26 yo M pmh multiple episodes of syncope as child p/w anxiety symptoms for months. No meds or illicits. His father died at age 39.
He has the following dysrhythmia:
Questions:
What is this rhythm?
What is your ED care and dispo?
Best answer by March 23 at noon is our winner.
Special note, the ECG was flipped right side up after VTACHomas’ comment below.
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eabram
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Looks like ventricular bigeminy (inverted on the y-axis) which is a ventricular premature beat and can be identified by its alternating narrow and wide complex beats. They are most commonly due to reentry, but can also be due to enhanced normal or abnormal automaticity as well as triggered activity resulting from afterdepolarizations.
Treatment in the ED would involve symptomatic treatment initially w/ either beta-blockers or calcium channel blockers. If that doesn’t work, you would move onto antiarrhytmics (being wary of use of 1C drugs because of increased mortality with this group in patients with previous MI). Amiodarone and sotalol can be used in patients who can’t tolerate 1C. Finally, patients can be admitted for radiofrequency catheter ablation. In all likelihood this would be dispo’d to the CCU but could be reasonably sent to a cards-tele unit if they were stable.
this looks a lot like bigeminy. especially in light of the alternating narrow and wide complex beats.
but there are some things that go against it. 1st: those wide beats have a p wave in front of them. theyre best seen in lead v2, but other leads have them as well. that makes me think that these are aberrantly conducted from either a sinus or atrial source. Ventricular origin is still possible, but less likely given how stone cold unchanging those p to wide-complex R intervals are.
So what could this be? be systematic. rate, rhythm, axis….is it regular or irregular? bigeminy or coupled beats should be regularly irregular…the very different morpohlogies make this look irregular, but check out lead 1 and v2 in which the morphologies are more similar. this is stone cold regular. like a metronome. no coupling.
so regular, near 150bpm, with p’s in front. ddx: sinus tach, a tach, a flutter with 2:1 with alternating morphologies. rate-related aberrancy, meaning that one the fascicles is refractory given the speed and you get a LBBB?
also the narrow, natively conducted beats have a bizarre axis. DDx for that? RVH, ventricular etiology, electrolytes….or could this be WPW? check out that slow upstroke after the p waves on those wide complex beats?
this could be Catecholaminergic Polymorphic Ventricular Tachycardia (which i may have had to look up) which is an inherited disease that can lead to syncope and possibly bidirectional vt or ventricular bigemy. giving the patients beta blocker and cardiology followup with possible AICD is recommended however i would probably have cardiology consult in the ED given the history prior to discharge.