Monday, March 2, 2015

EKG Challenge No. 11 - Mmmm.... That looks sort of fast...

You are working one evening in the emergency department when a 60-something year old female is slotted for a room.  Her chief complaint?  "Fever, weakness, vomiting".    Seeing that her triage heart rate was 157, you leave your granola bar where it is and immediately walk into the room to assess her.  You see an elderly-appearing female in moderate respiratory distress.  Her temperature is 38.2,  blood pressure is 125/87, RR is 32, oxygen saturation is 93% on 5L NC.  She has a history of a bone-marrow transplant and is chronically immunosuppressed. She endorses poor PO intake and several episodes of emesis over the last few days.  She says that she came in today when she developed some shortness of breath as well.  She denies any chest pain or palpitations.  On exam, her mucous membranes are dry, her abdomen non-tender, and her breath sounds are decreased in the right base.  You are a bit disturbed by the looks of her rhythm strip on the monitor so you get a 12-lead EKG:

Interpret the EKG.  What is your differential?  What would you do next?  

See the case conclusion here


  1. Looks like SVT with aberrancy, LBBB morphology, with likely rate related ischemic changes laterally. Given the question vignette it could even be sinus tachycardia, but I can't clearly see p waves at this rate.

  2. My first inclination is to find an old EKG with a prolonged QRS! My first concern is whether this is a wide complex tachycardia right at 150 which is consistent with V tach although I can convince myself there are some p waves in V4 and in V5.
    My ddx would include LBBB with sinus tach, LBBB with aflutter, metabolic derangements which specifically would include potassium and magnesium deficiency, and toxic effects of medications. I would start with antipyretics, IVF resuscitation, and close monitoring.

    1. There are p waves seen in V1 which is the best place to find them in a difficult to read ECG. I would call this sinus tachycardia. I'd consider dehydration with compensated shock. Also consider electrolyte derrangement given the presentation of emesis and poor po intake.

  3. My reading of the EKG:
    HR: 120bpm;sinus origin. Axis: LAD; LVH: Not present; PR: 120ms QTc: 483ms QRS: 80ms
    Prominent Q-waves and ST-elevation in leads V1, V2. ST-depression in V5, V6.
    Conclusion: Sinus tachycardia with LAD and ischemic changes.
    My differentials include cancer (acute leukemia), infection (fungal, bacterial, viral), and coronary artery disease.
    My assessment and plan:
    1. Dehydration; start fluid resuscitation; order CMP, ABGs
    2. Sepsis; start empiric antibiotics for CAP, opportunistic pathogens; order chest X-ray, CBC with peripheral smear and differential, blood culture x3, sputum gram stain and culture (if she produces any)
    3. Ischemic changes on EKG; continue to monitor; correct electrolyte imbalances as needed, will hopefully resolve with fluid resuscitation; order CK-MB, troponins

  4. Good comments, clearly a tough case. My clinical impression overall: sepsis with pneumonia. EKG impression: atrial flutter 2:1 with aberrancy/LBBB.
    Answers: DDx: sinus tachycardia with LBBB, a-flutter 2:1 conduction with aberrancy/LBBB, less likely VTach or SVT with aberrancy given that I can see P waves in II, V1.
    What would I do? Definitely treat for sepsis with cultures, serial lactates, IVF, early antibiotics, CXR/UA, source control. Check electrolytes. Definitely find old EKG looking for prior LBBB with same morphology. I would send for tacrolimus level also if she was on this, as tacrolimus toxicity can give n/v and lead to aspiration pneumonia. Now, the guru Amal Mattu says that when in doubt, treat a wide-complex tachycardia as VTach until proven otherwise, lest we convert to VFib with adenosine treatment. For this patient, I would propose aggressive hydration (2L with pressure bag) and monitoring heart rate. If it doesn't budge from 150's, then maybe it's atrial flutter 2:1 with LBBB instead of sinus tachy with LBBB. Potential treatments for a-flutter: procainamide (covers you for VTach), amiodarone (also covers you for VTach but less effective), electrical cardioversion if new AF, AV nodal blockade with beta blockers or CCB's, which is tough while treating sepsis.

  5. Sinus tachycardia with LBBB. Clinically her picture is consistent with sepsis. Start fluids and abx...assess decrease breath sounds at lung base to see if effusion versus infiltrate. Bedside echo would help at this point to look for hyperdynamic LV, dilated RV as well as pericardial effusion as leuk patients high risk for pericardial effusion. Would not treat with antiarrythmics at this time given clinical scenario as this could be very harmful to patient. Would pursue PE if infectious work up negative.

  6. I would really not go for VT. There are clearly P waves in many leads, with a consistent relation to QRS complex. Those P waves push very far from both VT and nodal SVT. Now, many P waves have normal P axis (in D1 and AVF) and V3 to V4, which suggest normal sinusal P waves and not automated atrial tachycardia. The only question here is: could it be 2:1 flutter (this is the only 2:1 possible rythm, with QRS over 150 (not 120). Although in some leads (V4-V6) we have the "impression" of flutter waving, baseline seems quite stable in D2 and V1, at least. Furthemore, if you try to place a "P" between 2 clear P waves in D3 (for a 2:1 rythm), you don't find a "P" where it should be. For all those reasons, I would call normal sinusal tac (in the contexte described above), although I would stay with a small concern about 2:1 flutter. A clue would be to treat the patient (fluid, etc) and check QRS variability on cardiac monitor. Flat line: flutter. Some variation (as we would see in any such adrenergic unstable patient): sinusal.

  7. Sorry, I meant normal P wave axis from "V3 to V6".