Wednesday, December 13, 2017

Sinus Rhythm With a Run of VT or AIVR

Sinus rhythm with a run of VT or AIVR

The ECG criteria for accelerated idioventricular are:  wide complex rhythm with no P waves associated, rate between 40 and 100 bpm.


On various websites there are a variety of rates listed for AIVR

Life in the Fast Lane: Rate 50-110 bpm.
ECG-pedia: 60-120 bpm
Emedicine Medscape 40 to 100 to 120 bpm
EKG Academy: 40 – 100 bpm.
ECGguru: 40 and 100 bpm



Monday, December 11, 2017

Atrial Fibrillation with Slow Ventricular Response

An 85 year old admitted with systolic failure.  Taking Digoxin 250 micrograms daily and Atenolol 75 mg daily.  He was admitted and started on IV Lasix.  The Digoxin was continued but held for HR < 60. The Atenolol was stopped and he was changed to Carvediolol (Coreg) 12.5mg daily, hold for HR < 60.


Sunday, December 10, 2017

Sinus Rhythm With a Run of VT or SVT Aberrancy?


Edward Burns, in Life in the Fast Lane, uses these criteria to distinguish between VT and SVT with aberrancy: 

https://lifeinthefastlane.com/vt-versus-svt-with-aberrancy/

These criteria favor VT:
Absence of typical RBBB or LBBB morphology
Extreme axis deviation (“northwest axis”) — QRS is positive in aVR and negative in I + aVF.
Very broad complexes (>160ms)
Positive or negative concordance throughout the chest leads,
RSR’ complexes with a taller left rabbit ear. This is the most specific finding in favour of VT. This is in contrast to RBBB, where the right rabbit ear is taller. 

In this strip we have a rSR' complex in V1.  The rabbit ear is taller on the right.  
The QRS complexes are positive in aVR and aVF and negative in lead I.  These do not meet the criteria for VT and suggest aberrancy. 


Saturday, December 9, 2017

Atrial Fibrillation With a Run of VT or SVT Aberrancy?

Atrial fibrillation with a run of VT or aberrancy.

This typically happens,  we have a patient that has some runs of nonsustained VT during the night.  We call it VT because Wide + fast + VT until proven otherwise.  The next morning, the cardiologist will make rounds and look at the strip and tell us that this is aberrancy and not VT.  

Floyd Miracle from ACLS Medical Training writes: 

Because the right bundle branch tends to have a slightly longer refractory period than the left bundle branch, at higher rates the right bundle branch may not be fully recovered from the previous cardiac cycle, which results in a right bundle branch block pattern.

Even though right bundle branch block aberrancy is more common than left bundle branch block aberrancy, both are possible


Edward Burns, in Life in the Fast Lane, uses these criteria to distinguish between VT and SVT with aberrancy: 

https://lifeinthefastlane.com/vt-versus-svt-with-aberrancy/

These criteria favor VT:
Absence of typical RBBB or LBBB morphology
Extreme axis deviation (“northwest axis”) — QRS is positive in aVR and negative in I + aVF.
Very broad complexes (>160ms)
Positive or negative concordance throughout the chest leads,
RSR’ complexes with a taller left rabbit ear. This is the most specific finding in favour of VT. This is in contrast to RBBB, where the right rabbit ear is taller. 

We don't have a 12 lead to look at, so we cannot use all of the criteria that are Edward Burns has listed. In this strip there are at least two criteria that favors SVT with aberrancy: 

1. The V1 lead shows a taller rabbit ear on the left (RSr')
2. During the run of "VT" the QRS complex is positive in aVR and aVR but negative in lead I


Friday, December 8, 2017

Sinus bradycardia with an R-on-T PVC

Sinus bradycardia with an R-on-T PVC.  This triggers an unusual pattern of couplets and bidirectional  beats.  The rhythm transitions into bigeminy and then into an atrial flutter.  The initial small positive R wave in aVR suggests a lead reversal problem.



Tuesday, December 5, 2017

Elective Cardioversion of Atrial Flutter Part II

This patient was admitted with a SVT.  She received adenosine 6 mg and 12 mg without conversion of the rhythm.  However, the adenosine did clarify the rhythm as an atrial flutter.  She was managed with a calcium channel blocker and anticoagulated.  An echo was done and no atrial clots were noted.  She underwent elective cardioversion and was successfully cardioverted after two attempts


12 Lead obtained in ICU



This is the strip off the monitor

These are the strips from the defibrillator/monitor.  This is the initial rhythm



The event summary strips











Follow up strip

Monday, December 4, 2017

Elective Cardioversion of Atrial Flutter Part I


This patient was admitted with a SVT.  She received adenosine 6 mg and 12 mg without conversion of the rhythm.  However, the adenosine did clarify the rhythm as an atrial flutter.  She was managed with a calcium channel blocker and anticoagulated.  An echo was done and no atrial clots were noted.  She underwent elective cardioversion and was successfully cardioverted after two attempts.  




