EKG of the Week – Week 19 ANSWERS
So, to be honest, I made this one a little harder on you than it was for me with the stem. This was billed to me as, Hey Doc, he’s in VTach in lead II. Not to give it away, but you’re either in VTach or not. I was leaning towards not in this case. The big question is, is this Torsades du Pointes (TDP), a form of polymorphic VTach or not? Let’s look at the Rhythm strip again with some marks on it, See Rhythm_1_Marked_Up:
All of the black lines on it were obtained by measuring the R-R Interval between the two red stars. Notice how the R-R interval is consistent in all of the places I measured. You should not be able to march out QRS complexes in TDP. So, feeling pretty good about this being artifact over TDP. This patient had a lot of reasons to go into TDP like taking multiple QT prolonging meds due to all those psych meds, Super high K, etc. So, if you take nothing else away from this, when a nurse calls you about a patient, especially when you don’t plan on doing anything, GO SEE THE PATIENT. Which is what I did. He was hemodynamically stable, with no complaints. His EKG from that morning had a normal QT, which is also reassuring. I felt pretty good with my decision that this was artifact and there was nothing to do.
Cardiology was eventually consulted and agreed that it was likely artifact. I believe their actual words were, “Please ask the patient not to use his electric toothbrush while connected to the tele monitor.”
Let’s do a quick TDP review:
Click on this link for a classic example of TDP from life in the fast lane (https://lifeinthefastlane.com/ecg-library/tdp/):
Notice the smooth, almost wavy nature of it? Our rhythm strip was missing that. Our was very harsh almost alternating large then small then large complexes. Notice also how you cannot march out underlying QRS complexes?
From Life in the fast lane:
- TdP is often short lived and self terminating, however can be associated with hemodynamic instability and collapse. TdP may also degenerate into ventricular fibrillation (VF).
- QT prolongation may occur secondary to multiple drug effects, electrolyte abnormalities and medical conditions; these may combine to produce TdP, e.g. hypokalaemia may precipitate TdP in a patient with congenital long QT syndrome.
- Recognition of TdP and the risk of TdP allows the instigation of specific management strategies (e.g. magnesium, isoprenaline, overdrive pacing, etc.)
Amal Mattu has an excellent case on artifact vs VTach: http://www.mededmasters.com/vtach-versus-artifact.html