A man in his 50s with witnessed arrest and ST elevation in aVR

Written by Meyers, edits by SmithA 50-ish year old man was working construction when he suddenly collapsed. Coworkers started CPR within 1 minute of collapse. EMS arrived within 10 minutes and continued CPR and ACLS, noting alternating asystole and sinus bradycardia during rhythm checks. He received various ACLS medications and arrived at the ED with a perfusing rhythm.Initial vitals included heart rate around 100 bpm and BP 174/96. Here is his initial ECG, very soon after ROSC:What do you think?Sinus tachycardia.  There is incomplete RBBB (QRS duration less than 120 ms).  There is diffuse STD, maximal in V4-V5 and lead II. There is a tiny bit of STE in aVL, and there is a significant amount of reciprocal STE in lead aVR, and less so in V1.Comment/Refresher on Lead aVR:Remember: think of lead aVR this way: "aVR= theaVerageReciprocal lead to the rest of the ECG " . There is no wall of the heart that corresponds to the direction of lead aVR, but rather it is the opposite direction of the main average vector of depolarization and repolarization of the heart, opposite leads V4-V6 and lead II. It is not really possible to have Occlusion MI that affects a myocardial wall and causes primary STE in lead aVR. Instead, lead aVR simply reflects any ECG finding which is found diffusely throughout the ECG, especially those findings which are directed opposite of it (V4-V6 and lead II).Thus, anything that causes widespread STD will always come with STE in aVR, and ...
Source: Dr. Smith's ECG Blog - Category: Cardiology Authors: Source Type: blogs

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