Ventricular Tachycadia

Discussion:

Wide Complex Tachycardia

• This EKG shows a fast wide complex tachycardia in the range of 270/min., lead V4 is missing due to a poor electode contact.
• Considering the patient's age and history of previous infarctions and low ejection fraction the diagnosis is almost certainly ventricular tachycardia.
• The QRS morphology favors ventricular tachycardia as this is a RBBB morphology with the R to S ratio in V6 is less than 1 and a Monomorphic R in V1.
• The patient was shocked with 200 joules (less probably have worked too) and regained sinus rhythm
• A cardiac cath showed a 100% LAD stenosis and an 80-90% circumflex stenosis with patient grafts to the LAD and OM. The EF was 15%.
• The patient was implanted with a defibrillator and is doing well with no shocks received 3 months post implant.

Words From the Web

comments: Dr. M. Rosengarten

heart@hrt.org , 18 Oct 1997

Wide QRS tachycardia, regular rhythm, northwest axis, right bundle branch morphology. Rate - almost 300 per minute. Differential diagnosis: Antidromic AVRT, Isthmus VT

Antidromic and orthodromic tachycardias refer to AV reentry where the conduction is antidromic if the conduction is along the AV node from the ventricle to the atrium and orthodromic if the conduction is from the atrium to the ventricle. An orthodromic tachycardia can have a narrow QRS complex or with a BBB while antidromic conduction shows maximal ventricular pre-excitation and is always wide. It is possible that this is an antidromic AV tachycardia but the rate seems fast for a re-entrant rhythm and the clinical history favors VT.

D. J. M., @maroon.tc.umn.edu, 18 Oct 1997

This regular, wide-QRS tachycardia with a rate of almost 300 bpm suggests antidromic AV reciprocating tachycardia. Was a history of pre-excitation elicited? Atrial flutter with 1:1 conduction and aberrancy and ventricular tachycardia cannot be excluded.

There was no history of pre-excitation. Atrial flutter with 1:1 conduction may be more common than we think. The morphology here though suggests VT as opposed to AFL with a BBB.

Treatment depends on stability. If the blood pressure is near normal, intravenous procainamide is a reasonable choice. I must admit to being a "chicken" and preferring sedation and cardioversion.

In a case like this the safest treatment is probably cardioversion with protection of the airway or perhaps cardioversion with out anesthesia (helps prevents aspiration if they are awake). Remember aspiration pnuemonia is a cause of death in patients "successfully" resuscitated from sudden death! If you were to try a medication lidocaine might be safer as it has less of a negative ionotrope than procainamide.

S., @compuserve.com, 21 Oct 1997

VT most likely. BP? SHOCK IF COMPROMISED

T.T., @aichi.med.or.jp, Oct 1997 13

Parpxysmal spraventricular tachycardia,about 300ppm, Persistent ventricular tachycardia is role out, becase of narrow QRS interval. I would like to know about his vital signs,blood pressure,respiration,and so on. I'll do cardioversion with low energy,100-150mWsec.Or medication, adenocine dephosphate 10 mg IV.and Oxygen 2-4L/m.

Wide is usually defined as a QRS greater than 120 ms, it is hard to read the grid but this one is in that range. Even if it was less than 120ms the QRS is abnormal with the dominant R in V1. Cardioversion is a good idea and 100 or 50 joules probably would have worked fine. For organized tachycardias low energies are probably best as more than one shock may be required!

Adenosine is one of the few medications that can help differentiate between VT and other arrhythmias such as AVNRT, AVRT and A flutter. Remember the use of verapamil is dangerous in this situation and should not be used. In this case with a patient who has lost consciousness cardioversion is probably the best choice.

J.A. D., @icon.co.za, 3 Nov 97

The patient has ventricular tachycardia arrising in the left ventricle and should probably be cardioverted in the emergency room.

B.K., @wave.net, 13 Nov 1997

from the tracing, i would guess that is was either v-tach or svt? did this individal just have a short run of this? if not for v-tach in the er i would have defib'd, started i.v.s, given epi, the whole acls protocol. or given lidocaine, or possible cardioversion. only if pt. has pulse.for svt adenosine, verapamil or possible cardoiversion. the tracing is hard to tell.

Remember defibrillation is for fibrillation and implies that there is no synchronization for the shock applied to the patient. Epinephrine is best left until you are in the midst of a full arrest as it may have an effect in raising vascular tone (I have not found it useful). Verapamil would have been an error and could have precipitated an arrest.

I.M.,@infomatch.com, 14 Nov 1997

This looks like an SVT with aberrant conduction for the folowing reasons:

• It appears that the QRS is fairly narrow.
• There is no good evidence of AV dissociation.(All QRS complexes are similar, no capture or fusion beats)
• It's hard to see on the monitor but there doesn't appear to be a Q in V6.

I would like to know if there is any other physical signs of AV dissociation such as cannon waves, variation in the intensity of S1, or a variable systolic BP.

I would like to slow the rate and look for more evidence of P waves to confirm my suspicion.

I think the QRS is more than 120ms and is abnormal with the tall R in V1 and rS in V6 suggests either VT. It is really heard to see A/V dissociation inN es like his as you really can't see the p waves on the EKG (in the ICU you might see an atrial recording or a CVP pulse wave). There is a chance that the JVP might show cannon waves. Adenosine would be the best bet if you wanted to slow a supraventricular but this one looks like V.T.

