Year: 2008
Type: article
Study design: Case Report
Abstract: I mages in E mergency M edicine Monomorphic Ventricular Tachycardia Amandeep Singh, MD Alameda County Medical Center - Highland General Hospital Supervising Section Editor: Rick A. McPheeters, DO Submission history: Submitted November 8, 2007; Revision Received January 26, 2008; Accepted February 2, 2008. Reprints available through open access at www.westjem.org [WestJEM. 2008;9:216.] An 83-year-old male with known coronary artery disease presented to our emergency department (ED) with a complaint of palpitations and associated minor chest discomfort while on his way to play a round of golf. Vital signs were significant for a blood pressure at 122/76 mmHg, heart rate at 180 beats per minute, respiration rate at 20 breaths per minute, temperature at 37oC, and SpO2 at 98% on room air. A 12-lead ECG showed a wide-complex tachycardia with no clearly discernible P waves and was thought to represent monomorphic ventricular tachycardia. Initial treatment with procainamide was attempted; however, within minutes of receiving this medication, his blood pressure dropped to 70/40 mmHg. Procedural sedation using etomidate and fentanyl, followed by electrical synchronized cardioversion using a biphasic defibrillator at 200J, successfully converted his rhythm to a sinus rhythm. The differential diagnosis for a wide-complex (i.e. QRS 0.12sec) regular tachycardia with no clearly discernible P waves prior to each QRS complex includes ventricular tachycardia, supraventricular tachycardia with preexisting or rate-related bundle branch block (e.g. SVT with LBBB), and supraventricular tachycardia with antidromic conduction through an accessory Volume IX, no . 4 : November 2008 pathway (e.g. antidromic WPW). Several proposed criteria may aid in the differentiation of these entities. 1,2 Contemporary teaching, however, mandates that a wide-complex tachycardia should be presumed ventricular tachycardia if the diagnosis is ambiguous. 3 Address for Correspondence: Amandeep Singh, MD. Department of Emergency Medicine, Alameda County Medical Center, 1411 East 31st Street, Oakland, CA 94602. Email: [email protected]. References 1. Brugada P, Brugada J, Mont L, Smeets J, and Andries EW. A new approach to the differential diagnosis of a regular tachycardia with a wide QRS complex. Circulation. 1991; 83:1649-1659. 2. Vereckei A, Duray G, Szenasi G, Altemose GT, and Miller JM. Application of a new algorithm in the differential diagnosis of wide- QRS complex tachycardia. Eur Heart J. 2007; 28:589-600. 3. Zipes DP, Camm AJ, Borggrefe M, et al. ACC/AHA/ESC 2006 guidelines for management of patients with ventricular arrhythmias and the prevention of sudden cardiac death: a report of the American College of Cardiology/ American Heart Association Task Force and the European Society of Cardiology Committee for Practice Guidelines. Circulation. 2006; 114:e385– e484. Western Journal of Emergency Medicine
Author: Amandeep Singh
Language: English
Subfield: Cardiology and Cardiovascular Medicine
Field: Medicine
Domain: Health Sciences
Open Access status: green
OpenAlex ID: W260436220