name-field-rate-this-content field-type-fivestar field-label-above"><div class="field-label">Rate this content:&nbsp;</div><div class="field-items"><div class="field-item even"><form class="fivestar-widget" action="/taxonomy/term/67/feed" method="post" id="fivestar-custom-widget--2" accept-charset="UTF-8"><div><div class="clearfix fivestar-average-text fivestar-average-stars fivestar-form-item fivestar-hearts"><div class="form-item form-type-fivestar form-item-vote"> <div class="form-item form-type-select form-item-vote"> <select id="edit-vote--4" name="vote" class="form-select"><option value="-">Select rating</option><option value="20">Give Sinus Tachycardia 1/5</option><option value="40">Give Sinus Tachycardia 2/5</option><option value="60">Give Sinus Tachycardia 3/5</option><option value="80" selected="selected">Give Sinus Tachycardia 4/5</option><option value="100">Give Sinus Tachycardia 5/5</option></select> <div class="description"><div class="fivestar-summary fivestar-summary-average-count"><span class="average-rating">Average: <span >3.3</span></span> <span class="total-votes">(<span >6</span> votes)</span></div></div> </div> </div> </div><input class="fivestar-submit form-submit" type="submit" id="edit-fivestar-submit--2" name="op" value="Rate" /><input type="hidden" name="form_build_id" value="form-xkodjkHZbitm-AebXa9hPyQpWY1rykw-L5Pc5d65QF4" /> <input type="hidden" name="form_id" value="fivestar_custom_widget" /> </div></form></div></div></div><div class="field field-name-field-taxonomy field-type-taxonomy-term-reference field-label-above"><div class="field-label">Related Terms:&nbsp;</div><div class="field-items"><div class="field-item even"><a href="/ecg/sinus-tachycardia" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Sinus tachycardia</a></div><div class="field-item odd"><a href="/ecg/tachycardia" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Tachycardia</a></div><div class="field-item even"><a href="/ecg/pr-segment" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">PR segment</a></div></div></div><ul class="links inline"><li class="addtoany first last"><span><span class="a2a_kit a2a_target addtoany_list" id="da2a_2"> <a class="a2a_dd addtoany_share_save" href="https://www.addtoany.com/share#url=https%3A%2F%2Fwww.ecgguru.com%2Fecg%2Fsinus-tachycardia-0&amp;title=Sinus%20Tachycardia"><img src="/sites/all/modules/addtoany/images/share_save_256_24.png" width="256" height="24" alt="Share"/></a> </span> </span></li> </ul> Thu, 10 Oct 2019 02:42:23 +0000 Dawn 777 at https://www.ecgguru.com https://www.ecgguru.com/ecg/sinus-tachycardia-0#comments Tachycardia In An Unresponsive Patient https://www.ecgguru.com/ecg/tachycardia-unresponsive-patient <div class="field field-name-field-ecg field-type-image field-label-hidden"><div class="field-items"><div class="field-item even"><a href="/ecg/tachycardia-unresponsive-patient"><img typeof="foaf:Image" src="https://www.ecgguru.com/sites/default/files/Tachycardia%20and%20Hyperkalemia.jpg" width="1800" height="713" alt="" /></a></div></div></div><div class="field field-name-field-ecg-interpretation field-type-text-long field-label-hidden"><div class="field-items"><div class="field-item even"><p class="MsoNormal"><strong style="mso-bidi-font-weight: normal;">&nbsp;</strong><strong style="font-size: 13.008px;"><span style="font-size: 10.0pt; line-height: 107%; color: #00b050;">The Patient</span></strong><span style="font-size: 10pt; line-height: 107%; color: #00b050;">&nbsp;&nbsp;&nbsp;&nbsp; </span><span style="font-size: 10pt; line-height: 107%;">This ECG was obtained from a 28-year-old woman who was found in her home, unresponsive.&nbsp; She was hypotensive at 99/35.&nbsp; No one was available to provide information about past medical history or the onset of this event.</span></p><p class="MsoNormal"><span style="font-size: 10.0pt; line-height: 107%;">Before you read my comments, pause to look at the ECG and see what YOU think.<span style="mso-spacerun: yes;">&nbsp; </span>We would welcome comments below from all our members!</span></p><p class="MsoNormal"><strong style="mso-bidi-font-weight: normal;"><span style="font-size: 10.0pt; line-height: 107%; color: #00b050;">The ECG</span></strong><span style="font-size: 10.0pt; line-height: 107%; color: #00b050;"><span style="mso-spacerun: yes;">&nbsp;&nbsp;&nbsp;&nbsp; </span></span><span style="font-size: 10.0pt; line-height: 107%;">This ECG is quite challenging, as it illustrates the helpfulness of ECG changes in patient diagnosis, and also points out how important clinical correlation is when the ECG suggests multiple different problems. Forgive me in advance, but there is a lot to say about this ECG.</span></p><p class="MsoNormal"><span style="font-size: 10.0pt; line-height: 107%;">The <strong style="mso-bidi-font-weight: normal;">heart rate</strong> is 148 bpm, and the <strong style="mso-bidi-font-weight: normal;">rhythm is regular</strong>, although not perfectly. <strong style="mso-bidi-font-weight: normal;">P waves</strong> are not seen, even though the ECG machine gives a P wave axis and PR interval measurement. The rate is fast enough to bury the P waves in the preceding T waves, especially if there is first-degree AV block. <strong style="mso-bidi-font-weight: normal;"><em style="mso-bidi-font-style: normal;"><span style="color: #7030a0;">Differential dx</span></em></strong><em style="mso-bidi-font-style: normal;"><span style="color: #7030a0;">:</span></em><span style="color: #7030a0;"> sinus tachycardia, PSVT, atrial flutter. </span>The very slight irregularity points more towards sinus tachycardia.<span style="mso-spacerun: yes;">&nbsp; </span>The rate of nearly 150 suggests atrial flutter with 2:1 conduction, but the only lead that looks remotely like it has flutter waves is V2. The lack of an onset or offset of the rhythm makes it difficult to diagnose PSVT with any certainty. </span></p><p class="MsoNormal"><span style="font-size: 10.0pt; line-height: 107%;">The ECG machine measures the QRS complex at .102 seconds (102 ms). I don’t believe this is correct, as the QRS has an additional wave due to <strong style="mso-bidi-font-weight: normal;"><a href="https://www.ecgguru.com/ecg/instructors-collection-ecg-week-september-23-2015-right-bundle-branch-block-0">right bundle branch block pattern</a></strong>, and the machine did not count this terminal wave.<span style="mso-spacerun: yes;">&nbsp; </span>I measure the actual <strong style="mso-bidi-font-weight: normal;">QRS duration</strong> at closer to .12 seconds (120 ms).<span style="mso-spacerun: yes;">&nbsp; </span>The J point, or end point of the QRS complex, is difficult to see in most of the leads because of slurring from the QRS to the ST segment.<span style="mso-spacerun: yes;">&nbsp; </span></span></p><p class="MsoNormal"><strong style="mso-bidi-font-weight: normal;"><em style="mso-bidi-font-style: normal;"><span style="font-size: 10.0pt; line-height: 107%; color: #7030a0;">Differential dx:</span></em></strong><span style="font-size: 10.0pt; line-height: 107%;"><span style="mso-spacerun: yes;">&nbsp;&nbsp; </span>There are some signs of <strong style="mso-bidi-font-weight: normal;"><a href="https://litfl.com/ecg-changes-in-pulmonary-embolism/">right ventricular failure</a></strong> on this ECG, but ECG is not 100% accurate for determining right heart strain. The ECG evidence must be confirmed by clinical correlation. <span style="mso-spacerun: yes;">&nbsp;</span>In a young person with sudden onset of right heart failure signs, one must consider <strong style="mso-bidi-font-weight: normal;">pulmonary embolus</strong>.<span style="mso-spacerun: yes;">&nbsp; </span>Some, but not all, of the ECG signs that can be associated with pulmonary embolism are:</span></p><p class="MsoListParagraphCxSpFirst" style="margin-left: 30.75pt; mso-add-space: auto; text-indent: -.25in; mso-list: l1 level1 lfo1;"><!--[if !supportLists]--><span style="font-size: 10.0pt; line-height: 107%; font-family: Symbol; mso-fareast-font-family: Symbol; mso-bidi-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt 'Times New Roman';">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </span></span></span><!--[endif]--><span style="font-size: 10.0pt; line-height: 107%;">Sinus tachycardia (44%)</span></p><p class="MsoListParagraphCxSpMiddle" style="margin-left: 30.75pt; mso-add-space: auto; text-indent: -.25in; mso-list: l1 level1 lfo1;"><!--[if !supportLists]--><span style="font-size: 10.0pt; line-height: 107%; font-family: Symbol; mso-fareast-font-family: Symbol; mso-bidi-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt 'Times New Roman';">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </span></span></span><!--[endif]--><span style="font-size: 10.0pt; line-height: 107%;">Right bundle branch block or incomplete RBBB (18%)</span></p><p class="MsoListParagraphCxSpMiddle" style="margin-left: 30.75pt; mso-add-space: auto; text-indent: -.25in; mso-list: l1 level1 lfo1;"><!