Your patient is a 56 yo F with past medical history remarkable for CKD, HTN presenting with chief complaint of progressive diffuse weakness, malaise and fatigue over the last 3 days
Exam: T 98.6 BP 148/92 HR 102 RR 16 SpO2 97% Glucose 99
Alert, conversive but fatigued. No pallor or jaundice
CV/lung/abd: slightly tachy but regular, no murmurs, otherwise unremarkable
Ext: Well healing surgical incision Lt upper arm
What is your impression of the EKG?
Regular wide complex rhythm without associated P-waves
T waves appear relatively peaked along septal leads
Regular, wide complex tachycardia without associated P waves should ALWAYS inspire the thought of Vtach…then Vtach…then Vtach again. This, however, is going a little slow for Vtach, which is usually >120bpm. Generally, QRS complexes are wide for 2 reasons: either aberrant conduction (bundle branch blocks, accessory pathways) or rhythms originating below AV node, aka idioventricular rhythms.
Without a previous EKG, this patient has either an accelerated junctional rhythm with LBBB or accelerated idioventricular rhythm (AIVR).
+ Why is this important?
Differentiating from VTach is ALWAYS important. Some etiologies of AIVR include electrolyte abnormalities, ischemia/infarction, structural disease, medications (i.e., digoxin toxicity). Interestingly, this patient was found to be hyperkalemic! Do not forget: hyperkalemia is the great masquerader (aka the syphilis of EKGs)
+ What should be your next step in mangement
Ensure stability of the patient, identify and treat the cause.
+ Additional resources
Amal Mattu ECG Weekly: http://www.mededmasters.com/bizarre--hyperkalemia.html
Life in the Fast Lane: http://lifeinthefastlane.com/ecg-library/aivr/ Medscape: http://emedicine.medscape.com/article/150074-overview#a4
Dr Grauer’s Rhythm Diagnosis Review: https://www.youtube.com/watch?v=Xoju_l0OYFE