This ECG is from a 74 yr old female. I don't have any more clinical information on the case unfortunately.Check out the comments on our original case here.
|Click to enlarge|
- Ventricular rate ~136 bpm
- Atrial rate ~ 270 bpm
- Regular atrial & ventricular activity
- Atrial activity best seen in leads I & V1
- Notching in terminal portion of QRS and also in isoelectric segment
|Atrial activity highlighted in leads I & V1|
Click to enlarge
- QRS - Prolonged (140ms)
- QT - 310ms
- Appropriate ST segment & T wave discordance
- Sgarbossa Negative
- Regular Wide Complex Tachycardia
- Evidence of 2:1 conduction
- Likely atrial tachycardia or atrial flutter
- LBBB Morphology
- DDx - Native, rate related or aberrancy
What would we want to ask our patient ?
The first thing to establish is whether we have time to take a full and detailed history. Clinical instability, e.g. hypotension, mandate urgent resuscitation and rhythm control.
But if we time for a 'chat' there are a number of things to establish in this patient including:
- Are they symptomatic ?
- Do they have palpitations ?
- Do they have - chest pain, dysponea, syncope or pre-syncope ?
- Do we have a cause ?
- Concurrent or recent illness ?
- Has this happened before ?
- Do they have a chronic dysrhythmia ?
- Do they have a cardiac history ?
- What are we going to do about it ?
- Do we have an accurate onset time ?
- Are they on long term anti-coagulation - warfarin, NOAC etc ?
- What do they want us to do ?
- Do we anticipate sedation / DCCV difficulties ?
- Previous episodes and outcome
- Previous sedation or GA
- Fasting status
- What is the long term plan ?
- Consider co-morbidities ?
- Social circumstance ?
- Patient / NOK wishes ?
Without knowing more about our patient it's difficult to establish the best management but broad consideration are:
- Rate vs Rhythm Control
- Correction of any underlying / precipitating condition e.g. infection, electrolyte abnormality, ischaemia etc.
- Long-term management / prevention
References / Further Reading
Life in the Fast Lane
- Chan TC, Brady WJ, Harrigan RA, Ornato JP, Rosen P. ECG in Emergency Medicine and Acute Care. Elsevier Mosby 2005.