EMS are called to a 52 yof who has been "off legs" for over 2 months.
This p/t is a diabetic, controlled with Metformin, currently on treatment by her GP for a UTI.
Over the past few months this lady has had reduced mobility and an increasing Shortness of Breath on excertion...
PMH:
Renal problems
Heart problems
Diabetic: (Tablet & diet controlled)
UTI's
Poor mobility
Vital signs:
HR: 154
BP: 134/56
SPo2: 94% on air. 100% via 28% therapy mask
BM: Blood sugar 33 mmol/L
Skin: Dry
Temp: 36.9
What features on the 12 lead ECG captured do you see ?
12 lead ECG captured
Dx-
ReplyDeleteA-fib with RVR, due to AVRT, most likely WPW.
Reasons-
Irregularly irregular, with no clear and consistant p waves. Ventricular response in the 150s. What appears to be a delta wave, or slurring of the initial R wave in leads II and III.
Post script
There is minor ST elevation in the septal leads, which is most likely either a normal variant or a side effect of the tachycardia. It is possible there are some left sided precordial ST changes, but even given the low voltage and wandering baseline, I would label them minimal at best. There is also diffuse limb lead T wave abnormalities. While a DDx of all this includes MI, given the minimal STE and location of it, the absence of hyperacute T waves or acute ST morphology, and the lack of reciprocal evidence, I would rule it negative for STEMI, but with mild rate related ischemia.
Jesse -
ReplyDeleteWith WPW, it seems to me the rhythm would have to be either be AF or AVRT, but it could not both, because AVRT implies a circus-movement tachycardia (orthodromic or antidromic) which would not be possible in the presence of AF.
I do think this ECG shows AF, but I don't think an accessory pathway is involved. The QRS complexes are not polymorphic, and the shortest R-R interval does not even close to 240 ms.
Best regards,
Tom B.
Tom-
ReplyDeleteThanks alot for the informative comment!
I am curious though; I was unaware that polymorphic QRS morphologies were indicative of WPW. Why is that? And is a 240ms R-R interval a sensitive/specific marker for WPW in the presence of AFib?
Thanks again,
Jesse
Look carefully at the features on this 12 lead ECG, what can this tell us relating to the anatomical difference of this patient???
ReplyDeleteI should admit the case is quite difficult.Firstly i do agree the rythm is atrial fibrillation .. The QRS voltage in V4-6 is short.. Am not sure about the heart axis!! is it normal or right axis deviation?? The QRS in lead I is biphasic , but positive in leads II and III !!!
ReplyDeleteUnfortunately i still have problems in identifying the axis of the heart!! Many thanks to you .. The case is very interesting
OMG !!!!!!! finally am able to post my comments :)
ReplyDelete