EKGenie September 2017

Case:

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

Vital Signs:

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?

+ Rate

~105

+ Rhythm

Regular wide complex rhythm without associated P-waves

+ Intervals

PR: n/a QRS: 154msec
QTc: 472msec

+ Pathology

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.

+ Diagnosis

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