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So here we have the ECG of an elderly gent who'd had an MI 20 years ago, and an episode of palpitations 6 years ago for which he had been cardioverted - but he wasn't sure whether by drugs or DC. Otherwise pretty fit and well considering. He didn't have palpitations as such this time. He had a mild chest ache, which was improving. Obs and exam: HR160-170 regular, BP140/80, no evidence of failure and not short of breath.  So, what's your diagnosis? And how will you treat him? This is actually his second ECG, so perhaps that justifies my being fooled and thinking that this might be an SVT with aberrant conduction. After all, it was very well tolerated and relatively narrow as broad complexes go (150msec). So I gave him adenosine 6, 12 and 18, which successfully made him feel awful, but didn't slow him one beat. Repeat ECG (as above) shows the little give-away capture beat, that rarity that sneaks into VTs when atrial activity exactly coincides with the start of the ventricular beat - generating a single normal beat. Nestled in there just after the V6 marker, best seen on the rhythm strip. 300mg Amiodarone then over 30 minutes, but no joy. Then he made it easy and dropped his BP a little, so electricity flowed, he went back into sinus after a single 90J sync shock and his BP afterwards was 170/100. Well done Tony for only giving 2.5ml of proposal; it worked a treat and he still snored afterwards. DONT sedate these like you would a young man with a dislocated shoulder... Arguably I should have zapped him earlier given his pain, but it really was mild, honest! Want a reminder of those subtle ECG signs of SVT vs VT? Here's a reminder of the ALS protocol for tachyarrythmias? 
Don't forget to comment - what you'd have done, or any other pearls of wisdom. Go on, I can take it!
6 Comments
Suzy Connor
15/9/2014 15:02:21
Thanks - and a useful link to the VT v SVT summary. Can t wait to talk about rabbits ears to cardiology reg next time.
zoeprice
18/9/2014 09:04:11
love these cases, just whiled away quite a bit of time, on the ECG above, apart from the capture best, do you think there are p waves present on rhythm strip ie AV dissociation?
Simon
19/9/2014 02:50:17
I couldn't convince myself of them at the time, but I think you're probably right. The quality of the pic isn't ideal (I'll do better next time!) but I think there is one sat on the shoulder of the 4th beat in V3 that you can't really argue with. Nice spot!
adam herbstritt
18/9/2014 11:05:07
Nice video from Amal Mattu on the subject of SVT vs VT.
adam herbstritt
18/9/2014 11:05:40
the link...
Simon
19/9/2014 03:13:23
Fascinating - a well spent 20 minutes. Leave a Reply. |
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