ECG Review: Should the Patient Be Shocked?
ECG Review
Should the Patient Be Shocked?
By Ken Grauer, MD, Professor, Department of Community Health and Family Medicine, University of Florida. Dr. Grauer is the sole proprietor of KG-EKG Press, and publisher of an ECG pocket brain book.
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Clinical Scenario
The ECG shown above was obtained from a patient with acute shortness of breath. The QRS complex was recognized to be wide, and the clinical question raised was whether the patient should be immediately shocked. How would you respond?
Interpretation
The rhythm is rapid, atrial activity is absent, and the QRS complex appears to be slightly widened on this 12-lead ECG obtained from a patient who is acutely symptomatic (i.e., with shortness of breath). If this rhythm represented ventricular tachycardia (VT), acute synchronized cardioversion would clearly be indicated. That said, it is unlikely that the rhythm seen here represents VT. Although fairly regular in parts of the tracing (especially toward the beginning of the ECG), the underlying irregular irregularity can more easily be seen over the last half of the tracing. Thus, the rhythm is atrial fibrillation with a rapid ventricular response. QRS widening may be the combined result of left anterior hemiblock (LAHB) occurring in association with left ventricular hypertrophy (LVH) both of which commonly produce slight lengthening of the QRS complex. Deep T wave inversion is seen in the lateral limb leads, and may reflect either "strain" and/or rate-related changes. Although VT should always be suspected when confronted with a wide-complex tachycardia in the absence of P waves, the irregular irregularity that marks the latter part of this tracing is highly suggestive of atrial fibrillation as the underlying rhythm. VT is not always perfectly regular but it should not be as irregular as the rhythm seen here. Comparison with prior tracings revealed a history of atrial fibrillation with QRS widening of identical morphology. Thus, although the patient was symptomatic, medical treatment aimed at slowing the ventricular response of atrial fibrillation was the management approach appropriately adopted here.
The ECG shown above was obtained from a patient with acute shortness of breath. The QRS complex was recognized to be wide, and the clinical question raised was whether the patient should be immediately shocked. How would you respond?Subscribe Now for Access
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