Right sided heart failure and tachycardia.

A middle-aged male presented with tachycardia, dyspnea, and 4+ bilateral leg edema.What is the rhythm?There had been an ice storm, and it was the busiest day in the history of our emergency department because of falls.  I reduced 12 fractures that evening and was in constant motion.  I looked at this and saw the negative component of the P-wave in V1, and immediately diagnosed sinus tachycardia.I did a bedside echo:There was good LV functionYou can see a very large RV (closest to probe) and RA (on far right).Lungs were clear to auscultation and there were no B-lines.Volume overload was confirmed with this:This shows the distended inferior vena cava (IVC), further supporting high right sided pressures and right heart failure.So he clinically had right heart failure, subacute in onset.  If I had simply looked carefully through his chart, I would have found that this was not all new, but rather an exacerbation of a chronic problem.Not having done that, pulmonary embolism was on the differential and we obtained a CT pulmonary angiogram:This shows a massive right atrium and dilated right ventricleAnother slice of the CT showing the same thing:A massively dilated right atriumLater, I looked back at the first ECG; Here it is again:It was suddenly clear to me from lead II across the bottom that this wasatrial flutter.Why is there a negative component to the atrial wave in V1?Normally, one of the rapid ways to differentiate sinus from flutter is too look for a...
Source: Dr. Smith's ECG Blog - Category: Cardiology Authors: Source Type: blogs