--[if !supportLists]--><span style="font-size: 10.0pt; line-height: 107%; font-family: Symbol; mso-fareast-font-family: Symbol; mso-bidi-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt 'Times New Roman';">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </span></span></span><!--[endif]--><span style="font-size: 10.0pt; line-height: 107%;">Right ventricular strain: T wave inversion in right precordial leads and inferior leads (only present here in V1 and Lead III, which is often normal).</span></p><p class="MsoListParagraphCxSpMiddle" style="margin-left: 30.75pt; mso-add-space: auto; text-indent: -.25in; mso-list: l1 level1 lfo1;"><!--[if !supportLists]--><span style="font-size: 10.0pt; line-height: 107%; font-family: Symbol; mso-fareast-font-family: Symbol; mso-bidi-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt 'Times New Roman';">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </span></span></span><!--[endif]--><span style="font-size: 10.0pt; line-height: 107%;">Right axis deviation (16%).<span style="mso-spacerun: yes;">&nbsp; </span>Present here, but not severe at around 100 degrees.</span></p><p class="MsoListParagraphCxSpMiddle" style="margin-left: 30.75pt; mso-add-space: auto; text-indent: -.25in; mso-list: l1 level1 lfo1;"><!--[if !supportLists]--><span style="font-size: 10.0pt; line-height: 107%; font-family: Symbol; mso-fareast-font-family: Symbol; mso-bidi-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt 'Times New Roman';">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </span></span></span><!--[endif]--><span style="font-size: 10.0pt; line-height: 107%;">S1 – Q3 – T3 the “classic” but not often present, sign of pulmonary embolism.<span style="mso-spacerun: yes;">&nbsp; </span>The<span style="mso-spacerun: yes;">&nbsp; </span>S wave in I may simply be the RBBB and the Q wave with T wave inversion may be a normal variant.</span></p><p class="MsoListParagraphCxSpMiddle" style="margin-left: 30.75pt; mso-add-space: auto; text-indent: -.25in; mso-list: l1 level1 lfo1;"><!--[if !supportLists]--><span style="font-size: 10.0pt; line-height: 107%; font-family: Symbol; mso-fareast-font-family: Symbol; mso-bidi-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt 'Times New Roman';">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </span></span></span><!--[endif]--><span style="font-size: 10.0pt; line-height: 107%;">Non-specific ST segment and T wave changes (50%)</span></p><p class="MsoListParagraphCxSpLast" style="margin-left: 30.75pt; mso-add-space: auto; text-indent: -.25in; mso-list: l1 level1 lfo1;"><!--[if !supportLists]--><span style="font-size: 10.0pt; line-height: 107%; font-family: Symbol; mso-fareast-font-family: Symbol; mso-bidi-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt 'Times New Roman';">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </span></span></span><!--[endif]--><span style="font-size: 10.0pt; line-height: 107%;">P pulmonale (we cannot see P waves)</span></p><p class="MsoNormal"><span style="font-size: 10.0pt; line-height: 107%;">There are also ST and T wave changes that resemble <strong style="mso-bidi-font-weight: normal;"><a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6282764/">Brugada Syndrome</a>, </strong>a genetic disorder of the sodium channel that can cause sudden death.<span style="mso-spacerun: yes;">&nbsp; </span>Illness can unmask the ECG changes that point to Brugada syndrome, but also there are conditions that cause similar ECG changes without the patient actually having a channelopathy. The shape of the ST and inverted T wave in V1 here are “Brugada like”. In Brugada Syndrome, those changes are usually seen in V1 and V2.<span style="mso-spacerun: yes;">&nbsp; </span></span></p><p class="MsoNormal"><span style="font-size: 10.0pt; line-height: 107%;">The loss of P waves and the tall, peaked T waves with narrow bases are indicative of <strong style="mso-bidi-font-weight: normal;"><a href="https://rebelem.com/ecg-changes-hyperkalemia/">hyperkalemia</a></strong>. It is difficult to determine just from the ECG how far along the patient is in serum potassium levels, but widening of the QRS with loss of voltage is a dire sign.<span style="mso-spacerun: yes;">&nbsp; </span>Because hyperkalemia can progress swiftly to a “sine wave” pattern, it is crucial to make the diagnosis and begin treatment as soon as possible.<span style="mso-spacerun: yes;">&nbsp; </span>Usually, the serum K is high because the K has moved out of the intracellular space and entered the serum. Rather than remove K from the body, it is necessary to “push” it back into the cells, where it rightly belongs.<span style="mso-spacerun: yes;">&nbsp; </span></span></p><p class="MsoNormal" style="margin-bottom: .0001pt;"><span style="font-size: 10.0pt; line-height: 107%;">And, to make matters even more confusing, this ECG show signs of drug toxicity, specifically <strong style="mso-bidi-font-weight: normal;"><a href="https://litfl.com/tricyclic-overdose-sodium-channel-blocker-toxicity/">sodium channel blocker overdose</a>.<span style="mso-spacerun: yes;">&nbsp; </span></strong>Tricyclic antidepressants and some antiarrhythmics fall into this broad category. <span style="mso-spacerun: yes;">&nbsp;</span>Remember, this patient was found unresponsive, and we have no remote OR recent medical history.<span style="mso-spacerun: yes;">&nbsp; </span>Everything is on the table.<span style="mso-spacerun: yes;">&nbsp;&nbsp; </span><span style="mso-spacerun: yes;">&nbsp;</span>ECG signs of sodium channel blocker OD include:</span></p><p class="MsoListParagraphCxSpFirst" style="margin-left: 30.75pt; mso-add-space: auto; text-indent: -.25in; mso-list: l0 level1 lfo2;"><!--[if !supportLists]--><span style="font-size: 10.0pt; line-height: 107%; font-family: Symbol; mso-fareast-font-family: Symbol; mso-bidi-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt 'Times New Roman';">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </span></span></span><!--[endif]--><span style="font-size: 10.0pt; line-height: 107%;">Sinus tachycardia</span></p><p class="MsoListParagraphCxSpMiddle" style="margin-left: 30.75pt; mso-add-space: auto; text-indent: -.25in; mso-list: l0 level1 lfo2;"><!--[if !supportLists]--><span style="font-size: 10.0pt; line-height: 107%; font-family: Symbol; mso-fareast-font-family: Symbol; mso-bidi-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt 'Times New Roman';">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </span></span></span><!--[endif]--><span style="font-size: 10.0pt; line-height: 107%;">Wide QRS complex</span></p><p class="MsoListParagraphCxSpMiddle" style="margin-left: 30.75pt; mso-add-space: auto; text-indent: -.25in; mso-list: l0 level1 lfo2;"><!--[if !supportLists]--><span style="font-size: 10.0pt; line-height: 107%; font-family: Symbol; mso-fareast-font-family: Symbol; mso-bidi-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt 'Times New Roman';">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </span></span></span><!--[endif]--><span style="font-size: 10.0pt; line-height: 107%;">Prolongation of the PR interval or QT interval</span></p><p class="MsoListParagraphCxSpMiddle" style="margin-left: 30.75pt; mso-add-space: auto; text-indent: -.25in; mso-list: l0 level1 lfo2;"><!--[if !supportLists]--><span style="font-size: 10.0pt; line-height: 107%; font-family: Symbol; mso-fareast-font-family: Symbol; mso-bidi-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt 'Times New Roman';">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </span></span></span><!--[endif]--><span style="font-size: 10.0pt; line-height: 107%;">Right bundle branch block</span></p><p class="MsoListParagraphCxSpLast" style="margin-left: 30.75pt; mso-add-space: auto; text-indent: -.25in; mso-list: l0 level1 lfo2;"><!--[if !supportLists]--><span style="font-size: 10.0pt; line-height: 107%; font-family: Symbol; mso-fareast-font-family: Symbol; mso-bidi-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt 'Times New Roman';">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </span></span></span><!--[endif]--><span style="font-size: 10.0pt; line-height: 107%;">Brugada pattern</span></p><p class="MsoNormal" style="margin-bottom: .0001pt; line-height: normal;"><strong style="mso-bidi-font-weight: normal;"><span style="font-size: 10.0pt; color: #00b050;">Hospital Follow Up<span style="mso-spacerun: yes;">&nbsp;&nbsp;&nbsp;&nbsp; </span></span></strong><span style="font-size: 10.0pt;">At this time, we have only a preliminary follow up report.<span style="mso-spacerun: yes;">&nbsp; </span>Notably, this young woman was found to be in <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5298445/">diabetic ketoacidosis</a>, with a blood glucose level of 1,332 mg/dL! As a result, she was also hyperkalemic, with a serum potassium of 8.2.<span style="mso-spacerun: yes;">&nbsp; </span>The severe dehydration and acidosis of DKA cause sinus tachycardia.</span></p><p class="MsoNormal"><strong style="mso-bidi-font-weight: normal;"><em style="mso-bidi-font-style: normal;"><span style="font-size: 10.0pt; line-height: 107%; color: #595959; mso-themecolor: text1; mso-themetint: 166; mso-style-textfill-fill-color: #595959; mso-style-textfill-fill-themecolor: text1; mso-style-textfill-fill-alpha: 100.0%; mso-style-textfill-fill-colortransforms: 'lumm=65000 lumo=35000';">Thanks to Sebastian Garay for donating this interesting ECG.