Shark Fin morphology recognized only by EM physician

Case submitted by Alex Bracey, Written by Alex Bracey and Pendell MeyersA man in his 70s complained of acute chest pain followed by witnessed cardiac arrest. He received immediate bystander CPR prior to EMS arrival. EMS found him in VF and administered 4 shocks, multiple doses of epinephrine, and amiodarone with intermittent ROSC, however he was in arrest on arrival to the ED with ongoing CPR via LUCAS device. Overall down time was 35 minutes from the time of arrest to arrival at the ED.First rhythm check in the ED showed PEA with a wide complex at a rate of approximately 30 bpm. Calcium and epinephine were given at CPR was restarted. He was intubated, and arterial and central venous access were established. The next rhythm check revealed a wide complex rhythm at 78 bpm with a pulse on the arterial line. Norepinephrine was initiated to maintain blood pressure.An ECG was obtained immediately:What do you think?There is a regular wide complex rhythm at a rate of about 85 bpm. The QRS complex is another example of the " shark fin morphology " , composed of RBBB and LAFB, with superimposed massive STE in the anterolateral leads.As you remember from our recent post,When the QRS is wide, the J-point will hide.Your next move, of course, is to:Trace it down and copy it over.Here is the result:Meyers comment: Alex sent me this ECG with no clinical information and my immediate response was: " Shark fin! This patient is likely post-ROSC or peri-ROSC, right? LAD occlusion. " I then sent i...
Source: Dr. Smith's ECG Blog - Category: Cardiology Authors: Source Type: blogs