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68 Year old male with an episode of dizziness

4/8/2016

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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).
Picture
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.
Picture
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!


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