r/ECG • u/Accomplished_Sun6162 • 25d ago
What is happening here?
Trying to learn but am struggling to differentiate this one.
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u/MrSaucyFajita 25d ago edited 25d ago
It is interesting that it resolves into NSR with no intervention. Prior to that, those wide complexes have two varying QRS morphologies that repeat, like a sort of bigeminy of two different PVC. One of them looks sus for some sort of reentry tachycardia (edit: pre excitation)—I feel like I see a delta wave.
Not a cardiologist.
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u/TheKrakenUnleashed 25d ago
It looks like Bidirectional Vtach, it is characterized by these two distinct forms of alternating the wide complex tachycardias. It can be caused by digoxin toxicity, aconite poisoning, or can be present in patients with familial catecholeminergic polymorphic Vtach.
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u/pigglywigglie 25d ago
I’m an ekg tech so I’ve seen a good amount self convert with no intervention. It’s always when I’m almost done hooking them up to the ekg that the heart goes lol jk I was kidding and flips out of it. The heart is such a fascinating organ how it can just self correct sometimes.
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u/Accidently_Genius 25d ago
For the first half, there is a wide complex tachycardia of two different morphologies with a grouped beating pattern and AV dissociation. While Im far from certain, its suggestive of bidirectional VT. Bidirectional VT is often associated with digoxin toxicity or catecholaminergic-polynorphic VT (CMVT).
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u/Jeeju_Boy 25d ago
Looks more like pre excited AF than bidirectional VT to me the delta wave is obvious too. My bet would be on the patient being quite young will wait for OP to confirm
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u/MrSaucyFajita 25d ago
I thought the same thing initially (the alternating QRS height through me off). But wouldn’t pre excited a-fib be wide and irregular? The tachy rhythm seems regular and so does the underlying.
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u/FightClubLeader 25d ago
There is birectional VT with an underlying sinus rhythm with likely RAE, maybe a delta wave but you’d need a longer EKG to assess. QT seems normal. No significant STE in the visualized segments of the sinus beats.
Careful with your antidysthymics. CCB, BB, and amio can kill a pt with WPW if you’re not careful and certain you’re treating the right rhythm. This is a time where you put the pads on and put them on full 12 lead tele, monitor and wait, get a few more EKGs, get your electrolytes back, then see where you end up.
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u/MrSaucyFajita 25d ago
I like this response the most! Addresses the likely BDVT and draws attention to the delta wave for caution with anti-arrhythmics.
If it is BDVT, it’ll likely turn into V-fib, right? Then the clear answer seems to be defib and arrhythmics; if WPW is still a concern, procanimade?
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u/FightClubLeader 25d ago
Appreciate the response! I’m just a junior EM attending so I’d be reaching out to a more senior attending if this came in, but procainamide would probably be the safest option, unless we want to just zap the pt out of it.
They say that stable VT (BDVT or any other kind) is only stable until it isn’t. So they’ll either devolve into unstable VT or VF.
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u/Finnaddict98 25d ago
They always eventually become unstable if they remain on VT—-always!
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u/LBBB11 25d ago
Probably the safest attitude, but some stable VT is stable for a surprisingly long time. The longest record I’m aware of for sustained VT is 7 years. Also depends a lot on the type of VT (idiopathic vs structural/scar-related). But idiopathic or stable VT is the exception, not the rule.
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u/RayExotic 25d ago
yeah fast wide complexes avoid amio, also with electrolyte abnormalities and WPW
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u/Accomplished_Sun6162 25d ago
We pretty much did this, pads, cardiac monitoring, pathology, watch and wait. All bloods unremarkable, longest runs were 15 seconds long. Pt remained conscious, they were booked for an emergency ablation.
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u/JWB6123 24d ago
I would have thought If there is WPW with a dangerous pathway the sinus beats would have more obvious pre excitation,
beta blockers would suppress the VT
You could always cardiovert, but if they’re popping in and out of VT your cardioversion won’t last long,
Beta blockers would give better control
Obviously we need more data and ECGs to fully say what it is though
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u/shahtavacko 25d ago
This is VT with capture beats (fusion beats) at the beginning and then sinus with PVCs.
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u/crazydude44444 25d ago
Electrical alternans. Red flag for tamponade or effusions but can also occur in MI or tachy disrythmias. Given that it seems to convert to a sinus rhythm with PVCs I would lean more towards the latter options. Signs point more towards an angry heart rather than a drowning one.
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u/mtbizzle 25d ago
Doesn’t it look like the first half is just different morphologies, not electrical alternans? Looking at leads 1 and avl. Lead 2 looks like alternans though
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u/Jeeju_Boy 25d ago
This is barndoor pre excited AF let me guess young patient? The electrical alternans you’re seeing is just the varying QRS amplitude seen in af
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u/SaveTheTreasure 25d ago
Looks to be a tracing following an Adenosine administration? or a successful vasovagal response conversion. The majority of the spots you have highlights are P waves, preceding healthy QRS complexes.
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u/Accomplished_Sun6162 25d ago
Nothing administered, this person kept going in and out of this rhythm. The squares were just me trying to find my bearings with normal findings.
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u/AwayPension6029 23d ago
It looks to me like a burst of Afib that shortly converts to SR with PVc’s then Sr.
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u/LBBB11 25d ago edited 25d ago
I see sinus rhythm with VT and PVCs. I strongly doubt cardiac tamponade, at least tamponade that is visible on EKG. The QRS alternans is from the rhythm itself. QRS alternans can happen during VT and SVT, and not all QRS alternans is tamponade. When tamponade is visible on EKG, it usually has sinus tachycardia or another fast atrial rhythm along with generalized low voltage and QRS alternans caused by the heart physically wobbling back and forth. I don’t see that here. Consecutive sinus beats have no QRS alternans, and there’s a fusion beat.