SVT or VT or SVT ***Abnormal ECG Unfonfirmed***

CASE PRESENTATION

A 50 yo male calls EMS for palpitations and chest discomfort. A 12 lead ECG (of course!) is obtained. The patient is short of breath and symptomatic. He remains awake, alert, oriented, and slightly diaphoretic. No obvious history.

12 LEAD ECG

12 LEAD ECG

ECG ANALYSIS AND INTERPRETATION

This ECG is particularly challenging, especially when the patient is symptomatic. Lifenet is raising all of the appropriate alerts, and you're faced with a couple of immediate treatment decisions. First, let's tackle therapy. 

1. In general, FIX THE RATE FIRST! Not only will fixing the rate provide relief from demand ischemia, but it may provide you with a diagnosis. This ECG is rapidly marching a long, and its very difficult in the heat of the moment to sort out p waves from QRS complexes from flutter waves. Demand ischemia occurs when the heart is unable to fill.

2. Unstable patient=SHOCK

3. Stable patient=consider drug therapy. In this case, adenosine **MAY** be an appropriate first line drug because the tachycardia is either some type of aberrant SVT or monomorphic VT

4. There are WIDESPREAD repolarization changes which I suspect are complicated by some lead placement issues. The narrow-looking complex in V2 doesn't fit with the rest of the ECG

5. The ECG is regular and FAST. VT usually occurs at a rate of 150; other differentials to consider in the setting of narrow complex tachycardia that is regular include SVT and A flutter. Intermittent and regularly occurring (small) positive deflections appear in this ECG to suggest an underlying atrial flutter rhythm

6. Examining lead one, the RIGHT rabbit ear is "taller." This favors SVT. Interestingly enough, RSR' complexes with a taller LEFT rabbit ear favor ventricular tachycardia. 

7. Other features that favor VT are absent, such as:
-AV dissociation
-Fusion beats
-Entirely positive or negative concordance in the chest (precordial) leads. This finding is best described as when the QRS complexes all point in the same (positive or negative) direction

8. With regard to the widespread ST segment elevation, it is never a bad idea to transport to a center capable of percutaneous coronary intervention. In this case, I suspect the widespread ECG changes (lots of ST segment depression) are due to repolarization  abnormalities or rate related ischemia. There doesn't appear to be a clear-cut anatomic distribution of the elevation. 

I shall offer my humble interpretation reminiscent of several recent radiology reads:
Regular, wide complex tachycardia suggesting either VT or an aberrantly conducted supraventricular rhythm. 2:1 atrial flutter is also in the differential. Correlate clinically. 

So the bottom line remains that I don't have a definitive interpretation here. Perhaps some of the other online ECG gurus could weigh in and provide some direction. What is clear, however, is that providers should keep some core principles in mind when confronted with a concerning and potentially confounding ECG:
1. Fix the rate first

2. Treat wide complex tachycardia as VT 

3. Always consider ischemia in your differential diagnosis