Sudden shock with a Nasty looking ECG. What is it?

A 60-something woman complained of sudden severe abd pain. She was found by medics agitated, hypotensive, diaphoretic, and in shock.There were 2 prehospital ECGs:What do you think?Smith: Uncertain supraventricular rhythm with PVCs. (SeeKen Grauer ' s analysis below). There is " shark fin " in I and aVL, which is due to a combination of a large R-wave due to left anterior fascicular block plus downsloping ST elevation due to OMI.  There is reciprocal STD in inferior leads.  There is a rather large R-wave in lead V1 and a very large R-wave in V2, suggesting an atypical RBBB.  There is huge ST depression across the precordial leads.  There is STE in aVR.  Thus, there is high lateral OMI with diffuse ST depression.  When I was shown this ECG, I said it looks like such widespread ischemia that is might be a left main occlusion, or LM ischemia plus circumflex occlusion (high lateral and posterior OMI).  Moreover, left main occlusion often presents near death.  In fact, most do not make it to the hospital alive, which explains why only a tiny percent of OMI are due to full LM occlusion.Here is the Queen of Hearts interpretation:There is a second prehospital ECG:Again, supraventricular rhythm with RBBB and LAFB, shark fin, and STD maximal in V3.  Posterior and high lateral OMI.But this time the Queen gets it wrong (thinks it is not OMI):There were runs of VT:Tha patient arrived in profound shock and had an ED ECG:Now there is some evo...
Source: Dr. Smith's ECG Blog - Category: Cardiology Authors: Source Type: blogs