# Is this V-Tach or Sinus Tach?



## AeroClinician (Oct 31, 2013)

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


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## EMT B (Oct 31, 2013)

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


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## FltMedicRob (Oct 31, 2013)

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


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## AeroClinician (Oct 31, 2013)

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.


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## VirginiaEMT (Oct 31, 2013)

Firehazmedic said:


> 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


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## medicsb (Oct 31, 2013)

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).


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## Christopher (Nov 1, 2013)

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.


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## jwk (Nov 1, 2013)

Sinus tach - looks like P waves in Lead I


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## VFlutter (Nov 1, 2013)

Christopher said:


> 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.


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## Leal271 (Nov 9, 2013)

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.


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## mycrofft (Nov 10, 2013)

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


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## mycrofft (Nov 10, 2013)

...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.


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## ekgshelly (Nov 10, 2013)

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.


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## Christopher (Nov 10, 2013)

ekgshelly said:


> 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:
> 
> ...



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.


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## Summit (Nov 11, 2013)

Looks like VT

machines can be fooled


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## medictinysc (Nov 12, 2013)

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


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## unleashedfury (Nov 13, 2013)

Double Post.


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## unleashedfury (Nov 13, 2013)

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.


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## Jawdavis (Nov 18, 2013)

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.


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## Christopher (Nov 18, 2013)

Jawdavis said:


> 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).


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## medic6676 (Nov 21, 2013)

Sinus tach, there are p-waves, small but present. Also the wide complex is due to the peaked wide T-waves. And the QRS read out is .122, which while it is wider than allowed, it is acceptable with the T-waves mentioned before.


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## Sothersmaylive (Nov 22, 2013)

I'm going with ST.  Lead one has p waves.


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## NBFFD2433 (Nov 22, 2013)

I'm not a Paramedic but very familiar with EKGs. It is V-Tach.


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## jwk (Nov 22, 2013)

Jawdavis said:


> Looks more like a left bundle branch block



Which, by definition, is a sinus rhythm.


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