</span></em></strong></p></div></div></div><div class="field field-name-field-rate-this-content field-type-fivestar field-label-above"><div class="field-label">Rate this content:&nbsp;</div><div class="field-items"><div class="field-item even"><form class="fivestar-widget" action="/taxonomy/term/67/feed" method="post" id="fivestar-custom-widget--3" accept-charset="UTF-8"><div><div class="clearfix fivestar-average-text fivestar-average-stars fivestar-form-item fivestar-hearts"><div class="form-item form-type-fivestar form-item-vote"> <div class="form-item form-type-select form-item-vote"> <select id="edit-vote--6" name="vote" class="form-select"><option value="-">Select rating</option><option value="20">Give Tachycardia In An Unresponsive Patient 1/5</option><option value="40">Give Tachycardia In An Unresponsive Patient 2/5</option><option value="60">Give Tachycardia In An Unresponsive Patient 3/5</option><option value="80" selected="selected">Give Tachycardia In An Unresponsive Patient 4/5</option><option value="100">Give Tachycardia In An Unresponsive Patient 5/5</option></select> <div class="description"><div class="fivestar-summary fivestar-summary-average-count"><span class="average-rating">Average: <span >3.6</span></span> <span class="total-votes">(<span >16</span> votes)</span></div></div> </div> </div> </div><input class="fivestar-submit form-submit" type="submit" id="edit-fivestar-submit--3" name="op" value="Rate" /><input type="hidden" name="form_build_id" value="form-4rbEFzbEH8xriNr0WL7acrHi87V3MO8I6RxRKjfNYeY" /> <input type="hidden" name="form_id" value="fivestar_custom_widget" /> </div></form></div></div></div><div class="field field-name-field-taxonomy field-type-taxonomy-term-reference field-label-above"><div class="field-label">Related Terms:&nbsp;</div><div class="field-items"><div class="field-item even"><a href="/ecg/tachycardia" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Tachycardia</a></div><div class="field-item odd"><a href="/ecg/sinus-tachycardia" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Sinus tachycardia</a></div><div class="field-item even"><a href="/ecg/right-bundle-branch-block-1" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Right bundle branch block</a></div><div class="field-item odd"><a href="/ecg/bifascicular-block" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Bifascicular block</a></div><div class="field-item even"><a href="/ecg/left-posterior-hemiblock" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Left posterior hemiblock</a></div><div class="field-item odd"><a href="/ecg/right-axis-deviation" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Right axis deviation</a></div><div class="field-item even"><a href="/ecg/sa-exit-block" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">SA exit block</a></div><div class="field-item odd"><a href="/ecg/wide-qrs-complex" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Wide QRS complex</a></div><div class="field-item even"><a href="/ecg/diabetic-ketoacidosis" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Diabetic ketoacidosis</a></div><div class="field-item odd"><a href="/ecg/hyperkalemia" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Hyperkalemia</a></div><div class="field-item even"><a href="/ecg/brugada-sign" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Brugada sign</a></div><div class="field-item odd"><a href="/ecg/tricyclic-antidepressant-overdose" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Tricyclic antidepressant overdose</a></div></div></div><ul class="links inline"><li class="addtoany first last"><span><span class="a2a_kit a2a_target addtoany_list" id="da2a_3"> <a class="a2a_dd addtoany_share_save" href="https://www.addtoany.com/share#url=https%3A%2F%2Fwww.ecgguru.com%2Fecg%2Ftachycardia-unresponsive-patient&amp;title=Tachycardia%20In%20An%20Unresponsive%20Patient"><img src="/sites/all/modules/addtoany/images/share_save_256_24.png" width="256" height="24" alt="Share"/></a> </span> </span></li> </ul> Wed, 21 Aug 2019 02:48:51 +0000 Dawn 775 at https://www.ecgguru.com https://www.ecgguru.com/ecg/tachycardia-unresponsive-patient#comments Syncope and tachycardia https://www.ecgguru.com/ecg/syncope-and-tachycardia <div class="field field-name-field-ecg field-type-image field-label-hidden"><div class="field-items"><div class="field-item even"><a href="/ecg/syncope-and-tachycardia"><img typeof="foaf:Image" src="https://www.ecgguru.com/sites/default/files/MR112%20Wide%20complex%20rhythm.jpg" width="2000" height="765" alt="" /></a></div></div></div><div class="field field-name-field-ecg-interpretation field-type-text-long field-label-hidden"><div class="field-items"><div class="field-item even"><p><strong>The patient:</strong>&nbsp; This ECG is taken from a 55-year-old man whose wife called 911 because he had a syncopal episode.&nbsp; When the paramedics arrived, he was conscious and alert, and denied any symptoms.&nbsp; He gave a history of "cardiac", diabetes, and opiate abuse.&nbsp; We do not know the nature of his cardiac history or his medications.&nbsp;&nbsp;</p><p>It is difficult to pinpoint a definite diagnosis with this lack of information and a clearly abnormal ECG.&nbsp; We will limit our discussion to listing the abnormalities seen:</p><p><strong>The ECG rhythm:</strong>&nbsp; There is a fast, regular rhythm that is supraventricular in origin (there are P waves).&nbsp; When a supraventricular rhythm has a rate of about 150 per minute, we should ALWAYS consider ATRIAL FLUTTER WITH 2:1 CONDUCTION.&nbsp; Atrial flutter produces P waves (flutter waves) at approximately 250-350 per minute.&nbsp; The normal AV node is able to conduct half of these, at a rate of about 150 per minute. Atrial flutter with 2:1 conduction is the most common presentation of new-onset atrial flutter.&nbsp; It is often missed by people who expect to see several flutter waves in a row, producing the "sawtooth pattern".&nbsp; That being said, atrial flutter is usually discernable in at least a few leads if it is present.&nbsp; We do not see any signs of flutter waves in this ECG.</p><p>That leaves us with a differential diagnosis of sinus tachycardia vs. one of the regular supraventricular tachycardias like reentrant tachycardias or atrial tachycardia.&nbsp; Sinus tachycardia can be recognized by several features. If we are fortunate enough to witness the onset or offset of the fast rhythm, will will recognize sinus tachycardia by a "warm up" or gradual speeding up of the rate, and a "cool down", or gradual slowing.&nbsp; On the other hand, SVTs often have abrupt onset and offset.&nbsp; Sinus tachycardia often has a very obvious cause, such as hypovolemia, fever, pain, anxiety, vigorous exercise, or hypoxia.&nbsp; Sinus tachycardia usually has a distinct, upright P wave in Lead II, and a clearly-seen, often negative, P wave in Lead V1.&nbsp; This ECG does not show the onset of the tachycardia, and is not long enough to evaluate for rate changes. Lead II appears to have upright P waves on the downslope of the previous T waves. V1 has deeply negative P waves, and V4 has the most clearly-seen P waves.&nbsp; Without being positive, this looks more like sinus tachycardia than a reentrant tachycardia.&nbsp; It would help to know more about the patient's condition.</p><p><strong>The QRS complexes:</strong>&nbsp; The QRS complexes are slightly wide at .106 seconds.&nbsp; This is not wide enough to consider bundle branch block.&nbsp; Other conditions can cause widening, such as left ventricular hypertrophy and hemiblock, as well as some drug and electrolyte effects.&nbsp; The frontal plane axis is abnormally leftward, which supports a left anterior hemiblock (left anterior fascicular block) diagnosis. There is not a distinct qR pattern in Lead I or rS in Lead III, however.&nbsp; Lead aVF appears to have a pathological Q wave - could this be why Lead III does not have a distinct r wave?&nbsp; &nbsp;</p><p>While the chest leads do not show increased voltage that would indicate left ventricular hypertrophy, the left axis and the tall QRS in aVL do meet the criteria for LVH.&nbsp; LVH is not diagnosed by ECG, but it does cause changes on the ECG, such as increased voltage in left-sided leads and a "strain" pattern.&nbsp; Leads I and aVL demonstrate the strain pattern of downsloping ST segments and T wave inversion, but the chest leads do not.&nbsp; &nbsp;</p><p>The QRS complexes in V2, V3, and V4 are fragmented, which is an equivalent to pathological Q wave.&nbsp; This may indicate a prior anterior wall M.I.&nbsp; There is very slight J-point elevation in the right-sided chest leads, but may be due to LVH.</p><p>Without knowing more about this patient's past medical history, or the results of his physical exam, it is difficult to assign meaning to all these abnormal findings.