11
Dec
2016

EKG of the Month Quiz!

Monthly quizzes with prizes for the winner is the next step for the new EKG curriculum! Please answer below our best interpretation of the EKG above — Dr Abu Hazeem and Dr Smer with add their comments as we go along.

The prize you ask? A 15$ gift card to Dunken Donuts! If we have multiple correct answers then the winners will be placed in a hat and one name picked out.

Good luck!

16 Responses

  1. Nagarjuna R Gujjula

    Rate looks faster with wide QRS complexes favoring Ventricular tachycardia, but there might be 2 more possibilities such as SVT with LBBB vs SVT with aberrancy seen in WPW. Comparing previous EKG for LBBB will help in managing.

    If previous EKG’s not available I rather treat as Ventricular Tachycardia as patient looks unstable with SOB and chest pain.

    It’s hard to differentiate wide complex tachycardia’s.

  2. Nagarjuna R Gujjula

    It is also less favoring towards V Tachycardia as the starting of QRS and nadir of S wave in the precordial leads ( V2 and V3) does not cross more than 100 ms, which should be > 100 ms if this is V Tach ( also called Brugada sign) and also the complexes seen in the precordial leads are mostly RS complexes but not complete R waves or QS complexes which also favors less for V Tachycardia.

    QRS width is just 120 m sec, usually in V Tachycardia the QRS should be more wide > 160 m sec.

  3. Ahmed

    I am going to say this is Monomorphic Ventricular Tachycardia – the hint is first three beats in long lead. The variant PR interval with 2nd beat with an impossibly short PR interval points to AV node dissociation possibly 2nd degree type 1 block. Also I think all precordial leads have negative concordance which is more consistent with VT (a little doubtful about V6)

  4. Nagarjuna R Gujjula

    Rate looks faster with wide complexes compelling for possible V Tachycardia. Although in general it’s hard to differentiate between wide complex tachycardia’s, there are few signs that can help us differentiate.

    1. Brugada sign: the QS interval should be > 100 msec, here it is 160 m sec.

    with these above signs, I would like to diagnose this as SVT with aberrancy. It is very important to differentiate in this clinical setting as management differs.

    There might be baseline LBBB, it’s important to compare with previous EKG as patient is presenting with chest pain, SOB and looks unstable.

  5. Prakrity

    The first beat appear to be sinus followed by junctional escape beat because it is narrow complex QRS and the PR interval preceding it is too short to conduct. Then it goes to SVT with aberrancy from the LBBB.
    If we apply the Brugada criteria, the precordial lead is not concordance V1-V4 is negative but V5 is intermediate and V6 is positive. The RS interval < 100ms in all precordial lead. Using the LBBB morphology criteria in Brugada's criteria, Initial R wave < 30-40 ms duration,
    notching or slurring of the S wave (Josephson’s sign) is absent and RS interval < 60-70 ms. I can see some p wave hidden in the ST interval here and there but an unable to march all the P wave.

    So I strongly think it is SVT with aberrancy from LBBB.

  6. Aiman

    Agree with SVT with aberrancy, rate dependent LBBB. Prakrity explained the use of Brugada criteria very nicely to differentiate between SVT with aberrancy vs. VT. Quick rule of thumb, if WCT morphology looks like typical LBBB or RBBB is it likely SVT with aberrancy rather than VT. Usually, VT associated with atypical bundle branch block morphology. Of course, you can’t be 100% sure, but this is simple practical point you can use with caution when you look at ECG with regular WCT.

    Since most of you agreed it is SVT with aberrancy, what’s the type of SVT, is it AVNRT, AVRT, AFL 2:1 or AT..! The hint in the first 4 beats.

  7. Aiman

    @ Ahmed and Prakrity. Although you made a good observation that the PR interval in the 2nd beat is short, that does not mean it can’t be conducted for several reasons. 1st, there could be an accessory pathway especially you are seeing wide complex tachycardia and one possibility is antidromic AVRT..! Second, if this is AT originating from a close focus close to the AV node, it could conduct with short PR interval.

    Typically, we do not think P wave could conduct to the following QRS if there is fusion of the P-and-QRS complex, especially in patients with AV block. Because in those situations, we know that there is delay/bock in the AV node, his, or bundles that make conduction between the atria (P wave) and the ventricles (QRS) very slow and blocked sometimes, that’s why we see long PR interval or non-conduction P waves. In these situations, very short PR interval takes you doubt that the P wave got conducted.

    If you take another look at 2nd beat in lead II & III, there is clear PR interval, though short.

  8. Dr. Smer

    @ Nagarjuna and the rest of the group.!

    1. Agree with you that when in doubt it is better to treat wide complex tachycardia as VT rather than SVT with aberrancy, especially when a patient is unstable, old or known to have history of CAD or CHF.

    2. It is important to understand that tachycardia rate does not differentiate between VT and SVT. VT could be slow VT and we see that all the time with ICD patients when we interrogate their device.

  9. Dr. Smer

    If we gave you an ECG with wide complex tachycardia throughout the EKG strip, we know it is very difficult to differentiate between VT and SVT with aberrancy.

    But the key finding in this ECG, is that it starts with PAC (Narrow complex QRS with different morphology P wave when compared to prior sinus beat), then it went into tachycardia, so this excludes VT. VT originates from the ventricle and here you have tachycardia originated from the atrium.

    So now, since VT is out, what do you think the tachycardia is, AVNRT like Kaye said, AVRT or AT…!

    Good luck

  10. Mahmoud AbuHazeem

    Things that point toward VT rather than SVT with aberrancy:

    A history of MI
    AV dissociation “might need special equipment to detect”
    Capture/fusion beats
    Extreme Lt axis deviation
    Very broad QRS complexes
    No response to carotid sinus massage or i.v adenosine
    Or by cardiac or esophageal ECG.
    If still in doubt, treat as VT.

  11. Mahmoud AbuHazeem

    The answer as provided by dr.Smer:

    AT with rate dependent aberrancy

    Details explanation; The strip start with sinus beat followed by PAC and then went into AT noted by change in the P wave morphology in in 2nd and 3rd beats when compared to the 1st beat. Also, there is rate dependent aberrancy (LBBB morphology) due to fast rate.

So, what do you think?

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