Young man with Gunshot wound to right chest with hemorrhagic shock, but bullet path not near heart. A case of irregular accelerated idioventricular rhythm (AIVR)

A young man presented with a gunshot wound to the right chest, with hemo-pneumothorax and hemorrhagic shock.He got a chest tube and intubation and massive transfusion and stabilized.CT of chest showed the bullet path through his right lung but nowhere near his heart.But he did get an EKG:What is this?  There were times when it would be usurped by sinus tachycardia, then return to this rhythm.There is a wide complex.  It is irregular.  It is not fast (cannot be VT).  There is no atrial activity to suggest atrial fibrillation.  There are whatcould be interpreted as delta wavesif, and only if, there were P-waves or other atrial activity preceding the QRS (pre-excitation can only happen when there is an impulse originating in the atria). Therefore, these are NOT delta waves and this is NOT pre-excitation!I could only conclude that this was anirregular accelerated idioventricular rhythm.  I concluded that it is safe and did not require treatment and to leave it alone unless it became too slow, at which point atropine would be indicated to increase the sinus rate to let that sinus rate take over.AIVR should never be treated with anti-dyrrhythmics!!  It is a stable rhythm.  Atropine is ok to improve the sinus rate if the heart rate is too slow.All troponins were negative.Formal echo was normal.Here are 4 more ECGs recorded over the ensuing hours:Another irregular AIVRBack to sinus rhythmThis is a normal regular AIVRAnother normal reg...
Source: Dr. Smith's ECG Blog - Category: Cardiology Authors: Source Type: blogs