Double Defibrillation

Report:

Atrial fibrillation.

VEBs

Multiform ventricular tachycardia

Spontaneous termination (top)

Transition to ventricular fibrillation (middle)

Accelerated idioventricular rhythm (bottom) 70 - 76/min

Retrograde conduction (first four and last two beats)

Sinus rhythm (bottom)

Comment:

Ventricular fibrillation in this setting is called "primary VF" and has traditionally been held to have little impact on the patients' outlook. There is, however, some recent evidence that it does indicate a worse prognosis105.

Atrial fibrillation, on the other hand, unequivocally worsens the prognosis in anterior MI, representing a "power failure" arrhythmia secondary to atrial hypertension. In inferior MI, the outlook is less sinister, as the atrium may be affected directly by the ischæmic process. The situation is analogous to the AV block in anterior and inferior MI.

The strips show continued stormy course in ICU. The multiform VT "degenerates" into ventricular flutter and VF, when a DCC (not shown) cardioverts the patient from both AF and VF! Runs of AIVR sandwich the sinus rhythm in the bottom strip.

Below (Fig 211a) is the Casualty 12-lead ECG with acute anterior MI and AF.