Is this V-Tach or Sinus Tach?

[AeroClinician]

You can see the extra large view if you click on it and open it on photobucket.com

 

[EMT B]

looks more like VTach than Sinus Tach...but im new at this EKG stuff

 

[FltMedicRob]

Looks like V-tach as there are no P-waves and wide QRS.

 

[AeroClinician]

I was thinking V-Tach as well because V-1 and V-6 have opposite deflections from each other. Indicating the electrical impulse is originating in the ventricles and depolarizing back up into the atria.

V1 located at the top of the heart and V6 located at the bottom of the heart.

 

[VirginiaEMT]

You can see the extra large view if you click on it and open it on photobucket.com

V-tach... ERAD, QRS Axis -96, positive V1, wide qrs

 

[medicsb]

I don't have the book in front of me, but I remember reading that a RBBB morphology that has a an R wave taller than the R' is specific for VT.

Also present is Josephson's sign in V2 (notching on the descending S wave near the nadir).

 

[Christopher]

At 130-140 bpm we need to strongly consider other causes than VT, but it certainly looks like it....

"Slower VT" causes:
- Sick, sad heart and actual VT
- Sick, sad heart and AIVR
- HyperK+
- Na-channel blocker OD
- Paced rhythm + tachycardia
- SVT w/ Aberrancy (sinus tach, junctional, etc)
- Digitalis

I'm a big fan of the "3AM Rule" when looking at a bizarre ECG like this one: double check lead placements.

Although, the Z-axis makes the frontal axis seem legitimate, so my bet is they're all on correctly and we have a likely ventricular rhythm.

My tentative DDx is "Slow VT" and search its causes. If any sort of renal history they're getting calcium before anything else. If this patient remains hemodynamically stable, we've got a great one to just hang out with and avoid overtreating.

If I'm pushed to treat, adenosine, then lidocaine, then cardioversion.

Slower VT (<150 bpm) is a known entity and apparently is more common now that our patients are routinely on antiarrhythmics of various classes. My last stable VT was at 140bpm and her AICD's VFVT zone was >150 so she never received any defibrillations or antitachycardia pacing. In the ED they adjusted her rate limit to 140 and she received an appropriate defibrillation.

 

[jwk]

Sinus tach - looks like P waves in Lead I

 

[VFlutter]

Slower VT (<150 bpm) is a known entity and apparently is more common now that our patients are routinely on antiarrhythmics of various classes. My last stable VT was at 140bpm and her AICD's VFVT zone was >150 so she never received any defibrillations or antitachycardia pacing. In the ED they adjusted her rate limit to 140 and she received an appropriate defibrillation.

I currently have a very similar patient. He has "Slow VT" and "Fast VT". He will frequently have runs of VT in the 110-120s, confirmed as VT by EP study and PPM, and is totally asymptomatic and spontaneously terminates after 5-10mins with no detection from the AICD. He will also have VT>150 and gets appropriate ATP and defibrillation. He is on Amio, Lopressor, and Mexetil which has eliminated the Fast VT but most likely potentiates the Slow VT. Interesting case.

 

[Leal271]

If it were slower rate with similar complexs and no p waves...IVR or AIVR which is ventricular . I believe its ventricular in nature, not sinus.

 

[mycrofft]

Aero, tell us how you would tell them apart and why this one puzzles you?

 

[mycrofft]

...and for my place in the pool, I'm with V-Tach because, even to a relative EKG idiot as myself, there is not a clear correlation of P's (mostly hard to find) to the rest of the complexes.

 

[ekgshelly]

Here is why you get the 12 lead, it can see things the human eye cannot.

I see all the arguments for VT, they are sound, and I'd definitely do a double take. My thoughts on why it could be sinus in origin:

the printout says the PR interval is .196 which means you would expect to seethe p wave begin nearly one large box before the QRS. At this tachycardic rate, that space is occupied by the t wave... so they may be fused together. Also, remember that BBB right or left typically results in widening of the QRS and often mimics STEMI presentation which is also mentioned on the printout.

I'd correlate with the patient presentation, if they are awake and dry I'd lean sinus and trust the monitor; if the patient was pale and soggy, I'd lean VT.

 

[Christopher]

Here is why you get the 12 lead, it can see things the human eye cannot.

I see all the arguments for VT, they are sound, and I'd definitely do a double take. My thoughts on why it could be sinus in origin:

the printout says the PR interval is .196 which means you would expect to seethe p wave begin nearly one large box before the QRS. At this tachycardic rate, that space is occupied by the t wave... so they may be fused together. Also, remember that BBB right or left typically results in widening of the QRS and often mimics STEMI presentation which is also mentioned on the printout.

I'd correlate with the patient presentation, if they are awake and dry I'd lean sinus and trust the monitor; if the patient was pale and soggy, I'd lean VT.

BBB's do not mimic STEMI, this is a common misconception. They may have ST-elevation, certainly, but those are secondary changes and are obviously not the primary changes of ischemia/infarction related ST-changes.

 

[Summit]

Looks like VT

machines can be fooled

 

[medictinysc]

When all else fails? Scratch your head and ask a cardiologist

 

[unleashedfury]

Double Post.

 

[unleashedfury]

from what I can see it looks like a sinus tach, but it has no pronounced p waves. so its looking like its ventricular in nature.

What was the patients complaint hx. and vitals.

I am not very strong at reading 12 lead ECG's. but I never go by what the monitor spits out as a diagnosis.

 

[Jawdavis]

Looks more like a left bundle branch block



E., Macmurdy K, Raitt M. Tachycardia With Typical Left Bundle Branch Block Morphology and VA Block: What is the Differential Diagnosis?. Journal Of Cardiovascular Electrophysiology [serial online]. May 2011;22(5):601-604. Available from: CINAHL Plus with Full Text, Ipswich, MA. Accessed November 18, 2013.

 

[Christopher]

Looks more like a left bundle branch block

E., Macmurdy K, Raitt M. Tachycardia With Typical Left Bundle Branch Block Morphology and VA Block: What is the Differential Diagnosis?. Journal Of Cardiovascular Electrophysiology [serial online]. May 2011;22(5):601-604. Available from: CINAHL Plus with Full Text, Ipswich, MA. Accessed November 18, 2013.

Except V1 has a predominantly positive terminal deflection (it is all positive actually).