&nbsp; It is unfortunate that he refused transport to a hospital, and we can only hope that he later found his way there for treatment.</p><p>Many thanks to Jon Hamilton for donating this ECG to the ECG Guru</p></div></div></div><div class="field field-name-field-rate-this-content field-type-fivestar field-label-above"><div class="field-label">Rate this content:&nbsp;</div><div class="field-items"><div class="field-item even"><form class="fivestar-widget" action="/taxonomy/term/67/feed" method="post" id="fivestar-custom-widget--4" accept-charset="UTF-8"><div><div class="clearfix fivestar-average-text fivestar-average-stars fivestar-form-item fivestar-hearts"><div class="form-item form-type-fivestar form-item-vote"> <div class="form-item form-type-select form-item-vote"> <select id="edit-vote--8" name="vote" class="form-select"><option value="-">Select rating</option><option value="20">Give Syncope and tachycardia 1/5</option><option value="40">Give Syncope and tachycardia 2/5</option><option value="60">Give Syncope and tachycardia 3/5</option><option value="80">Give Syncope and tachycardia 4/5</option><option value="100" selected="selected">Give Syncope and tachycardia 5/5</option></select> <div class="description"><div class="fivestar-summary fivestar-summary-average-count"><span class="average-rating">Average: <span >4.4</span></span> <span class="total-votes">(<span >7</span> votes)</span></div></div> </div> </div> </div><input class="fivestar-submit form-submit" type="submit" id="edit-fivestar-submit--4" name="op" value="Rate" /><input type="hidden" name="form_build_id" value="form-oNq2IbY_BbCUi0Z_xXHrseUNnMCVJwMnX8rMQOcK5Ws" /> <input type="hidden" name="form_id" value="fivestar_custom_widget" /> </div></form></div></div></div><div class="field field-name-field-taxonomy field-type-taxonomy-term-reference field-label-above"><div class="field-label">Related Terms:&nbsp;</div><div class="field-items"><div class="field-item even"><a href="/ecg/tachycardia" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Tachycardia</a></div><div class="field-item odd"><a href="/ecg/wide-qrs" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Wide QRS</a></div><div class="field-item even"><a href="/ecg/lad" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">LAD</a></div><div class="field-item odd"><a href="/ecg/left-axis-deviation" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Left axis deviation</a></div><div class="field-item even"><a href="/ecg/left-anterior-hemiblock" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Left anterior hemiblock</a></div><div class="field-item odd"><a href="/ecg/left-anterior-fascicular-block" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Left anterior fascicular block</a></div><div class="field-item even"><a href="/ecg/sinus-tachycardia" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Sinus tachycardia</a></div></div></div><ul class="links inline"><li class="addtoany first last"><span><span class="a2a_kit a2a_target addtoany_list" id="da2a_4"> <a class="a2a_dd addtoany_share_save" href="https://www.addtoany.com/share#url=https%3A%2F%2Fwww.ecgguru.com%2Fecg%2Fsyncope-and-tachycardia&amp;title=Syncope%20and%20tachycardia"><img src="/sites/all/modules/addtoany/images/share_save_256_24.png" width="256" height="24" alt="Share"/></a> </span> </span></li> </ul> Mon, 14 Jan 2019 04:32:51 +0000 Dawn 763 at https://www.ecgguru.com https://www.ecgguru.com/ecg/syncope-and-tachycardia#comments Left Bundle Branch Block https://www.ecgguru.com/ecg/left-bundle-branch-block-3 <div class="field field-name-field-ecg field-type-image field-label-hidden"><div class="field-items"><div class="field-item even"><a href="/ecg/left-bundle-branch-block-3"><img typeof="foaf:Image" src="https://www.ecgguru.com/sites/default/files/LB118.jpg" width="1631" height="1186" alt="" /></a></div></div></div><div class="field field-name-field-ecg-interpretation field-type-text-long field-label-hidden"><div class="field-items"><div class="field-item even"><p class="MsoNormal">This ECG was taken from an unknown patient.&nbsp; It shows sinus tachycardia with left bundle branch block. The ECG criteria for left bundle branch block are:<span style="font-size: 8pt;">&nbsp;</span></p><p class="MsoNormal">* Wide QRS (.12 seconds or greater)</p><p class="MsoNormal"><span style="font-size: 13.008px;">* Negative QRS deflection in V1</span></p><p class="MsoNormal">* Positive QRS in Leads I and V6<span style="font-size: 8pt;">&nbsp;</span></p><p class="MsoNormal"><span style="font-size: 8pt;">* Supraventricular rhythm</span></p><p class="MsoNormal">In addition to these criteria, left bundle branch block will cause repolarization abnormalities.&nbsp; This is because depolarization is altered through the left ventricle, which causes repolarization to also be altered.&nbsp; Instead of the electrical impulse traveling down the left bundle branch to depolarize the left ventricle, it depolarizes the right ventricle first, then spreads cell-to-cell across the larger left ventricle. The ST and T wave changes caused by left bundle branch block are normally “discordant”.&nbsp; That is, the ST segment will be elevated in leads with negative QRS complexes, and depressed in leads with positive QRS complexes.&nbsp; This elevation and depression of the ST segment may “imitate” the changes caused by acute myocardial infarction.&nbsp; They may also work to conceal M.I. changes, as we may not recognize &nbsp;STEMI as we attribute the ST changes to the left bundle branch block itself.<span style="font-size: 8pt;">&nbsp;</span></p><p class="MsoNormal">For more on determining the presence of acute M.I. when the patient has left bundle branch block, check out these links: &nbsp;<a title="LBBB w AMI" href="https://www.ecgguru.com/ecg/lbbb-acute-mi">ECG Guru, LBBB with AMI</a>; <a title="LITFL Sgarbossa Criteria" href="http://lifeinthefastlane.com/ecg-library/basics/sgarbossa/">Life in the Fast Lane, Sgarbossa Criteria</a>;&nbsp;<a title="EMS 12 Lead Sgarbossa" href="http://www.ems12lead.com/?feb_network_search_context=blog&amp;s=sgarbossa+">EMS 12-Lead, Sgarbossa Criteria;</a>&nbsp; <a title="Dr. Smith Mod Sgarbossa" href="http://hqmeded-ecg.blogspot.com/2011/05/lbbb-is-there-stemi.html">Dr. Smith's Modified Sgarbossa Criteria</a>.<a style="font-size: 13.008px;" title="EMS 12 Lead Sgarbossa" href="http://www.ems12lead.com/?feb_network_search_context=blog&amp;s=sgarbossa+"><span style="font-size: 8.0pt; line-height: 107%;">&nbsp;</span></a></p><p class="MsoNormal">This ECG has another interesting teaching point.&nbsp; In some leads, part of the QRS is flat or nearly flat with the baseline.&nbsp; Look at Lead I for an example.&nbsp; It is very hard to tell that this represents a wide QRS.&nbsp; Fortunately, the precordial leads, especially V1 through V4, show the width better.&nbsp; In reality, all the QRS complexes represent the time it takes to depolarize the ventricles, and that time is the same, regardless of which lead you are looking in.&nbsp; Some leads are just easier than others.&nbsp; It often helps to look at the QRSD (QRS duration) at the top of the page to see how the computer measured the QRS duration.&nbsp; It is usually accurate.&nbsp; In the illustrated case, the QRSD is measured in milliseconds, 124 ms (or .124 seconds).<span style="font-size: 13.008px;">&nbsp;</span><span style="font-size: 13.008px;">&nbsp;</span></p><p class="MsoNormal">You might also notice that the frontal plane axis is shifted to the left.&nbsp; That is, Lead II (viewpoint from left leg) has a negative QRS while Leads I and aVL (from left arm) are positive.&nbsp; This is common in left bundle branch block, because the left ventricle is being depolarized from the right ventricle, which is located inferior and medial. Because axis is affected by many factors, left axis deviation is not a prerequisite for the diagnosis of left bundle branch block.