Shocking Tachycardia !
Report:
Sinus tachycardia 144/min
Right bundle branch block
Left anterior hemiblock (axis –70o)
Acute anterior infarction.
Comment:
The Casualty staff claimed having seen fusion beats to support their line of therapy. None could be documented, in retrospect. There could have been VEBs, common in this setting. An infusion of amiodarone, started after the xylocaine, slowed the rhythm enough to be recognised as sinus (Fig 69a below); by then the patient was semiconscious and in pulmonary œdema; intubation and inotropic support, then counterpulsation were used. Emergency angiogram showed 90% stenoses in the left anterior descending and circumflex arteries, with similar lesion in the mid-portion of the right coronary artery. Neither stenting nor surgery were available in Canberra at the time. He survived multiple complications (including true ventricular tachycardia) and left the hospital two months later65.
The mistaken diagnosis of VT in sinus tachycardia with massive ST segment elevation (tombstoning) is not new66. I have myself seen Cardiologists apply DC countershocks to sinus tachycardia at least three times myself, but could obtain the tracings in only one of them (Case 94) because of the sensitivities involved. All I can say is that there, but for the grace of God, go I! One thing is certain: time spend perusing the full 12-lead ECGs, as opposed to glancing at the scary-looking monitors and their rhythm strips, is time well spent.
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