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A 6 week old is brought to your rural emergency department with several days history of irritability and poor feeding. On history there was poor/no antenatal care and the child was a home birth. On examination the child is afebrile, with a tachycardia and is haemodynamically stable. There is a 4/6 holosystolic murmur on cardiac auscultation and bilateral lung crepitations. An ecg is done and is shown below. Please answer the following:
 WHAT Does the ECG show?
The rate is 138. Normal P waves The QRS's in V4-5 overlap, indicating a Left Ventricular Hypertrophy. This is most likely due to a Vetriculoseptal defect (VSD) WHAT is the most likely diagnosis
This is a VSD. VSD's cause a left to right shunt. Over time they result in pulmonary hypertension and right ventricular hypertrophy, which then reverses the shunt. This can lead to Eisenmenger's syndrome, resulting in cyanosis and heart failure. At 4 to 6 weeks, the features of heart failure begin to appear. what investigations would you like to order?
The diagnosis has almost been made clinically. We already have an ECG. We need a Chest-Xray, which may show cardiomegaly and a cardiac echo to follow.
1 Comment
STEMI mimics(1) are important to understand, because in taking the time to investigate the mimic, we can miss opportunity for early treatment of the real disease. Unlike STEMI equivalents, which have been covered previously, some of the mimics are not as serious. Here are some examples. 1. Normal ST ElevationThis can be in 2 forms, where in both the ST segment is concave:
The ECG below is from a male who presents with chest pain. It is normal.  (3) 2. Benign Early Repolarisation (BER)This condition is present in a younger population group and amongst athletes. There are three types:
Point notch with elevation STE with concave up morphology V2-V6, II, III, avF usually < 2mm No reciprocal changes Symmetrical Concordant T wave STE/T-wave height <0.25 in V6 Benign Early Repolarisation may not be that benign, being associated with serious arrhythmias in some studies.  BER Source: Cardiac Bootcamp Online Course 3. PericarditisDiffuse STE ST/T-wave >0.25 There are 4 stages in pericarditis:
 Pericarditis. Source: Cardiac Bootcamp Live Course  4. LBBBST-T and QRS discordant. STE is concave and <5mm 5. HyperkalaemiaPeaked T waves Downsloping ST segment. 6. Brugada SyndromeType I: Coved Pattern
 Type I Coved Pattern Brugada(4) Type II: Saddle-back
 Type II Saddle-Back pattern Brugada(4) 7. Pulmonary EmbolismCan present with STE in Precordial leads A more common presentation of right ventricular injury is STE in V1-V3 and/or ST depression of V4-V6. Theories for why STE occurs in the precordial leads include:
 (7) References
A 28 yo patient presents to the emergency department complaining of palpitations of 2 hours duration. He has no other symptoms and has no past medical history of note. He is afebrile, with a respiratory rate of 14 a heart rate of 237bpm and a blood pressure of 119/67. An ECG is done and is shown below. What does the ECG show and what is your diagnosis? Is it Ventricular Tachycardia?  ANSWER
This is a wide 'ish' complex tachycardia at a rate of 237bpm. There is a RBBB morphology. The axis is extreme. If we use the 120 CRAM formula to see if it VT: Faster than 120bpm (but not too fast)- It is faster than 120. Wider than 120ms- It is borderline. Concordance: No Initial R wave in aVR: No AV Dissociation: No Morphology: RBBB pattern however there is an rsR pattern not indicative of VT R/S > 1 I would consider this more likely to be Supraventricular Tachycardia (SVT) with a RBBB, even with the axis as it is. How would you manage this haemodynamically stable patient? (a) Adenosine (b) Cardioversion (c) Sotalol IV (d) Amiodarone ANSWER
This can be a difficult question to answer. For those who prefer cardioversion in every patient with a WCT, that's a very appropriate approach.. However, is there any harm in giving Adenosine? There are 3 things to consider:
The patient was given Adenosine and reverted as shown below. Was this an Idiopathic Ventricular Tachycardia. How do you differentiate it from Ventricular tachycardia or from an SVT with aberrancy?  What is Idiopathic Ventricular Tachycardia?Idiopathic Ventricular Tachycardia (VT), occurs in structurally normal hearts and comprises about 10% of VT cases. This is a more benign form of VT, with patients rarely suffering from sudden cardiac death. Definitive treatment includes medications or ablation. Patients presenting to the emergency department with this arrhythmia, can be cardioverted and some will respond to AV nodal blockers such as Adenosine or Calcium Channel Blockers or Beta Blockers. However, even if the arrhythmia reverts with these, the patient should still be discussed with cardiology, especially if they fit the particular ECG patterns discussed below. Idiopathic VT can be mistaken for a supra ventricular tachycardia(SVT) with aberrancy and it will respond in some cases to AV nodal blockers, just like an SVT with aberrancy, so beware. However there are some distinct differences in morphology and axis, that allow us to identify it. Classifications can be confusing. For simplicity we can classify them as:
I recently gave a webinar on wide complex tachycardias(WCT) and other ECGs. Here are 4 WCT ECGs for you to try. The question I would like you to answer is simple:
Is this Ventricular Tachycardia (VT)? Then watch the 4 minute video with the answers, below.
ECG 1
An elderly patient who is hypotensive and has had a collapse/fall is found to have a WCT on the monitor. This ECG is done. Is this VT? 
ECG 2
A 19 yo woman presents with palpitations. An ECG is done which shows this WCT. Is this VT? 
ECG 3
A 58 yo patient present to the Emergency Department complaining of palpitations. Is this VT? 
ECG 4
A 60 yo male presents with palpitations. Is this VT? 
THE ANSWERS
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AuthorDr Peter Kas 
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