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NOTE: Today's post is from our publication in JACC Case Reports —
(Nirdosh Rassani, MBBS & Ken Grauer, MD — Jan, 2026) (https://www.jacc.org/doi/10.1016/j.jaccas.2026.107164)
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The patient in today's case is a man in his late 20s — who presented to the ED about 6 hours after ingesting a finger-breadth piece of Jadwar (Figure-1).
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| Figure-1: Photograph of Delphinium denudatum (Jadwar). |
Details of today's case can be found in our JACC Case Reports article (available at the above link).
- Suffice it to say that the patient's symptoms at the time of presentation were limited to mild flushing, increased sweating and palpitations.
- He was alert — with stable vital signs.
On seeing this patient's initial ECG (that I've reproduced in Figure-2) — it is easy to understand his chief complaint of "palpitations".
QUESTION:
- How would you interpret this initial ECG?
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| Figure-2: The initial ECG in today's case — obtained from a man in his 20's who ingested Jadwar. (To improve visualization — I've digitized the original ECG using PMcardio). |
MY Thoughts on the ECG in Figure-2:
This patient's initial ECG is extremely worrisome. That's because there is a constantly changing QRS morphology. It's hard to tell if there any "normal" beats.
- To facilitate assessment in Figure-3 — I've numbered the beats in the long lead II rhythm strip.
- Can you tell what is going on? (See below).
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| Figure-3: I've numbered the beats in today's initial ECG. |
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The Long-Lead II Rhythm Strip:
This is a complicated rhythm strip. I outline my stepwise "thought process" for assessment below:
- The rhythm is irregularly irregular.
- As noted — QRS morphology is constantly changing throughout the long lead II rhythm strip. Many of the beats are wide.
- There are some narrow beats. Three of these narrow beats look similar and are upright in the long lead II (ie, beats #5,12,18). Presumably these 3 beats are supraventricular!
- A short pause precedes beats #5 and 18 — but I see no sign of atrial activity. If P waves were present — I would expect to see them in the short pause that precedes beats #5 and 18. Given the overall irregularity with occasional narrow beats but no sign of P waves — I suspect that the underlying rhythm is AFib (Atrial Fibrillation).
- There are multiple wide beats in the long lead II. Other than beats #5,12,18 — all of the other positive QRS complexes are clearly wide (ie, beats #1,2,3,4; #6; #9,10,11; #14; #19). Each of these beats look to be of ventricular etiology.
- Fortunately — the long lead II rhythm strip is simultaneously recorded with the 12-lead tracing above it. The reason this is so helpful in this tracing — is that this allows us to view the QRS complexes that are negative in the long lead II in other simultaneously-recorded leads. For example — although beat #13 looks fairly narrow in the long lead II — it is actually a wide (presumably ventricular) beat when viewed in simultaneously-recorded leads V2,V3.
- Beat #16 is all negative and appears to be slightly widened in the long lead II — but it looks much wider, and clearly of ventricular etiology in simultaneously-recorded leads V1,V2,V3.
- Beat #15 in the long lead II looks intermediate in QRS morphology between beats #14 and #16. Is the intermediate QRS shape of beat #15 the result of fusion between beats arising from 2 different ventricular sites?
- On the other hand — not only is beat #21 narrow in the long lead II — but it appears to also be narrow in simultaneously-recorded leads V4,V5,V6. This suggests that beat #21 may be supraventricular, with its negative QRS morphology in the long lead II explained by aberrant conduction. Perhaps other fairly narrow, negative complexes in the long lead II are also supraventricular with aberrant conduction?
My Impression of Figure-3:
This is an extremely complicated tracing. My assessment:
- The underlying rhythm appears to be AFib.
- There are multiple wide beat QRS morphologies that most-likely represent non-sustained runs of PMVT (PolyMorphic Ventricular Tachycardia).
- Those beats that are narrower in the long lead II exhibit beat-to-beat variation in QRS morphology, suggestive of aberrant conduction and/or fusion with ventricular ectopy.
- PEARL #1: What counts in assessment of Figure-3 is the overall "Gestalt" of what is likely to be happening. It simply is not worth spending excessive time trying to "dissect" the etiology of every beat in this tracing — as this is a thankless, if not impossible task. Instead, our goal for interpreting the rhythm is to arrive at an overall assessment — and this appears to be underlying AFib with non-sustained runs of PMVT.
- PEARL #2: As noted above — beat #21 is probably supraventricular with aberrant conduction. As a result, I looked closely at ST-T wave morphology and the QT interval for this beat. Note within the RED rectangle in Figure-3 — that there appears to be marked ST depression in leads V5,V6 for beat #21 (BLUE arrow) — as well as QT prolongation considering the overall rapid rate.
