tag:blogger.com,1999:blog-549949223388475481.post7760512394135596495..comments2024-03-26T22:42:04.176-05:00Comments on Dr. Smith's ECG Blog: Wide Complex Tachycardia and CyanosisUnknownnoreply@blogger.comBlogger11125tag:blogger.com,1999:blog-549949223388475481.post-88670965355607859072019-10-25T14:50:26.570-05:002019-10-25T14:50:26.570-05:00@ Chess — Thanks for your comment! Nothing is 100%...@ Chess — Thanks for your comment! Nothing is 100%. As I mentioned in my comment (just above this) — the presence of clubbing would tell us that this patient has some sort of severe cardiopulmonary disease that is CHRONIC. As I mentioned in my comments — there were several clues that this WCT (Wide-Complex Tachycardia) rhythm might be supraventricular (ie, possible sinus P waves buried in the ST-T wave during the tachycardia — and narrow initial deflections in several leads). So if there was good reason for this patient to have a very abnormal BASELINE ECG (ie, such as severe cyanotic [clubbing inducing] congenital heart disease) — then a supraventricular etiology becomes that much more likely. Note — this does NOT rule out VT (!!!) — but based on the above ECG characteristics PLUS knowledge that the patient has severe congenital heart disease — I felt a supraventricular etiology became more likely. Hope that helps explain your question — :)ECG Interpretationhttps://www.blogger.com/profile/02309020028961384995noreply@blogger.comtag:blogger.com,1999:blog-549949223388475481.post-6127825996916948862019-10-25T13:32:35.931-05:002019-10-25T13:32:35.931-05:00thank you alot dr smith and dr Ken for your commen...thank you alot dr smith and dr Ken for your comments my question is why just by the clubbing of fingers we can eliminate the ventricular tech <br />chesshttps://www.blogger.com/profile/07202947574392212660noreply@blogger.comtag:blogger.com,1999:blog-549949223388475481.post-74107237438897054122017-03-14T17:58:07.760-05:002017-03-14T17:58:07.760-05:00sounds right, but I'm not sure. It's no i...sounds right, but I'm not sure. It's no impediment to place all 3 thoughSteve Smithhttps://www.blogger.com/profile/08027289511840815536noreply@blogger.comtag:blogger.com,1999:blog-549949223388475481.post-76131377016484201802017-01-13T07:14:32.030-06:002017-01-13T07:14:32.030-06:00Mario,
I don't think so. I just don't see...Mario,<br />I don't think so. I just don't see any baseline that looks like flutter.<br />SteveSteve Smithhttps://www.blogger.com/profile/08027289511840815536noreply@blogger.comtag:blogger.com,1999:blog-549949223388475481.post-24674500738201713752017-01-12T22:11:57.408-06:002017-01-12T22:11:57.408-06:00I should have written: '' antidromic AVRT&...I should have written: '' antidromic AVRT''. Thanks for reply!Anonymoushttps://www.blogger.com/profile/17513846747982914434noreply@blogger.comtag:blogger.com,1999:blog-549949223388475481.post-28058521536176479002017-01-12T17:05:27.433-06:002017-01-12T17:05:27.433-06:00This is a GREAT case. As Dr. Smith mentioned — he ...This is a GREAT case. As Dr. Smith mentioned — he showed me this ECG and has published my comment above. Please NOTE — I did NOT have any history at all, nor did I know the patient had clubbing. If I had known that — I would have suspected from the outset that this was a supraventricular rhythm and not VT. As a result — cardioversion would probably not be recommended. Of interest, as we now see the post-conversion tracing — I believe those very subtle-but-present slightly angulated tiny deflection in lead II at the peak of the T wave during the tachycardia may be sinus P waves — as the post-conversion tracing seems to show similar shape and PR interval P waves after conversion to sinus rhythm.<br /><br />So the comments I’d add to this excellent post by Dr. Smith are the following:<br />— Clearly cardiovert your wide tachycardia of unknown etiology patients IF you have evidence that the patient is hemodynamically unstable as a result of the tachycardia. This patient was cyanotic but had a normal blood pressure throughout — so one has to wonder whether what was being seen was more of a chronic condition with exacerbation producing sinus tachycardia as a result of inadequate oxygenation rather than a VT rhythm (ie, not necessarily something to cardiovert).