Scenario
A 35 year old man is brought to your Emergency Department following two seizures.
His observations are:
Question
Describe and interpret his ECG (100%)
Answer
FACEM VAQ Exam 2009.1 – Question 7
- The overall pass rate for this question was 52/81 (64.2%)
- ECG showing regular broad complex tachycardia with widened QRS and abnormal terminal R wave in aVR.
- Again the examiners were disappointed with the response to this straight forward question.
- Pass criteria were identifying the abnormalities listed plus considering toxic ingestion (especially Tricyclic Antidepressant Overdose (TCA)) as a cause in this scenario.
- Fail criteria were absence of the above.
ACEM Fellowship Visual Aid Questions
About Mike Cadogan
TCA overdose/toxicity, as patient’s symptoms of seizures (indicative of large ingestion of medication) plus an R wave in the aVR.
broad complex tachy. regular R-R interval
no discrete p waves seen
HR 125b/min
abnormal T waves , a hump is seen on the st segment which may be a retrograde p wave
no a-v dissociation,no capture ,
no fusion beats
its definitely a supraventricular tachy with aberrant ventricular conduction
AV junctional tachycardia with aberration 1st diagnosis
AVNRT with aberration
the slow 125bpm rate goes more in favour of junctional tachy
he might have got seizures,hypotension because of a sinus arrest.
Suggestion of TCA vs other Na+ blockade. Wide complex with QRS prolongation and 4+ elevation of terminal R in AvR. Highly suggestive of overdose. Give NaHCO3, consider Mg2+.
ED Doc
ECG 02: in my opinion ECG showed:
Supraventricular tachycadia with aberrant conduction (underlying most likely blocked atrial tachycardia otherwise atrial flutter). The Ventricular rate 125 bpm (atrial rate 250bpm). In lead V2 is clearly visible P or F waves on the baseline and at the end of the QRS.
Great blog.