Sunday, December 3, 2017

Pacemaker Failure: Failure to Capture

The patient was having intermittent episodes of failure to capture.  Her pacemaker was interrogated and she was transferred to back to the hospital that placed it. The underlying rhythm looks like second degree heart block type II.  




Saturday, December 2, 2017

Sinus Rhythm Changing to AIVR

The patient begins in sinus rhythm.  After the 4th complex he has a sustained run of AIVR/VT.  The rate stays around 100 bpm.  He remained stable and did not show any hemodynamic compromise.












Friday, December 1, 2017

AICD Defibrillation of VT

This patient had an AICD.  He was a DNR.  These pages show something of the changes in his heart rhythm.  It terminated in VT.  His AICD did fire but was unsuccessful in converting the rhythm.






Thursday, November 30, 2017

Wednesday, November 29, 2017

R-on-T PVC Leading to Polymorphic VT

This patient had an atrial pacemaker.  These are seen in the 1st and 3rd complexes.  A multifocal couplet follows the 3rd complex.  This is followed by a junctional escape beat.  At the end of the T wave of this complex, a PVC occurs and triggers a brief run of VT.  This is followed by a single atrial paced beat then sinus rhythm.



Tuesday, November 28, 2017

Successful Elective Cardioversion of Atrial Flutter

The patient was adequately anticoagulated.  A TEE study did not reveal any atrial clots.  Successful cardioversion was performed at 50 J which converted the patient to sinus bradycardia.



Monday, November 27, 2017

2:1 AV-block

These two pages show the transition of a second degree type I block (Wenckebach) to what appears to be a second degree type II block.  See the comments by Vince DiGiulio




Sunday, November 26, 2017

AICD Defibrillation of Polymorphic VT

The patient has initial biventricular paced beats then develops nonsustained polymorphic VT.  His automated internal cardiac defibrillator sensed the rhythm and fired (second page) and this is followed by some biventricular paced beats. 




Monday, November 13, 2017

EKG Quiz

01. Identify the following rhythm:

a. Sinus rhythm with unifocal PVCs
b. Sinus tachycardia with unifocal PVC
c. Sinus bradycardia with bigeminal PVCs
d. Sinus rhythm with multifocal PVCs

02. Identify the following rhythm:

a. Atrial flutter with a PVC
b. Atrial fibrillation with a PVC
c. Sinus rhythm with a PAC
d. Sinus bradycardia with a PJC

03. Identify the following rhythm:

a. Idioventricular rhythm with a salvo of PVCs
b. Sinus bradycardia with nonsustained VT
c. Ventricular pacing with a triplet of PVCs
d. Junctional rhythm with consecutive PVCs

04. Identify the following rhythm:

a. Sinus arrhythmia with PACs
b. Sinus bradycardia with a couple of PACs
c. Sinus rhythm with unifocal PVCs
d. Sinus rhythm with some PJCs

05. Identify the following rhythm:

a. Sinus bradycardia with unifocal PVCs
b. Sinus bradycardia with bigeminal PACs
c. Sinus bradycardia with trigeminal l PVCs
d. Sinus bradycardia with multifocal PVCs

06. Identify the following rhythm:

a. Sinus rhythm with unifocal PVCs
b. Sinus rhythm with bigeminal PVCs
c. Sinus rhythm with trigeminal PVCs
d. Sinus rhythm with quadrigeminal PVCs

07. Identify the following rhythm:

a. Sinus arrhythmia with bigeminy
b. Sinus rhythm with trigeminal PACs
c. Sinus rhythm with multifocal PVCs
d. Sinus rhythm with frequent PJCs

08. Identify the following rhythm:

a. Sinus rhythm with unifocal PVCs
b. Atrial flutter with multifocal PVCs
c. Accelerated idioventricular rhythm with bigeminy
d. Atrial fibrillation with a couplet

09. Identify the following rhythm:

a. Sinus rhythm with unifocal PVCs
b. Sinus bradycardia with bigeminal PVCs
c. Sinus arrhythmia with frequent PVCs
d. Sinus arrest with a triplet of PVCs

10. Identify the following rhythm:

a. Sinus arrhythmia with unifocal PVCs
b. Sinus rhythm with bigeminal PACs
c. Sinus rhythm with frequent PJCs
d. Sinus rhythm with multifocal PVCs


Answer
01. b. Sinus tachycardia with unifocal PVC
02. a. Atrial flutter with a PVC
03. c. Ventricular pacing with a triplet of PVCs
04. d. Sinus rhythm with some PJCs
05. d. Sinus bradycardia with multifocal PVCs
06. a. Sinus rhythm with unifocal PVCs
07. b. Sinus rhythm with trigeminal PACs
08. d. Atrial fibrillation with a couplet
09. b. Sinus bradycardia with bigeminal PVCs
10. b. Sinus rhythm with bigeminal PACs