<br /><br />— Realize that sometimes one CAN be fooled by the presence of severe underlying heart disease (including congenital heart disease) that may produce marked abnormality in the baseline QRS. While not in any way definitive — the leads we noted that had initial narrow deflections that “looked supraventricular” provide subtle clue that this may be the case here.<br /><br />— Rather than saying “SVT with aberrancy is not at all unlikely” — I would change this to say, SVT with preexisting IVCD due to some form of severe underlying heart disease is not at all unlikely”. Remember, “SVT with Aberration” as a cause of a wide tachycardia means that when the rate SLOWS, the QRS widening goes away. That is NOT the case here. Aberrant conduction most often manifests QRS morphology that resembles some form of bundle branch block and/or hemiblock — and that is also NOT the case here. So I never suspected “aberrant conduction” here — but instead, suspected severe underlying heart disease as a possible cause of this wide tachycardia that to me had some features not suggestive of VT. The moment we learn the patient has clubbing and a long history of “some heart defect” — VT becomes far less likely.<br /><br />— The concepts described by Dr. Smith in this blog are advanced. Suspecting that this rhythm is not VT is clearly challenging, even to interpreters with many years of experience. But this is a WONDERFUL case for great insightful discussion. THANKS for publishing!<br /><br />ECG Interpretationhttps://www.blogger.com/profile/02309020028961384995noreply@blogger.comtag:blogger.com,1999:blog-549949223388475481.post-11269196815650245842017-01-12T10:53:31.711-06:002017-01-12T10:53:31.711-06:00All ECG findings (atypical morphology of RBBB, app...All ECG findings (atypical morphology of RBBB, apparently monophasic R wave in aVR, negative QRS in V6) were suggestive for VT but to your close scrutinity there were some clues for interpreting this wide complex tachycardia as supraventricular tach with preexistent intraventricular conduction defect. Great case and very insightful explanations on the differentials and management!<br /><br />Just only for speculative purposes, could the initial rhythm be atrial flutter with 2:1 conduction given the rate and the fact that often patients with corrected congenital defect suffer (especially after involvement of atria) from those arrhythmias?<br />Mario Parrinellohttps://www.blogger.com/profile/07136945770330333718noreply@blogger.comtag:blogger.com,1999:blog-549949223388475481.post-44435437056101446472017-01-12T06:48:43.740-06:002017-01-12T06:48:43.740-06:00Allen,
That is correct!
SteveAllen,<br />That is correct!<br />SteveSteve Smithhttps://www.blogger.com/profile/08027289511840815536noreply@blogger.comtag:blogger.com,1999:blog-549949223388475481.post-56046427394441885372017-01-12T04:29:00.387-06:002017-01-12T04:29:00.387-06:00Doctor Smith:
Thanks for providing such a fantas...Doctor Smith:<br /> Thanks for providing such a fantastic case! I have a question: Since much of these algorithms (Brugada, Vereckei, Sasaki) are largely based on slow initial onset of QRS to be VT, I think that they could only be applied to differentiate VT from SVT with aberrancy, but not SVT with IVCD (like hyperkalemia, anti-arryhtmic drugs toxicity) and orthodromic AVRT which all have slow initial onset of QRS. Is that right?<br />Thank you very much!Anonymoushttps://www.blogger.com/profile/17513846747982914434noreply@blogger.comtag:blogger.com,1999:blog-549949223388475481.post-50693808192194274782017-01-11T07:47:20.724-06:002017-01-11T07:47:20.724-06:00Peter,
I'm not entirely certain.
But I'll ...Peter,<br />I'm not entirely certain.<br />But I'll try to find out.<br />Anyway, it is easy to move all 3 leads, so I haven't really objected to it!<br />SteveSteve Smithhttps://www.blogger.com/profile/08027289511840815536noreply@blogger.comtag:blogger.com,1999:blog-549949223388475481.post-76153196577680918602017-01-10T23:49:49.584-06:002017-01-10T23:49:49.584-06:00Steve,
Regarding the Lewis lead,
I have no experie...Steve,<br />Regarding the Lewis lead,<br />I have no experience in using this lead, but since you only monitor lead I, wouldn't it be sufficient to only replace the RA and LA lead? P Hammarlundhttps://www.blogger.com/profile/12795866723817205360noreply@blogger.com