to the bedside…
the case.
a 34 year old female presents to ED with palpitations and chest pain.
You are handed her ECG prior to reviewing or speaking to the patient….
[DDET Describe & interpret her ECG…]
- Rate.
- 134 bpm
- Rhythm.
- Regular.
- No obvious P’s.
- Axis.
- Markedly rightward [ +156* ]
- Intervals.
- PR – n/a
- QRS – 90msec
- QTc ~ 420msec
- Additional.
- RBBB pattern (< 120msec therefore incomplete)
- Right ventricular hypertrophy w/ RV strain pattern
- very large R-wave (V1) [>>7mm] + R/S >>1
- deep S-wave [V6] + R/S <1.
- ST depression + TWI (V1-3)
- ?Flutter wave V2.
Interpretation.
- Young female w/ chest pain.
- Narrow complex tachycardia w/out clear P-waves
- is this SVT or Atrial flutter ??
- Incomplete RBBB w/ right ventricular hypertrophy & strain pattern.
- Differential Dx:
- ?Pulmonary embolism with right-heart strain
- ?chronic lung disease w/ cor pulmonale or pulmonary hypertension
- ?underlying congenital heart disease
[/DDET]
[DDET You head to the bedside…]
Your patient looks very well.
- Alert & speaking full sentences.
- Observations:
- SaO2 100% on room air.
- P 134. BP 126/-. RR 20.
- Afebrile.
- Obvious old, well-healed midline-sternotomy scar.
- Clear chest.
“It’s ok Doc, I’ve had this before” she tells you.
Her background:
- Transposition of Great Vessels.
- Mustard procedure (see below).
- Recurrent atrial flutter.
- Previous electrophysiology studies [multiple re-entry circuits identified and ablated].
[/DDET]
[DDET The diagnosis…]
Atrial flutter with right ventricular hypertrophy secondary to congenital heart disease.
[/DDET]
[DDET What happens next ??]
- We discuss the pro’s & con’s of electrical vs chemical cardioversion.
- Electrical cardioversion is chosen.
- Ketofol (30/30mg)
- 50J synchronised shock…
- She is discharged a few hours later !!
[/DDET]