N.M.@ns.hnet.net16 Nov 1997

VT unk if conc./or unconc. or if we have a pulse w/ this no pulse--treat as VF

From: "M.H. J.,@northland.lib.mi.us, 21 Nov 1997

Rate: 300bpm Rhythm: Ventricular Tachycardia I'm currently taking an ECG assessment class and would like to know what the notches in Lead I, V5, and V6 mean. Do they indicate a bundle branch block? Also I would like to know what do you do in this situation. We haven't covered emergency procedures.

Notching is most useful in wide complex tachycardias that have a left bundle configuration. Notching of the down stroke in V2 in LBBB tachycardia suggest VT. Here the QRS is abnormal due to VT not a conduction abnormality.

M.F.S., @teleline.es, 29 Nov 1997

May be an atrial flutter with 1:1 conduction and right bundle branch functional block. Acute treatment: electrical cardioversion (syncronized DC shock at 25-50 joules). Chronic treatment for avoiding new episodes: ? Thanks

We thought that his was VT but in one patient with Atrial flutter with 1:1 conduction control was obtained with nadolol and digoxin. Note this patient did not have ventricular pre-excitation.

S.D.:, @mail.sanofi.com.ar, 29 Nov 1997

It looks like a V.T. I would try lidocaine IV and if not effective, then cardioversion. If the patients is hemodinamically unstable I would try first cardioversion.

L.C., @voyager.net, 29 Nov 1997

In a 50 year old with known coronary disease, I'd think VT until unequivocally proven otherwise, although this one is REALLY fast. The QS pattern in aVF also suggests VT, along with the extreme axis. I would like to know if he is hemodynamically stable (assuming the syncope was brief and he is now conscious and perfusing): if so, I would give Lidocaine IV followed by Procainamide (trying adenosine might cross my mind, and probably wouldn't hurt, but again, I still think it's VT). If he showed any signs of instability, including angina or continued depressed level of consciousness, I'd sedate him (maybe) and cardiovert.

Yes if lidocaine fails this is still could be VT and although procainamide might work it might not, and could make things worse with it's negative ionotropic effect. If you give it, usually less is better, and I find that small doses such as 100mg have an effect in the absence of a loading dose. Be careful with loading doses over 500 mg. I would keep the procainamide for the patient who keeps returning to VT . IV amiodarone is also a good choice for a difficult VT as long as it is not Torsade de Pointes. Yes sedation can be optional and lack of it may help prevent aspiration pneumonia. Curiously most patients accept a shock (one) if you tell them what you are going to do. Also even if you give IV sedation such as midazolam due to poor circulation it often just doesn't seem to work until after you shock the patient and sinus rhythm returns and transports it to the brain.

A.N.@nlink.com.br, 3 Dec 1997

I think this is a monomorphic ventricular tachycardia. I would cardiovert this man.

J.R.@mb.sympatico.ca, 14 Dec 1997

This is a case of atrial flutter (possibly fibrilation) with 1 to 1 conduction down an accessory pathway. The patient should be cardioverted and then have EPS studies with a view to ablating the accessory pathway(s)via radiofrequency ablation.

M.K.,@aol.com,17 Dec 1997

This is a wide QRS Tachycardia.I would give the Patient Ajmalin to differentiate between a SVT with BBB or a VT. If the Patient is unstable I would do a Cardioversion . Then I would search for possible Drugs or Elektrolyte Disturbances which may be the cause of this Arrhythmia. Because the Patient has a CAD this Arrhythmia might be due to Ischemia so that an angiography should be done .

Lidocaine or adenosine would probably be safer choices to differentiate the tachycardia. Angiography was done and is a good idea in most pateints with VT/VF.

M.N.A.,@ultranet.com.br, 28 Dec 97

 EKG: Ventricular Taquicardya-Conduta: eletric cardioversion and coronaryografia

K.,@teleport.com, 5 Jan 98

v6 with a rs is a strong indicator of VT. Axis in no mans land is a strong indicator of VT. What does the previous ECG look like? How is the patient.

Good point, it is possible that the EKG in sinus shows a conduction pattern that is not normal. This was not the case here. The only problem is that you see the EKG with sinus rhythm only after you terminate the tachycardia.

V.P., @yahoo.com,14 Jan 1998

The ECG shows a fast wide-QRS tachycardia (300 b/min), which fulfills morfologic criteria for ventricular tachycardia. I would immediately treat the patient with DC-shock. It would be important to know the mediacation taken by the patient, a previous ECG in sinus rhythm and the serum levels of ions (K, Na, Ca).

D.A., @NAU.EDU, 16 Jan 1998

First of all, let me say that I am a Cardiopulmonary Physical Therapist,not a physician. However, I look at this EKG and say without hesitation that his syncopal episode was directly due to the fact that he was in Ventricular Tachycardia. He fainted because of poor perfusion to his brain and other organs.

I would like to know the following :1. What medications is he on - or is supposed to be on. Beta Blockers, Antiarrhythmics?2. This patient should be immediately cardioverted because of sustained V-Tach. A code arrest should be called. If this individual is still awake, then a partial code should be called to either pharmacologically or electrophysiologically cardiovert him back to a NS rhythm.