</p></div></div></div><div class="field field-name-field-rate-this-content field-type-fivestar field-label-above"><div class="field-label">Rate this content:&nbsp;</div><div class="field-items"><div class="field-item even"><form class="fivestar-widget" action="/taxonomy/term/67/feed" method="post" id="fivestar-custom-widget--5" accept-charset="UTF-8"><div><div class="clearfix fivestar-average-text fivestar-average-stars fivestar-form-item fivestar-hearts"><div class="form-item form-type-fivestar form-item-vote"> <div class="form-item form-type-select form-item-vote"> <select id="edit-vote--10" name="vote" class="form-select"><option value="-">Select rating</option><option value="20">Give Left Bundle Branch Block 1/5</option><option value="40">Give Left Bundle Branch Block 2/5</option><option value="60" selected="selected">Give Left Bundle Branch Block 3/5</option><option value="80">Give Left Bundle Branch Block 4/5</option><option value="100">Give Left Bundle Branch Block 5/5</option></select> <div class="description"><div class="fivestar-summary fivestar-summary-average-count"><span class="average-rating">Average: <span >2.5</span></span> <span class="total-votes">(<span >2</span> votes)</span></div></div> </div> </div> </div><input class="fivestar-submit form-submit" type="submit" id="edit-fivestar-submit--5" name="op" value="Rate" /><input type="hidden" name="form_build_id" value="form-bVBfCKozILDh1YzevskAD4BYUmGJTbaB74KT4tcJQCE" /> <input type="hidden" name="form_id" value="fivestar_custom_widget" /> </div></form></div></div></div><div class="field field-name-field-taxonomy field-type-taxonomy-term-reference field-label-above"><div class="field-label">Related Terms:&nbsp;</div><div class="field-items"><div class="field-item even"><a href="/ecg/left-bundle-branch-block-0" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Left bundle branch block</a></div><div class="field-item odd"><a href="/ecg/left-axis-deviation" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Left axis deviation</a></div><div class="field-item even"><a href="/ecg/sinus-tachycardia" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Sinus tachycardia</a></div></div></div><ul class="links inline"><li class="addtoany first last"><span><span class="a2a_kit a2a_target addtoany_list" id="da2a_5"> <a class="a2a_dd addtoany_share_save" href="https://www.addtoany.com/share#url=https%3A%2F%2Fwww.ecgguru.com%2Fecg%2Fleft-bundle-branch-block-3&amp;title=Left%20Bundle%20Branch%20Block"><img src="/sites/all/modules/addtoany/images/share_save_256_24.png" width="256" height="24" alt="Share"/></a> </span> </span></li> </ul> Wed, 18 Jan 2017 00:36:28 +0000 Dawn 723 at https://www.ecgguru.com https://www.ecgguru.com/ecg/left-bundle-branch-block-3#comments Teaching Series - Tachycardia and Left Anterior Fascicular Block https://www.ecgguru.com/ecg/teaching-series-tachycardia-and-left-anterior-fascicular-block <div class="field field-name-field-ecg field-type-image field-label-hidden"><div class="field-items"><div class="field-item even"><a href="/ecg/teaching-series-tachycardia-and-left-anterior-fascicular-block"><img typeof="foaf:Image" src="https://www.ecgguru.com/sites/default/files/LAH101%20A.jpg" width="1800" height="666" alt="" /></a></div><div class="field-item odd"><a href="/ecg/teaching-series-tachycardia-and-left-anterior-fascicular-block"><img typeof="foaf:Image" src="https://www.ecgguru.com/sites/default/files/LAH101%20%20-%20B_0.jpg" width="1600" height="1175" alt="" /></a></div><div class="field-item even"><a href="/ecg/teaching-series-tachycardia-and-left-anterior-fascicular-block"><img typeof="foaf:Image" src="https://www.ecgguru.com/sites/default/files/LAH101%20%20C.jpg" width="1707" height="1309" alt="" /></a></div></div></div><div class="field field-name-field-ecg-interpretation field-type-text-long field-label-hidden"><div class="field-items"><div class="field-item even"><p class="MsoNormal"><span style="font-size: 12.0pt; line-height: 107%;">This series of three ECGs is from a 60-year-old man who was brought to the Emergency Department after being involved in a motor vehicle accident.&nbsp; No injuries were found, but the patient was severely intoxicated by alcohol consumption.&nbsp; He was conscious but agitated.</span><span style="font-size: 12pt;">&nbsp;</span></p><p class="MsoNormal"><strong><span style="font-size: 12.0pt; line-height: 107%;">ECG NO. 1&nbsp;&nbsp; &nbsp;&nbsp;15:07:23</span></strong></p><p class="MsoNormal"><span style="font-size: 12.0pt; line-height: 107%;">The first ECG was taken by fire-rescue personnel at the scene of the accident. His hemodynamic status was stable, and the rate was not addressed in the field. ECG No. 1 shows a supraventricular rhythm at 161 bpm, with a narrow QRS and P waves visible before each QRS.</span><span style="font-size: 12pt;">&nbsp;</span></p><p class="MsoNormal"><span style="font-size: 12.0pt; line-height: 107%;">A notable feature of this ECG are the left axis deviation, by default diagnosed at left anterior hemiblock (left anterior fascicular block).&nbsp; The .10 second QRS width is typical of LAHB, as is the rS pattern in Lead III.</span></p><p class="MsoNormal"><span style="font-size: 12.0pt; line-height: 107%;">Also &nbsp;noted is the unusual R wave progression in the precordial leads.&nbsp; The R waves are prominent in V2, and then fail to progress across the precordium, and the S waves persist.&nbsp;</span><span style="font-size: 12pt;">This is probably due to the hemiblock.</span><span style="font-size: 12pt;">&nbsp; </span><span style="font-size: 12pt;">We do not know this patient’s medical history, except that he self-described as an “alcoholic”.</span><span style="font-size: 12pt;">&nbsp; </span><span style="font-size: 12pt;">LAFB can be associated with coronary artery disease.</span><span style="font-size: 12pt;">&nbsp;</span></p><p class="MsoNormal"><strong><span style="font-size: 12.0pt; line-height: 107%;">ECG NO. 2&nbsp;&nbsp;&nbsp;&nbsp; &nbsp;15:20:38</span></strong></p><p class="MsoNormal"><span style="font-size: 12.0pt; line-height: 107%;">Now being evaluated in the Emergency Dept., we see the patient's heart rate is 163 bpm.&nbsp; Some variability in the rate was noted with patient agitation and activity, so it was determined that the rhythm was probably sinus tachycardia.&nbsp; There were no other significant changes in the ECG from the first one.&nbsp; Unfortunately, we no longer have access to lab results, so we do not know his electrolyte or hydration status.&nbsp; Labs confirmed ETOH intoxication.</span><span style="font-size: 12pt;">&nbsp;</span></p><p class="MsoNormal"><strong><span style="font-size: 12.0pt; line-height: 107%;">ECG NO. 3&nbsp; &nbsp;15:43:26</span></strong></p><p class="MsoNormal"><span style="font-size: 12.0pt; line-height: 107%;">After IV fluids and a short rest, the patient is much less agitated, and is conversant.&nbsp; His heart rate is now 105 bpm.&nbsp; This rate was reached by gradual increments, further evidence that this was SINUS TACHYCARDIA all along.&nbsp; Reentrant rhythms (AVNT, AVNRT, atrial flutter) start and stop abruptly.&nbsp; Some leads on ECG No. 3 may suggest an underlying atrial flutter (aVR, aVF), but the waves do not “march out”.</span><span style="font-size: 12pt;">&nbsp;</span></p><p class="MsoNormal"><strong><span style="font-size: 12.0pt; line-height: 107%;">SINUS TACHYCARDIA VS. PSVT</span></strong></p><p class="MsoNormal"><span style="font-size: 12.0pt; line-height: 107%;">At rates over 140 per minute, it can sometimes be difficult to differentiate sinus tach from reentrant tachycardias (PSVT).&nbsp; Seeing gradual adjustments of the rate favors a diagnosis of sinus tach.&nbsp; Also, seeing an obvious “cause” of sinus tach helps.&nbsp; In this case, the patient was a chronic alcohol abuser who was intoxicated.&nbsp; This is associated with sinus tachycardia, due to stimulation of catecholamine secretion and cell membrane alterations.&nbsp; Also, he was agitated and possibly dehydrated.</span></p></div></div></div><div class="field field-name-field-rate-this-content field-type-fivestar field-label-above"><div class="field-label">Rate this content:&nbsp;</div><div class="field-items"><div class="field-item even"><form class="fivestar-widget" action="/taxonomy/term/67/feed" method="post" id="fivestar-custom-widget--6" accept-charset="UTF-8"><div><div class="clearfix fivestar-average-text fivestar-average-stars fivestar-form-item fivestar-hearts"><div class="form-item form-type-fivestar form-item-vote"> <div class="form-item form-type-select form-item-vote"> <select id="edit-vote--12" name="vote" class="form-select"><option value="-">Select rating</option><option value="20">Give Teaching Series - Tachycardia and Left Anterior Fascicular Block 1/5</option><option value="40">Give Teaching Series - Tachycardia and Left Anterior Fascicular Block 2/5</option><option value="60">Give Teaching Series - Tachycardia and Left Anterior Fascicular Block 3/5</option><option value="80" selected="selected">Give Teaching Series - Tachycardia and Left Anterior Fascicular Block 4/5</option><option value="100">Give Teaching Series - Tachycardia and Left Anterior Fascicular Block 5/5</option></select> <div class="description"><div class="fivestar-summary fivestar-summary-average-count"><span class="average-rating">Average: <span >3.1</span></span> <span class="total-votes">(<span >11</span> votes)</span></div></div> </div> </div> </div><input class="fivestar-submit form-submit" type="submit" id="edit-fivestar-submit--6" name="op" value="Rate" /><input type="hidden" name="form_build_id" value="form-PTnV96SWfIW73xVXgpfKMVGrqpAmSHS4xcJLX-wnYQU" /> <input type="hidden" name="form_id" value="fivestar_custom_widget" /> </div></form></div></div></div><div class="field field-name-field-taxonomy field-type-taxonomy-term-reference field-label-above"><div class="field-label">Related Terms:&nbsp;</div><div class="field-items"><div class="field-item even"><a href="/ecg/sinus-tachycardia" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Sinus tachycardia</a></div><div class="field-item odd"><a href="/ecg/supraventricular-tachycardia" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Supraventricular tachycardia</a></div><div class="field-item even"><a