Friday, October 03, 2008

EKG Du Jour - #11: Tombstone Alternans

0400AM: "Uh, Dr. Fisher, we're having a little trouble. She keeps having this strange rhythm and loses her pressure."

Me: "Could you send me her EKG?"

Them: "Sure. We're sending it now:"

Click image to enlarge."

One of my Top Ten ugliest EKG's with some amazing findings.

How many can you find?



Anonymous said...

Too many. Any wonder why they keep losing pressure when the patient goes into VTach...

Did perchance they go to the cath lab? Hope so!

Anonymous said...

Is that torsades at the end of the strip?

DrWes said...

lostonthefloor -

No. It was contraindicated...

trifling -


Anonymous said...

I'm having a really hard time interpreting the remainder of the strip though. It seems like every other QRS complex has ST changes. The remaining QRS complexes do not.

But on the QRS complexes that DO have ST changes I see elevations in II, III, AVF, V5, and V6. So... inferolateral MI?

It isn't a regular rhythm either. It looks to me like it's regularly irregular. It is narrow complex though, so I'm not sure how it could be Vtach. I don't really see any p waves, so is this an accellerated junctional rhythm, with some sort of aberrant conduction pathway?

Sorry if I'm totally off, but I had fun trying to interpret it anyway :)

DrWes said...

tifling jester -

Take a K of 6.8, add it to a prolonged QT interval exceeding 700 msec on prior EKG's from bactrim in a patient with liver failure, and an acute inferoposterior MI with lateral extention and then add (presumed) atrial bigeminal PACs with a single PVC that degenerates to Torsades de pointes, and you see what happens. I was fascinated by the alternating ST segment elevation that occurred with the premature beats and and relative depression seen with the longer RR intervals. I am at a loss to explain the physiology of this finding. This patient had multiple other problems ongoing, including an infectious process that precluded taking the individual to the cath lab.

Anonymous said...

Cool, thanks for the explanation.

Anonymous said...

DR. Wes! I'm a cardiac technician from Portugal, electrocardiology is an enormous passion to me, and I have a hudge file with hundreds of ECG's colected from the ED I work at, some pretty rare, and I have one just like this one, except the Vtach!!