Peeling back the layers

Ok, stay with me here on the intro.  I don’t have a decent photo of an onion so we’ll have to make do with some flowers.  Because EKG’s can have a lot of layers, you peel one back, and only then get to the root cause.  Like these trout lilies, they start in one stage and get to another



Enough of the flowers, let’s get to the case:

60’s y.o. man with chest pressure, diaphoresis, light-headedness

As always, start with the rate.  The complexes cycle regularly a little faster than 2 big boxes, it looks about 180, way too fast for sinus tach in an adult, and usually too fast for Aflutter.  The complexes look wide, the EKG isn’t really getting back to baseline between the cycles.  In theory this could be an SVT with aberrancy, but given the vignette of CP, diaphoresis, and light-headedness I think you have to start by asking yourself why the wide complex regular tachycardia isn’t V tach.  If you look at the QRS complexes we see a predominantly downward deflection in I and predominantly upward deflection in V1, both of which are more consistent with Vtach than an SVT as documented here over the last month.  Indeed, most of you did correctly identify this as monomorphic V Tach.

But why is the patient in V tach?  Let’s cardiovert the patient and find out, shall we?


I thought about making this follow-up EKG the quiz for this week, but I think we all can identify the big infero-posterior STEMI that’s the underyling cause.

The take-home point is that V tach is not generally a disease of well hearts.  Look at the post conversion EKG closely (especially when you’re treating bradycardia), STEMI’s aren’t always this obvious!

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