4/22/24, 12:23 AM Wide, Complex and Troublesome • LITFL • Cardiovascular curveball
Wide, Complex and Troublesome
Chris Nickson ● Apr 3, 2024
HOME LITFL CLINICAL CASES
aka Cardiovascular Curveball 013
A junior colleague asks if he can discuss a case with you.
His patient is a 23 year-old man who presents with 2 hours of rapid regular palpitations
associated with ‘not feeling quite right’. These symptoms came on while he was running on
a treadmill at his local gym. He has no significant past medical history. Apart from a
tachycardia, examination is unremarkable and he is hemodynamically stable.
This is his ECG:
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4/22/24, 12:23 AM Wide, Complex and Troublesome • LITFL • Cardiovascular curveball
Questions
Q1. Describe the ECG.
Answer and interpretation
Your colleague says he thinks it is an SVT with aberrant conduction because the patient is
young, haemodynamically stable and has no history of heart disease.
Q2. What is your response?
Answer and interpretation
Your colleague suggests, citing the 2010 ILCOR guidelines, that adenosine could be
administered and if the patient reverts then the diagnosis of SVT with aberrancy will be
confirmed.
Q3. What is your response to this suggestion?
Answer and interpretation
Q4. How can VT and SVT be reliably distinguished?
Answer and interpretation
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4/22/24, 12:23 AM Wide, Complex and Troublesome • LITFL • Cardiovascular curveball
Q5. How would you treat this patient?
Answer and interpretation
Q6. What was the diagnosis in the above ECG?
Answer and interpretation
References
CLINICAL CASES
Cardiovascular Curveball
more Curveballs…
Chris Nickson
Chris is an Intensivist and ECMO specialist at the Alfred ICU in
Melbourne. He is also a Clinical Adjunct Associate Professor at Monash
University. He is a co-founder of the Australia and New Zealand Clinician
Educator Network (ANZCEN) and is the Lead for the ANZCEN Clinician
Educator Incubator programme. He is on the Board of Directors for
the Intensive Care Foundation and is a First Part Examiner for the College
of Intensive Care Medicine. He is an internationally recognised Clinician
Educator with a passion for helping clinicians learn and for improving the
clinical performance of individuals and collectives.
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4/22/24, 12:23 AM Wide, Complex and Troublesome • LITFL • Cardiovascular curveball
After finishing his medical degree at the University of Auckland, he
continued post-graduate training in New Zealand as well as Australia’s
Northern Territory, Perth and Melbourne. He has completed fellowship
training in both intensive care medicine and emergency medicine, as well
as post-graduate training in biochemistry, clinical toxicology, clinical
epidemiology, and health professional education.
He is actively involved in in using translational simulation to improve
patient care and the design of processes and systems at Alfred Health.
He coordinates the Alfred ICU’s education and simulation programmes
and runs the unit’s education website, INTENSIVE. He created the
‘Critically Ill Airway’ course and teaches on numerous courses around the
world. He is one of the founders of the FOAM movement (Free Open-
Access Medical education) and is co-creator of litfl.com, the RAGE
podcast, the Resuscitology course, and the SMACC conference.
His one great achievement is being the father of three amazing children.
On Twitter, he is @precordialthump.
| INTENSIVE | RAGE | Resuscitology | SMACC
2 Comments
Morris Rivera NOVEMBER 20, 2020 / 23:24 REPLY
Nice case. I’m wondering if there’s any evidence that cardioversion in response to
vagal maneuvers rules in SVT (versus VT). I had a recent case for which this was
my justification for concluding the pt had SVT (in addition to other reassuring risk
features like young age and benign PMH) but I can’t claim to have read that
anywhere.
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4/22/24, 12:23 AM Wide, Complex and Troublesome • LITFL • Cardiovascular curveball
Ezra Limm FEBRUARY 20, 2022 / 23:09 REPLY
Here is my systematic analysis. It meets brugada criteria. Dx VT.
Looking for general signs of VT:
– Very broad complexes > 160ms? No.
– Extreme northwest axis? No. aVF and I are positive.
– Lead II Brugada RWPT > 50ms? No. It is about 40ms here.
Then go down the Brugada algorithm.
– Absence of RS complexes in all precordial leads? Ie. All leads pointing one way?
No.
– RS > 100ms (2.5 blocks) in any precordial leads? No. they measure about 50ms.
– AV dissociation? **** Possible – buried P waves in rhythm strip. ***
– BBB pattern? Yes – S in V1 so LBBB morphology.
— BBB general morphology criteria: V6 QS waves? No. V6 R/S <1? No.
— LeftBBB specific morphology criteria:
—— V1 Josephson notch? No;
—— **** V1 RS > 60ms? YES! Measures almost 80ms. ****
Dx VT.
i’ll be honest – wouldnt have picked RVOT VT on initial review.
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4/22/24, 12:23 AM Wide, Complex and Troublesome • LITFL • Cardiovascular curveball
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