"Ventricular Tachycardia Vs Movement Artifacts"

63 years old male patient presented to ED with palpitations.

The initial ECG showed SVT, treated with 6 mg of Adenosine which helped to cardiovert the patient back to sinus rhythm on the monitor.

A post cardioversion ECG was requested, & all of a sudden the nurse came to you asking for help as the ECG below is what came out of the ECG machine.

What is your diagnosis & management plan??

Discussion:

This is an interesting ECG as we can use it to highlight an important basic fact about the ECG that can help the beginners to look at the ECG completely differently.

This fact is: When you go horizontally with the ECG paper, then you are going WITH TIME, but if you move vertically, TIME STOPS".

What I mean by this simply is that if you take any point on an ECG paper, anything just above or below this exact point has happened in the same time.

Here is a different ECG to explain this rule.

You will notice that when you move horizontally with the ECG paper & find an abnormal beat or rhythm anywhere, & you follow it up & down, you will find a similar abnormality.

So if we apply this to our ECG, we will find a really interesting thing which is that our patient has had a normal sinus rhythm in lead I, but he also has had what looks like Polymorphic VT in leads II & III.

This would make sense if we are moving horizontally (e.g. sinus rhythm in lead I & then VT in aVR or aVL) as we are moving with time, but it is impossible if you move vertically as what happens in lead I happens in the same time in leads II & III.

This can only happen in one condition.

Answer:

The only way to explain this is that this is "MOVEMENT ARTIFACTS"

If you follow the normal looking complexes down, you will be able to differentiate the normal complexes from the artifacts waves, & if you move horizontally, you will appreciate how regular the rhythm is.

This patient was slightly hypothermic & was having repeated shivering episodes caused the above changes, & the repeat ECGs after rewarming him were completely normal.

Here is another example of a movement artifact mimiking ventricular tachycardia, and again, if you follow our rule and compare lead III with lead I & II, you will clearly see the answer, & then you will be able to identify & map the actual complexes across the whole ECG.

Courtesy to Dr. Anas Halim, Emergency Physician, KSA.

So, I hope that you can now look at the ECG below & answer that question in 2 seconds,,

Do I need to worry about this ECG?

Here is a link to a video that discusses the above case with some more details:

https://www.youtube.com/watch?v=HRzRpvKp-UY&list=PL9UPY1P9K6fNSHzP_gPIbTu6TjZGAL0iR&index=15