ECG of the Week

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Aprz

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VFlutter

VFlutter

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My Ddx is antidromic AVNRT or RVOT VT
 
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Aprz

The New Beach Medic
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I can see why you'd say RVOT VT, but why antidromic AVNRT?

I posted on there, I was saying that of course I'd treat as VT until proven otherwise, but my initial impression of this 12-lead was that it didn't look like what VT normally looks like to me. I could pretty much only figure out the rate and axis: rate is 167-187. Axis is +90 to + 120 (I has smallet amplitude, based on I, inferior leads look positive, aVR biphasic, aVL negative. The precordial leads seem to have some progression (not all negative or positive). It doesn't have RBBB or LBBB morphology.

Some things seem to point SVT. Some things point to VT.

My friend who asked me about this 12-lead, he introduced Sasaki's rule. I guess by step 2 and 3, this would be VT. Something seems off to me so for fun I just say SVT with aberrancy on Tom's blog, lol.
 
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Aprz

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I've never heard of RVOT VT until earlier today. Looking at what I described earlier, I think this is RVOT VT. Looking at other 12-leads of RVOT VT too, they look similar.
 
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Aprz

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He posted up the findings. Vtach.
 
Christopher

Christopher

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Aprz said:
I've never heard of RVOT VT until earlier today. Looking at what I described earlier, I think this is RVOT VT. Looking at other 12-leads of RVOT VT too, they look similar.
Click to expand...

I agree 95%, the one difference in this ECG is the nadir of the QRS complexes in the inferior leads are fractionated and the QRS duration is wide-wide. In your typical RVOT-VT's seen in structurally normal hearts the complexes are clean and quick (i.e. 140-160ms).

In favor of RVOT-VT:
  • Axis
  • V1-negative (LBBB appearance)
  • Age (somewhat)

Against:
  • Inferior morphology
  • QRS duration suggests structural or ischemic abnormalities
  • Age (somewhat)
 
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jwk

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So how long would you debate this rhythm if you saw it on your monitor? Tick - tock - tick - tock.......
 
Christopher

Christopher

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jwk said:
So how long would you debate this rhythm if you saw it on your monitor? Tick - tock - tick - tock.......
Click to expand...

You usually have more time than you think. I've noted EMS rushes Rx of brady- and tachyarrhythmias.

I generally take the time to get a good 12-Lead, a long rhythm strip of II and V1 (and maybe V6), and if I'm feeling froggy (if my partner is rocking out an IV) I'll work on alternative lead placements if I'm not 95% certain.

However, I have the luxury of having procainamide in my drug box so any quibbling about a rhythm is not necessary as it will work safely for most all of them.
 
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NYMedic828

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I will never be able to interpret ECGs like you guys do...
 
Christopher

Christopher

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NYMedic828 said:
I will never be able to interpret ECGs like you guys do...
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Just takes practice! Even if all you do is read 1 ECG per day (and by read, I mean read) you'll probably read 365 more ECG's than most :)

Harvard's WaveMaven is a great place to get lots of practice. With the last batch of medic students I helped teach I worked through ~150 of those ECG's. We found every P-wave, PRi, QRSd, etc. No artifact was left unexplained! Their confidence in interpretation was increased measurably.

If you like dead tree's Amal Mattu's ECG's for Emergency Physicians volumes 1 and 2 are a great place to get practice ECG's (like 400 in total).
 
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NYMedic828

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Christopher said:
Just takes practice! Even if all you do is read 1 ECG per day (and by read, I mean read) you'll probably read 365 more ECG's than most :)

Harvard's WaveMaven is a great place to get lots of practice. With the last batch of medic students I helped teach I worked through ~150 of those ECG's. We found every P-wave, PRi, QRSd, etc. No artifact was left unexplained! Their confidence in interpretation was increased measurably.

If you like dead tree's Amal Mattu's ECG's for Emergency Physicians volumes 1 and 2 are a great place to get practice ECG's (like 400 in total).
Click to expand...

Wave maven is great I used it when in medic class on my own.

Unfortunately I'm focused on my online schooling and prepping for te fire academy at the moment.
 
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Aprz

The New Beach Medic
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Thanks Christopher.
 
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Christopher

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TheLocalMedic said:
Okay, to be honest I was really trying to find a reason to argue that this was SVT with aberrant conduction, but I'm still stuck calling it VT. Shucks...

I also had to look up the "rabbit ears" thing that I first learned in a 12 lead course a while ago and found this page: http://www.kallus.com/er/clinical/svt from vt.pdf
Click to expand...

The SVT guidelines there are somewhat non-specific, but that's Ok as long as you don't Rule-Out VT using them.
 
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Aprz

The New Beach Medic
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Well, aren't you right TheLocalMedic? The answer was VT I thought.
 
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