href="/ecg/psvt" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">PSVT</a></div><div class="field-item odd"><a href="/ecg/teaching-series" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Teaching series</a></div><div class="field-item even"><a href="/ecg/left-anterior-fascicular-block" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Left anterior fascicular block</a></div><div class="field-item odd"><a href="/ecg/left-anterior-hemiblock" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Left anterior hemiblock</a></div><div class="field-item even"><a href="/ecg/poor-r-wave-progression-0" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Poor R wave progression</a></div></div></div><ul class="links inline"><li class="addtoany first last"><span><span class="a2a_kit a2a_target addtoany_list" id="da2a_6"> <a class="a2a_dd addtoany_share_save" href="https://www.addtoany.com/share#url=https%3A%2F%2Fwww.ecgguru.com%2Fecg%2Fteaching-series-tachycardia-and-left-anterior-fascicular-block&amp;title=Teaching%20Series%20-%20Tachycardia%20and%20Left%20Anterior%20Fascicular%20Block"><img src="/sites/all/modules/addtoany/images/share_save_256_24.png" width="256" height="24" alt="Share"/></a> </span> </span></li> </ul> Sat, 15 Oct 2016 21:48:02 +0000 Dawn 712 at https://www.ecgguru.com https://www.ecgguru.com/ecg/teaching-series-tachycardia-and-left-anterior-fascicular-block#comments ECG Basics: Sinus Tachycardia vs. PSVT https://www.ecgguru.com/ecg/ecg-basics-sinus-tachycardia-vs-psvt <div class="field field-name-field-ecg field-type-image field-label-hidden"><div class="field-items"><div class="field-item even"><a href="/ecg/ecg-basics-sinus-tachycardia-vs-psvt"><img typeof="foaf:Image" src="https://www.ecgguru.com/sites/default/files/160%20ST%20v%20AT.jpg" width="1800" height="272" alt="" /></a></div></div></div><div class="field field-name-field-ecg-interpretation field-type-text-long field-label-hidden"><div class="field-items"><div class="field-item even"><p>Narrow-complex tachycardias can be very confusing to students of basic-level ECG. &nbsp;There are very many rhythms that fall into the broad category of narrow-complex tachycardia. &nbsp;We usually further divide them into sinus tachycardia and other "supraventricular tachycardias". &nbsp;The basic student will want to make this distinction, as well as be able to differentiate atrial fib and atrial flutter from the other SVTs. &nbsp;The more advanced student will want to go into more detail about which mechanism for supraventricular tachycardia is present.</p><p><strong>Just the basics, please. &nbsp;&nbsp;</strong>When the tachycardia is regular, it is most important to determine whether it is a SINUS TACHYCARDIA or a SUPRAVENTRICULAR TACHYCARDIA. &nbsp;(Yes, we are aware that sinus rhythms are supraventricular, but the term "supraventricular tachycardia" or "SVT" is usually reserved for the fast, regular rhythms that are not sinus.) &nbsp;So, what clues will be most helpful to our beginner students?</p><p><strong>Rate &nbsp; </strong>&nbsp;SVTs tend to be faster than sinus tachycardia. &nbsp;More importantly, they are fast regardless of the patient's situation. &nbsp;Sinus tachycardia almost always is reacting to the patient's situation. &nbsp;For instance, a 22-year-old woman resting in a chair with a heart rate of 150 is likely to have an SVT. &nbsp;A 22-year-old woman who is running in a 10 k marathon race and has a heart rate of 160 is responding appropriately to an increased need for oxygen and nutrients to her cells. Sinus tachycardia will ususally be 160 or less, and have an obvious reason for being, such as fever, pain, anxiety, exercise, hypovolemia, hypoxia, or drugs. &nbsp;Unfortunately, many beginning students are told that any narrow-complex tachycardia with a rate of 150 or less is sinus, and over 150 is SVT. While they may be right most of the time, or on the written test they are about to take, this rule should not be applied in "real life". &nbsp;Sinus rhythms can go over 150, and SVTs can be slower than 150. &nbsp;So, what other clues should we be teaching beginners?</p><p><strong>Consider the clinical situation &nbsp; &nbsp;</strong>Look for an obvious cause for sinus tachycardia. &nbsp;If none is found, strongly consider SVT. &nbsp;Remember that pedi<span style="font-size: 13.008px; line-height: 1.538em;">atric patients have faster heart rates, especially infants. &nbsp;If the strip is on a test, with no clinical information, consider these:</span></p><p><strong><span style="font-size: 13.008px; line-height: 1.538em;">Onset and offset &nbsp;&nbsp;</span></strong><span style="font-size: 13.008px; line-height: 1.538em;">Since we develop sinus tachycardia as a reaction to some other condition, the onset of the faster rate will be gradual. &nbsp;That is, each beat will be closer to the last until maximum rate is reached. &nbsp;This may take only a few beats, but there will be a gradual lengthening of the R-to-R intervals. &nbsp;SVT, on the other hand, will usually begin very abruptly, with a premature atrial contraction (PAC). &nbsp;From that beat forward, there is a fast, regular rhythm. &nbsp;We call this <strong>paroxysmal</strong> supraventricular tachycardia, because it begins paroxysmally. &nbsp;These rhythms usually END abruptly, as well. &nbsp;If we are fortunate to see the onset or offset of the tachycardia, we will know whether it is sinus or ectopic in origin.</span></p><p><strong><span style="font-size: 13.008px; line-height: 1.538em;">P waves &nbsp; &nbsp;&nbsp;</span></strong><span style="font-size: 13.008px; line-height: 1.538em;">Sometimes, a tachycardia is so fast that P waves are buried in the preceding T waves and we can't evaluate them. &nbsp;This can make it difficult to differentiate between sinus tachycardia and PSVT. &nbsp;It helps to have multiple leads, especially a 12-lead ECG, because P waves show up better in some leads than in others. &nbsp;Suggest to your students that they check Leads II and V1 if they have the option. &nbsp;PSVT rhythms are often REENTRANT rhythms, caused by a circular conduction pathway that allows one impulse to circle around and reenter the ventricles. &nbsp;These rhythms often have retrograde P waves, which will be negative in the inferior leads (II, III, aVF). &nbsp;SVTs may also have P waves that are after the QRS. &nbsp;Also, the P waves in an ectopic tachycardia will usually look different than the sinus P waves. &nbsp;So, if we catch the onset of the tachycardia, and it is sudden, with a change in the appearance of the P waves, we are certain to have a PSVT.</span></p><p><span style="font-size: 13.008px; line-height: 1.538em;"><strong>Response to treatment.</strong> &nbsp; Sinus tachycardia may respond temporarily to a Valsalva maneuver, or bearing down, but it will return because the <strong>cause</strong> of the sinus tachycardia is still present. &nbsp;Supraventricular tachycardia often is stopped by a Valsalva maneuver or carotid sinus massage. &nbsp;Sinus tachycardia usually responds promptly to addressing its cause - relieving pain, reducing fever, calming anxiety, etc.</span></p><p><span style="font-size: 13.008px; line-height: 1.538em;">It helps to give the students factual information, even when it is necessary to simplify. &nbsp;That way, when they go on to more advanced training, they do not have to "unlearn" factoids they have memorized. &nbsp;I have had to help students "unlearn" the 150 per minute "rule" hundreds of times. &nbsp;And, thanks to the widespread use of rhythm generators for training, many people firmly believe that "sinus tach has a P wave and a T wave and SVT has only a T-P". &nbsp;</span></p></div></div></div><div class="field field-name-field-rate-this-content field-type-fivestar field-label-above"><div class="field-label">Rate this content:&nbsp;</div><div class="field-items"><div class="field-item even"><form class="fivestar-widget" action="/taxonomy/term/67/feed" method="post" id="fivestar-custom-widget--7" accept-charset="UTF-8"><div><div class="clearfix fivestar-average-text fivestar-average-stars fivestar-form-item fivestar-hearts"><div class="form-item form-type-fivestar form-item-vote"> <div class="form-item form-type-select form-item-vote"> <select id="edit-vote--14" name="vote" class="form-select"><option value="-">Select rating</option><option value="20">Give ECG Basics: Sinus Tachycardia vs. PSVT 1/5</option><option value="40">Give ECG Basics: Sinus Tachycardia vs. PSVT 2/5</option><option value="60">Give ECG Basics: Sinus Tachycardia vs. PSVT 3/5</option><option value="80" selected="selected">Give ECG Basics: Sinus Tachycardia vs. PSVT 4/5</option><option value="100">Give ECG Basics: Sinus Tachycardia vs. PSVT 5/5</option></select> <div class="description"><div class="fivestar-summary fivestar-summary-average-count"><span class="average-rating">Average: <span >4</span></span> <span class="total-votes">(<span >3</span> votes)</span></div></div> </div> </div> </div><input class="fivestar-submit form-submit" type="submit" id="edit-fivestar-submit--7" name="op" value="Rate" /><input