EKG: What is this?

Eric Boehm, RN, EMT-P

11/7/2010 3:28:43 PM #

This looks very much like torsades-de-pointes.  Just considering the lead II along the bottom, the morphology changes are consistent with torsades.  Playing devil's advocate for a moment and saying that this is artifact from the seizure, I would administer 2mg of ativan and re-run the EKG.  

If my assumption is correct and this is not artifact (pulses correlate with EKG or are absent), and the loss of perfusion to the CNS secondary to the torsades is causing the seizure activity, then I would consider this an unstable V-tach and take appropriate measures following ACLS protocol - synchronized cardioversion and administration of a ventricular antirhythmic such as amiodarone.  I'd also strongly consider running in 1gm of mag sulfate quickly. The first few beats before the onset of the torsades/artifact, also show some curiousities that are not normally seen in a 24 y/o female.  There is a distinct Q wave and what appears to be significan ST depression in lead II and III.  My guess would be an prior MI or congenital abnormality.  

Nick Adams

11/7/2010 4:59:39 PM #

I agree with you Eric.  I would like to note that it looks like the patient's QTI is prolonged in lead II and III which could predispose the patient to Torsades-De-Pointes.  If the patient was seizing prior to and during the whole EKG, the "Artifact" would be in all leads, not just the augmented and precordial leads (which would lead me to believe Torsades).  If she starts to seize during low blood flow to the brain secondary to Torsades, then I would assume that the seizure started after seeing the initiation of the Torsades.  Maybe the patient would not seize if she were laying down to improve perfusion to the brain.  Do we have an IV already?  If so, 2mg of Ativan should be given to stop the seizure activity.  If the seizures stop and the rhythm persists, then defibrillation is indicated for unstable torsades-De-Pointes (Syncronized cardiovesion will not sync with Torsades).  Definately, the patient should be given 2 mg of Magnesim Sulfate if torsades is suspected.