68 year old male presented to the Emergency Department after experiencing an episode of conscious collapse (felt lightheaded initially, sweaty, nausea, vomiting with associated chest discomfort). Was found to have a BBB by AV.
PMHx:
IHD-CABG's previously
HTN, Hypercholesterolemia
Femoropopliteal bypass
Was stable hemodynamically on initial assessment and the initial ECG is as shown below: (No previous ECG's on records to compare to).
PMHx:
IHD-CABG's previously
HTN, Hypercholesterolemia
Femoropopliteal bypass
Was stable hemodynamically on initial assessment and the initial ECG is as shown below: (No previous ECG's on records to compare to).
Initial troponin was elevated. Patient was being cardiac monitored when he was noticed to be tachycardic. ECG is as shown below. Systolic BP was 80/- with the patient conscious and conversing normally with minimal symptoms.
So what is the rhythm? How to work it out?
A few features suggesting VT:
==>AV disassociation(can be appreciated in V1)
==>Extreme axis
==>Lead V6: qS pattern
==>Left rabbit ear (Rsr')-V1
==>QRS narrower compared to initial ECG (QRS duration in initial ECG appears slightly greater)- Happens when the ventricular tachycardia arises close to the conducting system
==>Initial R wave in aVR (terminal R wave is seen in TCA toxicity)
Other criteria for VT: Classical wellens criteria and Brugada criteria
While getting ready for sedation/cardioversion,patient became unresponsive with CPR being commenced. Was back to normal conscious state after 15-30 seconds. Repeat ECG was similar to the initial ECG.
A brief overview of management:
Non sustained VT( >/= 3 ventricular beats,rate >120/min, Duration <30 seconds)
Beta blockers
Calcium channel blockers
Antiarrhythmics
Sustained VT( Duration >/= 30 seconds)
All Unstable VT: SHOCK/DEFIBRILLATION
Monomorphic VT
Stable: Synchronized cardioversion following appropriate sedation
In refractory or recurrent VT: antiarrhythmics
Class I: Procainamide(can slow down the rate even if it fails to revert),Lignocaine
Class III: Amiodarone
Polymorphic VT with prolonged QT(Torsades)
Stable: IV magnesium. Overdrive pacing if no response to IV magnesium
Polymorphic VT with normal QT
Polymorphic VT with normal QT
Beta blockers if BP tolerates
Amiodarone
Thanks to Sashi for the great case!
A few features suggesting VT:
==>AV disassociation(can be appreciated in V1)
==>Extreme axis
==>Lead V6: qS pattern
==>Left rabbit ear (Rsr')-V1
==>QRS narrower compared to initial ECG (QRS duration in initial ECG appears slightly greater)- Happens when the ventricular tachycardia arises close to the conducting system
==>Initial R wave in aVR (terminal R wave is seen in TCA toxicity)
Other criteria for VT: Classical wellens criteria and Brugada criteria
While getting ready for sedation/cardioversion,patient became unresponsive with CPR being commenced. Was back to normal conscious state after 15-30 seconds. Repeat ECG was similar to the initial ECG.
A brief overview of management:
Non sustained VT( >/= 3 ventricular beats,rate >120/min, Duration <30 seconds)
Beta blockers
Calcium channel blockers
Antiarrhythmics
Sustained VT( Duration >/= 30 seconds)
All Unstable VT: SHOCK/DEFIBRILLATION
Monomorphic VT
Stable: Synchronized cardioversion following appropriate sedation
In refractory or recurrent VT: antiarrhythmics
Class I: Procainamide(can slow down the rate even if it fails to revert),Lignocaine
Class III: Amiodarone
Polymorphic VT with prolonged QT(Torsades)
Stable: IV magnesium. Overdrive pacing if no response to IV magnesium
Polymorphic VT with normal QT
Polymorphic VT with normal QT
Beta blockers if BP tolerates
Amiodarone
Thanks to Sashi for the great case!
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