type="hidden" name="form_build_id" value="form-p3lMNkGW7PKnT_qmyFcLnc98SIibXKrJQddvPH0emeg" /> <input type="hidden" name="form_id" value="fivestar_custom_widget" /> </div></form></div></div></div><div class="field field-name-field-taxonomy field-type-taxonomy-term-reference field-label-above"><div class="field-label">Related Terms:&nbsp;</div><div class="field-items"><div class="field-item even"><a href="/ecg/ecg-basics" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">ECG Basics</a></div><div class="field-item odd"><a href="/ecg/basic-ecg" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Basic ECG</a></div><div class="field-item even"><a href="/ecg/rhythm-strip" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Rhythm strip</a></div><div class="field-item odd"><a href="/ecg/sinus-tachycardia" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Sinus tachycardia</a></div><div class="field-item even"><a href="/ecg/narrow-complex-tachycardia" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Narrow-complex tachycardia</a></div><div class="field-item odd"><a href="/ecg/psvt" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">PSVT</a></div><div class="field-item even"><a href="/ecg/paroxysmal-supraventricular-tachycardia" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Paroxysmal supraventricular tachycardia</a></div></div></div><ul class="links inline"><li class="addtoany first last"><span><span class="a2a_kit a2a_target addtoany_list" id="da2a_7"> <a class="a2a_dd addtoany_share_save" href="https://www.addtoany.com/share#url=https%3A%2F%2Fwww.ecgguru.com%2Fecg%2Fecg-basics-sinus-tachycardia-vs-psvt&amp;title=ECG%20Basics%3A%20%20Sinus%20Tachycardia%20vs.%20PSVT"><img src="/sites/all/modules/addtoany/images/share_save_256_24.png" width="256" height="24" alt="Share"/></a> </span> </span></li> </ul> Thu, 21 Apr 2016 06:13:47 +0000 Dawn 696 at https://www.ecgguru.com https://www.ecgguru.com/ecg/ecg-basics-sinus-tachycardia-vs-psvt#comments ECG Basics: Sinus Tachycardia, Peaked T Waves, and Baseline Artifact https://www.ecgguru.com/ecg/ecg-basics-sinus-tachycardia-peaked-t-waves-and-baseline-artifact <div class="field field-name-field-ecg field-type-image field-label-hidden"><div class="field-items"><div class="field-item even"><a href="/ecg/ecg-basics-sinus-tachycardia-peaked-t-waves-and-baseline-artifact"><img typeof="foaf:Image" src="https://www.ecgguru.com/sites/default/files/159%20Sinus%20Tach%20Baseline%20Artifact%20Peaked%20T%20waves.jpg" width="1800" height="373" alt="" /></a></div></div></div><div class="field field-name-field-ecg-interpretation field-type-text-long field-label-hidden"><div class="field-items"><div class="field-item even"><p>This strip offers several good teaching opportunities. &nbsp;If it were a 12-lead ECG, no doubt it would be a bonanza! &nbsp;First, there is sinus tachycardia at a rate of about 138 per minute. &nbsp;The P waves are all alike and regular. &nbsp;The T waves are tall and narrow, with a sharp peak. &nbsp;This is often a transient sign of hyperkalemia, and should be investigated with serum electrolyte tests and with a 12-lead ECG. &nbsp;In addition, the baseline shows a wandering type of artifact. &nbsp;This is due to the patient's deep breathing, and the fact that the arm electrodes were placed on the chest. &nbsp;This patient was a diabetic in ketoacidosis with hyperkalemia.&nbsp;</p></div></div></div><div class="field field-name-field-rate-this-content field-type-fivestar field-label-above"><div class="field-label">Rate this content:&nbsp;</div><div class="field-items"><div class="field-item even"><form class="fivestar-widget" action="/taxonomy/term/67/feed" method="post" id="fivestar-custom-widget--8" accept-charset="UTF-8"><div><div class="clearfix fivestar-average-text fivestar-average-stars fivestar-form-item fivestar-hearts"><div class="form-item form-type-fivestar form-item-vote"> <div class="form-item form-type-select form-item-vote"> <select id="edit-vote--16" name="vote" class="form-select"><option value="-">Select rating</option><option value="20" selected="selected">Give ECG Basics: Sinus Tachycardia, Peaked T Waves, and Baseline Artifact 1/5</option><option value="40">Give ECG Basics: Sinus Tachycardia, Peaked T Waves, and Baseline Artifact 2/5</option><option value="60">Give ECG Basics: Sinus Tachycardia, Peaked T Waves, and Baseline Artifact 3/5</option><option value="80">Give ECG Basics: Sinus Tachycardia, Peaked T Waves, and Baseline Artifact 4/5</option><option value="100">Give ECG Basics: Sinus Tachycardia, Peaked T Waves, and Baseline Artifact 5/5</option></select> <div class="description"><div class="fivestar-summary fivestar-summary-average-count"><span class="average-rating">Average: <span >1</span></span> <span class="total-votes">(<span >1</span> vote)</span></div></div> </div> </div> </div><input class="fivestar-submit form-submit" type="submit" id="edit-fivestar-submit--8" name="op" value="Rate" /><input type="hidden" name="form_build_id" value="form-vYAb1LI59aSOO1DVgWyqGHfiYK50oscnwD9FUc-Afhg" /> <input type="hidden" name="form_id" value="fivestar_custom_widget" /> </div></form></div></div></div><div class="field field-name-field-taxonomy field-type-taxonomy-term-reference field-label-above"><div class="field-label">Related Terms:&nbsp;</div><div class="field-items"><div class="field-item even"><a href="/ecg/rhythm-strip" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Rhythm strip</a></div><div class="field-item odd"><a href="/ecg/ecg-basics" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">ECG Basics</a></div><div class="field-item even"><a href="/ecg/basic-ecg" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Basic ECG</a></div><div class="field-item odd"><a href="/ecg/sinus-tachycardia" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Sinus tachycardia</a></div><div class="field-item even"><a href="/ecg/peaked-t-waves" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Peaked T waves</a></div><div class="field-item odd"><a href="/ecg/hyperkalemia" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Hyperkalemia</a></div><div class="field-item even"><a href="/ecg/artifact" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Artifact</a></div></div></div><ul class="links inline"><li class="addtoany first last"><span><span class="a2a_kit a2a_target addtoany_list" id="da2a_8"> <a class="a2a_dd addtoany_share_save" href="https://www.addtoany.com/share#url=https%3A%2F%2Fwww.ecgguru.com%2Fecg%2Fecg-basics-sinus-tachycardia-peaked-t-waves-and-baseline-artifact&amp;title=ECG%20Basics%3A%20%20Sinus%20Tachycardia%2C%20Peaked%20T%20Waves%2C%20and%20Baseline%20Artifact%20"><img src="/sites/all/modules/addtoany/images/share_save_256_24.png" width="256" height="24" alt="Share"/></a> </span> </span></li> </ul> Mon, 14 Mar 2016 03:45:16 +0000 Dawn 691 at https://www.ecgguru.com https://www.ecgguru.com/ecg/ecg-basics-sinus-tachycardia-peaked-t-waves-and-baseline-artifact#comments Inverted T waves in Lateral Wall https://www.ecgguru.com/ecg/inverted-t-waves-lateral-wall <div class="field field-name-field-ecg field-type-image field-label-hidden"><div class="field-items"><div class="field-item even"><a href="/ecg/inverted-t-waves-lateral-wall"><img typeof="foaf:Image" src="https://www.ecgguru.com/sites/default/files/CAD108.jpg" width="1800" height="1317" alt="" /></a></div></div></div><div class="field field-name-field-ecg-interpretation field-type-text-long field-label-hidden"><div class="field-items"><div class="field-item even"><p>This ECG was obtained from a 49-year-old man who was a patient in an Emergency Dept. &nbsp;We do not know his presenting complaint, only that he had a history of insulin-dependent diabetes mellitus (IDDM). &nbsp;It was noted by the donor of the ECG that the patient had no chest pain, no shortness of breath, and no other cardiac symptoms. &nbsp;We do not know his hydration or electrolyte status. &nbsp;There are quite a few interesting abnormalities on this ECG, and the exact interpretation would, of course, depend upon the patient's clinical status. &nbsp;It would definitely help to be there!</p> <p>First, we note a sinus tachycardia at a rate of 118 bpm. &nbsp;This could be due to very many causes, including but not limited to: &nbsp;dehydration, pain, anxiety, high or low blood glucose, fever, or CHF. &nbsp;The PR and QT intervals are within normal limits. &nbsp;The QRS complexes are narrow. &nbsp;The axis is normal at 0 degrees. &nbsp;The QRS voltage in the lateral leads is on the high side of normal, but we do not know this patient's body type. &nbsp;Voltage as read by the ECG can be influenced by a thin chest (making voltage look larger) or a large chest (making voltage lower).