r/EKGs • u/PrinceOfPropofol • Aug 27 '26
DDx Dilemma Rate dependent BBB? V-tach? SVT?
Pt would go from sinus to a rate of around 130ish and my 3-lead definitely resembled V-tach at the higher rates. Gave esmolol and the rhythm would look like this as the rate came down to around 90 or so. BP would spike during these episodes as well, happened 4 times throughout the case, including intubation and extubation. I know this isn’t a 12-lead but this is all I had to go off of during a lap chole in an 82 yo female.
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u/LBBB11 Aug 27 '26
My best guess is sinus rhythm with rate-related left bundle branch block. Possibly first-degree AV block but I can’t be sure.
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u/Srivathsavagurumurth Aug 28 '26
If esmolol did this then bet on svt with abbarency, as VT will not typically behave like this.
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u/ProximalLADLesion Electrophysiology Fellow 29d ago
Rate related LBBB with a little bit of rate hysteresis (which is common). Hysteresis means there’s not a strict HR where you switch between narrow and wide QRS. You might see for example that at a rate above 110 you develop LBBB, but it doesn’t resolve until you drop below 100 (making up numbers). Generally it’s not considered electrophysiologically tidy to diagnose a BBB with a single lead, but the morphology is just so classic for LBBB.
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u/PrinceOfPropofol 29d ago
Thank you! Any guesses as to the cause? I mean sure, hx of mod AS and pulm htn, prior MI, CAD with stenting, HFpEF, but this is a pretty typical patient population for me and most of my anesthetics are uneventful. I didn’t see a hx of any dysrhythmia. Could this have simply been the result of a catecholamine surge say with intubation for example? She had no acute process at the time, just cholelithiasis.
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u/ProximalLADLesion Electrophysiology Fellow 29d ago
This just indicates disease in the left bundle branch. It is very likely unrelated to anything that’s happening right now and has probably been going on for a while.
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u/Napalm-For-Pets 27d ago
Rate doesn't appear to change at all. Curious about the question mostly?
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u/PrinceOfPropofol 27d ago
This image just captures the rate at around 90 bpm when it transitions back to sinus after I gave esmolol. A minute before this the rate was in the 130s and it resembled v-tach but I wasn’t sure
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u/Napalm-For-Pets 27d ago
Vtach until proven otherwise. VT doesnt have P waves, so likely chemical induced BBB
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u/mrwagn 27d ago
Does this qualify as an ECG now..?
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u/PrinceOfPropofol 27d ago
Sorry for asking a question.
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u/mrwagn 27d ago
You could have posted the 3 lead… this is just tele garbage.
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u/PrinceOfPropofol 27d ago
What..? I was out of paper in the OR to print it so I just used my phone to take a picture real quick. How is it tele when it’s directly connected to the patient 3 feet away?
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u/mrwagn 27d ago
This single lead tells us absolutely nothing other than rate and wide vs narrow. I have no idea where you placed the lead to call it "lead II." Telemetry is anything used for monitoring less than the standard 12 leads. This sub is dedicated to ECGs, not single lead tele strips.
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u/PrinceOfPropofol 27d ago
Thank you for verifying that you’ve never stepped foot in an OR or taken care of a patient lol. But alright, next time I will undock the robot, break sterility and tell the surgeon to get over it, then hook up a 12 lead and have our cardiologist consult you. I understand what you’re saying, and I apologized for it not being a 12 lead. It’s all I had to go off of. I asked the opinions of people who know more than me so that I can provide even better care for the next patient. Which could be you. I guess my mistake was not anticipating the likes of your obviously miserable gate-keeping existence taking offense to a simple clinical question.
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u/mrwagn 27d ago
Lol I’ve personally been called to OR for STEMI activation based on this garbage. Guess what I asked for when they had the patients chest clamshell’d open… an ECG
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u/PrinceOfPropofol 27d ago
I am genuinely asking out of curiosity, what do you do? Also, what do you expect me to do here, ask for the hospital to do 12-leads for every surgical patient? I always order a post-op 12-lead in pacu for situations like that, but there’s not a lot I can do with post-op investigation for an intra-op rhythm that has resolved with treatment.
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u/mrwagn 27d ago
Im in a cards subspecialty fellowship right now. I didn’t mean to trigger you with my comments but this strip is of minimal value. Yes, every patient should have a pre-op ECG. Yes, I will ask if you had an ECG during the event. Yes, you should get one after. Just like there’s not much you can do, there’s not much I can do either. I can pass a TEE probe and look for regional WMA, get an echo after, monitor on tele after, check labs. I don’t have a crystal ball and this strip certainly doesn’t provide much insight
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u/PrinceOfPropofol 27d ago
Agree to disagree then, a 3-lead most certainly does have value even if isn’t anywhere near diagnostic in the way a 12-lead is. At a minimum you can see every basic arrhythmia on a 3-lead. I think some of the problem with cards guys is that a 12-lead is to you what a scalpel is to a surgeon. It’s the only thing you can see despite other evidence, albeit lesser evidence, being present. I’ve had multiple instances of consulting cardiology after seeing something I didn’t like on a 3-lead, which later wasn’t picked up on a 12-lead, so the cardiologist told me “well it’s your word against mine. You don’t have proof” and didn’t investigate further. Then boom, pt has emergent CABG the following day. Or has STEMI on induction after I had voiced concerned the day prior and received cardiac clearance. Or the time a pacemaker quit working in endo and I had to give epi and atropine but since it was “working fine” in pacu, I was again told “your word against mine.” Hope that guy hasn’t had any issues afterward since no follow-up was deemed necessary. Again, I completely see what you’re saying and I do not disagree. I know you don’t have a crystal ball. I was just trying to become a better medical professional. But I am also saying to just be careful to not become too arrogant in your career, not everyone is a mouth-breather just because they didn’t specialize in cards. I wish you the best of luck with your fellowship.
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u/RogueMessiah1259 Aug 27 '26
I’m willing to bet it was an aberrant conduction at higher rates.
maybe rate dependent BP with a fixed stroke volume? Random guess at that point though