VT? Or Supraventricular tachycardic rhythm with aberrancy?

A 70 something male presented in severe respiratory distress.The patient had altered mental status and so he was prepared for intubation.  Before intubation, he became  hypotensive.On the monitor patient had wide-complex tachycardia. The following 12-lead was obtained:What do you think?Differential is ventricular tachycardia versus supraventricular tachycardia with aberrancy versus sinus tachycardia with a aberrancy.  There are possible P waves in lead II. But these could be an extension of the QRS, so sinus tach is not certain.  Certainty could come with the use of Lewis leads. Much easier is to see if the rate varies from moment to moment, especially if it decreases with supportive care.This QRS is not typical of any kind of bundle branch block, which makes aberrancy much less likely.  Given that this QRS looks nothing like any normal kind of a aberrancy, it is reasonable to use electrical cardioversion. Here is a normal LBBB:In LBBB, monophasic wide R-waves should be limited to the lateral leads in left bundle branch block, as in this ECG. In that ECG above, there are monophasic R-waves starting in lead V2 all the way out to V6.  Given patient ' s acute drop in his blood pressure, the patient was cardioverted with synchronized cardioversion at 200 J with no change in his rhythm.  But why does this EKG look nothing like left bundle branch block?  After the patient was stabilized with supportive ...

Source: Dr. Smith's ECG Blog - October 21, 2023 Category: Cardiology Authors: Steve Smith Source Type: blogs