ECG Rounds Challenging ECG's with explanations.

DIAGNOSIS: Ventricular Tachycardia

EXPLANATION: There is a wide complex tachycardia present with a QRS duration of at least 120 msec and a rate of 186 bpm.

The axis is far to the right at 150 degrees, but not quite in "no man's land";. There is no concordance in the precordial leads and there are no signs of A-V dissociation present either clinically or on the ECG.

The clinical history is that of a 36 year old female with dyspnea as her only symptom and congestive heart failure noted on chest x-ray. Her BP was normal. She eventually admitted to cocaine use. As in the previous ECG, the one useful finding is the morphology of the QRS in V1. There is a monophasic R wave present; this is 90% specific for V-tach.

The patient received lidocaine and adenosine without effect. She was sedated and cardioverted at 100 J with resumption of a normal sinus rhythm.

Thanks to Drs John Horning, MD and Antonio Ciccone, DO for the tracing.

Editor: Sol Nevins MD FACEP. Faculty, Emergency Medicine Residency, Morristown Memorial Hospital, Morristown, N.J.