tag:blogger.com,1999:blog-3364570834099131201.post8668290233438926543..comments2024-03-23T08:57:50.965-04:00Comments on ECG Interpretation: ECG Interpretation Review #86 (Regular WCT – VT – SVT – DeWinter T Waves – Aberrant Conduction – Capture Beats)ECG Interpretationhttp://www.blogger.com/profile/02309020028961384995noreply@blogger.comBlogger6125tag:blogger.com,1999:blog-3364570834099131201.post-8959348032320991132014-04-20T20:07:27.011-04:002014-04-20T20:07:27.011-04:00Thank you for your comments Peter! I agree that th...Thank you for your comments Peter! I agree that there are times (as in this case) when you just don't know what the rhythm is. But there are other times when within a few seconds you can determine with high accuracy if the rhythm is likely to be supraventricular or VT - and knowing that can guide your therapy. THANKS again for your interest and comments!ECG Interpretationhttps://www.blogger.com/profile/02309020028961384995noreply@blogger.comtag:blogger.com,1999:blog-3364570834099131201.post-92159864837606095182014-04-20T15:41:38.082-04:002014-04-20T15:41:38.082-04:00First of all I would like to say thank you for the...First of all I would like to say thank you for the enlightening case. As a pit doc in the ED, as well as EMS physician, I believe one of the most valuable tenets that came out of the AHA-ACLS guidelines was the concept of treating all WCT the same. No more enphasis on rabbit ears etc. If its unstable you shock, otherwise you try meds. Sometimes you shock ST but that is fair game if its wide and the patient is unstable. I agree with you that something doesnt look classic VT here so barring a history of profound hypovolemia or suggestive of massive PE to explain the tachycardia, I would have moved straight to a shock. As I teach my students it is "the drug with a half life of less than a second." As this patient was moribund, a successful bresuscitation was very unlikely. I probably would have done a quick bedside echo. Pericardial effusion or right heart dilation would have led me to pericardiocentesis or thrombolytics along with pressors and not cardiovert first, but without a bedside echo and or convincing history otherwise I would have shocked. Challenging case. Thanks again for sharing.Peter Bensonhttps://www.blogger.com/profile/18267845077389420082noreply@blogger.comtag:blogger.com,1999:blog-3364570834099131201.post-41411520461929525452014-04-19T16:50:20.455-04:002014-04-19T16:50:20.455-04:00@ Vince - Thanks for your astute comments - which ...@ Vince - Thanks for your astute comments - which I generally agree with. The T waves are not quite tall enough to qualify as a "full DeWinter syndrome", at least in Figure 1 - although the clinical context plus ST-T wave appearance in leads V2-thru-V5 in the post-conversion tracing I believe is at least "suggestive" (the word I very carefully chose, rather than "diagnostic") of DeWinter T waves - especially in view of ST elevation in leads aVR and aVL which adds support to a more proximal location of LAD occlusion (See Figure 2 in this Blog post). And - given this appearance in the Figure 2 post-conversion tracing - I think the somewhat less T wave peaking with somewhat more ST depression we see during the tachycardia in Figure 1 IS consistent with likely result of proximal LAD occlusion (albeit with T waves not quite as tall as they should be for patients who "read the textbook" prior to having their acute stemi).ECG Interpretationhttps://www.blogger.com/profile/02309020028961384995noreply@blogger.comtag:blogger.com,1999:blog-3364570834099131201.post-5558511623575611832014-04-19T11:35:57.009-04:002014-04-19T11:35:57.009-04:00Great case and well-presented Ken! This may be one...Great case and well-presented Ken! This may be one of my favorites you've ever dissected. While we'd obviously rather not shock VT, I agree that it can be forgiven, if not expected, in this instance (especially since that's what I would have done).<br /><br />My opinion does differ, however, regarding those upsloping T-waves with ST-depression. By my eye they lack the symmetric, rounded-top very prominent in at least 7, if not all 8 of the tracings originally published by de Winter. I would be more apt to call this a case of true left-main occlusion or maybe occlusion at the takeoff of the LAD without de Winter's findings as evidenced by diffuse subendocardial ischemia, but because of the patient's unfortunate (and probably unavoidable) we're left guessing.Vince Dhttps://www.blogger.com/profile/10636259293820649555noreply@blogger.comtag:blogger.com,1999:blog-3364570834099131201.post-2466675271857558842014-04-19T11:27:18.170-04:002014-04-19T11:27:18.170-04:00This comment has been removed by the author.Vince Dhttps://www.blogger.com/profile/10636259293820649555noreply@blogger.comtag:blogger.com,1999:blog-3364570834099131201.post-92124335630874898282014-04-19T09:36:16.944-04:002014-04-19T09:36:16.944-04:00Thanks....Thanks....Dr. Skawmanhttps://www.blogger.com/profile/14169439725617418849noreply@blogger.com