</p> <p>There are T wave abnormalities in the lateral leads: &nbsp;I, aVL, V5 and V6. &nbsp;The T waves are inverted, which can have many meanings. &nbsp;However, when inverted T waves are in the lateral leads, as opposed to the inferior or right chest leads, it is often a sign of ischemia. &nbsp;The flat, horizontal ST segments can also signify coronary artery disease (CAD). &nbsp;This patient denied cardiac symptoms, but his age and history of IDDM make it probably that CAD is a factor. &nbsp;The leads with T wave inversion also have a small amount of ST segment depression. &nbsp;The right precordial leads, V1 and V2, have a small amount of ST elevation, &nbsp;This possibly represents a reciprocal change to the ST depression in V5 and V6.</p> <p>Because we are not at the bedside of this patient, there are many details we do not know. &nbsp;But these inverted T waves could be ischemic T waves, and this requires that the patient be further evaluated.</p> <p>As always, we welcome comments, as this ECG probably has more to say!</p> <p>&nbsp;</p> <p>REFERENCES: &nbsp;<a href="http://ecg-interpretation.blogspot.com/2012/07/ecg-interpretation-review-47-normal.html">Dr. Ken Grauer</a>, &nbsp;<a title="LITFL T waves" href="http://lifeinthefastlane.com/ecg-library/basic/t-wave/">Life In The Fast Lane</a>, <a title="World J Cardiology" href="http://www.ncbi.nlm.nih.gov/pmc/articles/PMC43225305/#__ffn_sectitle">World Journal of Cardiology</a>&nbsp;</p> </div></div></div><div class="field field-name-field-rate-this-content field-type-fivestar field-label-above"><div class="field-label">Rate this content:&nbsp;</div><div class="field-items"><div class="field-item even"><form class="fivestar-widget" action="/taxonomy/term/67/feed" method="post" id="fivestar-custom-widget--9" accept-charset="UTF-8"><div><div class="clearfix fivestar-average-text fivestar-average-stars fivestar-form-item fivestar-hearts"><div class="form-item form-type-fivestar form-item-vote"> <div class="form-item form-type-select form-item-vote"> <select id="edit-vote--18" name="vote" class="form-select"><option value="-">Select rating</option><option value="20">Give Inverted T waves in Lateral Wall 1/5</option><option value="40">Give Inverted T waves in Lateral Wall 2/5</option><option value="60">Give Inverted T waves in Lateral Wall 3/5</option><option value="80" selected="selected">Give Inverted T waves in Lateral Wall 4/5</option><option value="100">Give Inverted T waves in Lateral Wall 5/5</option></select> <div class="description"><div class="fivestar-summary fivestar-summary-average-count"><span class="average-rating">Average: <span >4</span></span> <span class="total-votes">(<span >4</span> votes)</span></div></div> </div> </div> </div><input class="fivestar-submit form-submit" type="submit" id="edit-fivestar-submit--9" name="op" value="Rate" /><input type="hidden" name="form_build_id" value="form-3rGVS2ZCWJngC0-h98UZzR_qd7XVRYiauvMKyUMiOoQ" /> <input type="hidden" name="form_id" value="fivestar_custom_widget" /> </div></form></div></div></div><div class="field field-name-field-taxonomy field-type-taxonomy-term-reference field-label-above"><div class="field-label">Related Terms:&nbsp;</div><div class="field-items"><div class="field-item even"><a href="/ecg/t-wave-inversion" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">T Wave Inversion</a></div><div class="field-item odd"><a href="/ecg/ischemia" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Ischemia</a></div><div class="field-item even"><a href="/ecg/sinus-tachycardia" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Sinus tachycardia</a></div><div class="field-item odd"><a href="/ecg/pathological-q-waves" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Pathological Q waves</a></div><div class="field-item even"><a href="/ecg/bi-atrial-enlargement" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Bi-atrial enlargement</a></div><div class="field-item odd"><a href="/ecg/left-ventricular-hypertrophy" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Left ventricular hypertrophy</a></div><div class="field-item even"><a href="/ecg/strain-pattern" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Strain pattern</a></div></div></div><ul class="links inline"><li class="addtoany first last"><span><span class="a2a_kit a2a_target addtoany_list" id="da2a_9"> <a class="a2a_dd addtoany_share_save" href="https://www.addtoany.com/share#url=https%3A%2F%2Fwww.ecgguru.com%2Fecg%2Finverted-t-waves-lateral-wall&amp;title=Inverted%20T%20waves%20in%20Lateral%20Wall"><img src="/sites/all/modules/addtoany/images/share_save_256_24.png" width="256" height="24" alt="Share"/></a> </span> </span></li> </ul> Wed, 11 Nov 2015 02:45:52 +0000 Dawn 676 at https://www.ecgguru.com https://www.ecgguru.com/ecg/inverted-t-waves-lateral-wall#comments ECG Basics: Sinus Tachycardia https://www.ecgguru.com/ecg/ecg-basics-sinus-tachycardia <div class="field field-name-field-ecg field-type-image field-label-hidden"><div class="field-items"><div class="field-item even"><a href="/ecg/ecg-basics-sinus-tachycardia"><img typeof="foaf:Image" src="https://www.ecgguru.com/sites/default/files/152%20Sin%20Tach%20ASMI.jpg" width="1800" height="256" alt="" /></a></div></div></div><div class="field field-name-field-ecg-interpretation field-type-text-long field-label-hidden"><div class="field-items"><div class="field-item even"><p>This is a good teaching strip on many levels. &nbsp;At the BASIC level, we see a strip that clearly meets all the criteria for sinus tachycardia: &nbsp;a regular rhythm over 100/min. with P waves that look normal and all look alike. &nbsp;The rate is 110 per minute. &nbsp;The PR interval is just at the upper limits of normal at .20 second, or 200 ms. &nbsp;The QRS complex is within normal limits, but slightly wide at .10 seconds.</p><p>This strip is good for teaching rate determination by several different methods. &nbsp;It is helpful that QRS complexes 1, 5, and 10 fall on the dark lines of the paper.</p><p>This is a Lead II rhythm strip, and it is helpful to show students that not ALL Lead II strips produce an upright QRS complex. &nbsp;Of course, correct lead placement should be confirmed. &nbsp;In this particular case, the patient had suffered an anterior - septal wall M.I., and has a left anterior hemiblock, also called left anterior fascicular block. &nbsp;This shifts the frontal plane axis to the left, causing Lead II to have a negative QRS. &nbsp;Axis can't be accurately determined from one lead, but axis shift explains the negative QRS in this strip.</p></div></div></div><div class="field field-name-field-rate-this-content field-type-fivestar field-label-above"><div class="field-label">Rate this content:&nbsp;</div><div class="field-items"><div class="field-item even"><form class="fivestar-widget" action="/taxonomy/term/67/feed" method="post" id="fivestar-custom-widget--10" accept-charset="UTF-8"><div><div class="clearfix fivestar-average-text fivestar-average-stars fivestar-form-item fivestar-hearts"><div class="form-item form-type-fivestar form-item-vote"> <div class="form-item form-type-select form-item-vote"> <select id="edit-vote--20" name="vote" class="form-select"><option value="-">Select rating</option><option value="20">Give ECG Basics: Sinus Tachycardia 1/5</option><option value="40">Give ECG Basics: Sinus Tachycardia 2/5</option><option value="60">Give ECG Basics: Sinus Tachycardia 3/5</option><option value="80">Give ECG Basics: Sinus Tachycardia 4/5</option><option value="100" selected="selected">Give ECG Basics: Sinus Tachycardia 5/5</option></select> <div class="description"><div class="fivestar-summary fivestar-summary-average-count"><span class="average-rating">Average: <span >4.3</span></span> <span class="total-votes">(<span >6</span> votes)</span></div></div> </div> </div> </div><input class="fivestar-submit form-submit" type="submit" id="edit-fivestar-submit--10" name="op" value="Rate" /><input type="hidden" name="form_build_id" value="form-RClN3B7iw59WDZ6XfProT56TSpGyBWatWZ489DUwEnI" /> <input type="hidden" name="form_id" value="fivestar_custom_widget" /> </div></form></div></div></div><div class="field field-name-field-taxonomy field-type-taxonomy-term-reference field-label-above"><div class="field-label">Related Terms:&nbsp;</div><div class="field-items"><div class="field-item even"><a href="/ecg/sinus-tachycardia" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Sinus tachycardia</a></div><div class="field-item odd"><a href="/ecg/rhythm-strip" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Rhythm strip</a></div><div class="field-item even"><a href="/ecg/ecg-basics" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">ECG Basics</a></div><div class="field-item odd"><a href="/ecg/basic-ecg" typeof="skos:Concept" property="rdfs:label skos:prefLabel" datatype="">Basic ECG</a></div></div></div><ul class="links inline"><li class="addtoany first last"><span><span class="a2a_kit a2a_target addtoany_list" id="da2a_10"> <a class="a2a_dd addtoany_share_save" href="https://www.addtoany.com/share#url=https%3A%2F%2Fwww.ecgguru.com%2Fecg%2Fecg-basics-sinus-tachycardia&amp;title=ECG%20Basics%3A%20Sinus%20Tachycardia"><img src="/sites/all/modules/addtoany/images/share_save_256_24.png" width="256" height="24" alt="Share"/></a> </span> </span></li> </ul> Thu, 11 Jun 2015 02:53:14 +0000 Dawn 643 at https://www.ecgguru.com https://www.ecgguru.com/ecg/ecg-basics-sinus-tachycardia#comments