- PEARL #3: The unusual rhythm in Figure-3 is best interpreted in light of the clinical situation. This clinical situation is that today's patient ingested Jadwar prior to the onset of his symptoms!
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About Jadwar:
Jadwar (Delphinium denudatum) is a traditional medicinal herb widely used in South Asia as a "universal antidote" for treating a wide variety of neurologic, analgesic and gastrointestinal conditions. Among its attributed actions include pain relief, an anti-inflammatory effect, reduced fatigue, antidote properties (for snake or scorpion bites), addiction recovery (to help manage narcotic dependency) — as well as for treatment of URIs and other common infections.
- Although Jadwar itself is generally considered safe and of low toxicity when used appropriately — Jadwar may sometimes be adulterated with aconite (which can occur if/when herbal medicines are improperly prepared).
- Aconite ingestion may be highly toxic and even fatal. The mechanism stems from binding to and persistently activating voltage-sensitive sodium channels in excitable cells (including myocardial, nerve and muscular tissue). This results in sustained sodium influx with persistent sodium channel activation (Chan — Clin Toxicol 47(4):279-285, 2009).
- Patients with aconite ingestion may present with a combination of neurologic features (paresthesias with facial or limb numbness) — motor effects (muscle weakness) — and cardiovascular effects that may be severe (hypotension, chest pain, palpitations from a variety of arrhythmias including refractory ventricular tachycardia and ventricular fibrillation).
- Management of aconite poisoning is largely supportive until effects of ingestion have worn off. IV Lidocaine was successfully used in our case for its sodium-channel blocking effect that counteracts aconitine toxicity.
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CASE Follow-Up:
Detailed description of today's presentation is covered in our JACC Case Reports article. In brief — laboratory evaluation of this patient was largely normal, with exception of low-normal serum Mg++ (treated with IV Mg++ replacement). Serum Troponins were negative and Echo showed surprisingly normal LV function despite the arrhythmia.
- Within 30 minutes of administering IV Lidocaine (IV bolus followed by IV infusion) — there was a dramatic reduction in the frequency and duration of PMVT episodes — with complete suppression of ventricular ectopy achieved by 6 hours.
- IV Lidocaine infusion was continued for 24 hours — followed by observation on telemetry for an additional 24 hours, after which the patient was discharged from the hospital.
To facilitate comparison in Figure-4 — I've added the discharge ECG below this patient's initial tracing. This discharge tracing reflects what was seen on telemetry during the last 40+ hours of observation.
- Note return of normal sinus rhythm (RED arrow P waves in the long lead II of ECG #2) — and the complete absence of ventricular ectopy!
- The lateral chest lead ST depression in ECG #2 is now minimal — with normalization of the QT interval.
- PEARL #4: In support of my suspicion that beat #21 in the initial tracing was indeed a supraventricular beat — is the finding of similar QRS morphology for this beat in leads V5,V6 of ECG #1 — with QRS morphology in leads V5,V6 after restoration of sinus rhythm in ECG #2. This suggests that the reason beat #21 was negative in the long lead II of ECG #1 was indeed aberrant conduction.
- The "PEARL" — is that sometimes the etiology of certain beats or rhythms of uncertain etiology in an initial tracing may become clear by careful comparison of morphology on subsequent tracings.
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| Figure-4: Comparison of today's initial ECG — with the discharge ECG recorded 48 hours later. |
FINAL Thoughts (Addendum added on 3/29/2026):
Today's case proved satisfying by the complete recovery made by this patient who had ingested a potentially lethal dose of medicinal herb.
- Technically — the rhythm in today's case should probably be classified as Torsades de Pointes — because, as highlighted in Figure-4 — the rhythm is PMVT with a preexisting long QTc (which we know is true — because after treatment the QTc normalizes, confirming that it was initially prolonged).
- That said — I called this rhythm "PMVT" despite this initially prolonged QTc because Torsades typically manifests more of a "pattern", in the form of alternating predominant positivity transitioning to predominant negativity in a repetitive fashion (ie, "twisting of the baseline" — as per the French translation of its name). In contrast — I thought today's initial rhythm manifests more of a random variation in QRS morphology.
- PEARL #5: Clinically — the semantics of whether today's initial rhythm is PMVT or Torsades is not important. This is because the KEY management concept for this rhythm is identification and treatment of the cause (which was successfully accomplished in today's case by Mg++ replacement + IV Lidocaine + a good dose of "luck", that with close monitoring the adverse effects from this toxic ingestion would wear off and the patient would recover).
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Related Material:
- ECG Blog #231 — reviews the various types of VT terminology.
- See Viskin et al (Circulation 144:823-839, 2021) — for an in-depth review of PMVT.
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Acknowledgment: My appreciation to Nirdosh Rassani (from Quetta, Pakistan) for the case and this tracing.
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