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Orthopedics

September 2004 EKG Case

A 70 year old male becomes lightheaded and falls while walking his dog.  He has a Colles’ fracture and is brought to the emergency department and has a pulse of 150 and a BP of 140/75.  He admits to several episodes of palpitations over the past few days. He was diagnosed with a myocardial infarction 5 years ago.

What does the EKG show and what is the diagnosis?
Rate:  160
Rhythm:  Ventricular tachycardia
Axis:  Right axis deviation
QRS:   Wide complex (0.24sec)

EKG diagnosis: Ventricular tachycardia

Clinical diagnosis: Ventricular tachycardia
                           Ischemic heart disease
                           Colles’ fracture

Practice points: -Ventricular tachycardia is the default diagnosis for all regular wide complex tachycardias
                       -The history of a previous MI and the patient’s age make VT by far the most likely diagnosis
                       -The differential of wide complex tachycardia includes:
                                         -ventricular tachycardia
                                         -supraventricular tachycardia with pre-existing bundle branch block or rate dependent bundle branch block
                                         -This patient is not hemodynamically compromised.  This is still compatible with the diagnosis of ventricular tachycardia
                                         -VT is usually regular in the absence of fusion or capture beats
                                         -The patient’s age (> 35) is 90% predictive of ventricular rather than supraventricular tachycardia
                                         -When there is a RBBB pattern, the R > R’ in V1 is suggestive of a ventricular origin

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