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A woman in her 50s with no medical problems presented to the range, 4000-11 000/L; to convert to 109/L, multiply by .001) and
emergency department with complaints of chest burning, short- a potassium level of 3.3 mEq/L (reference range, 3.5-5.0 mEq/L; to
ness of breath, diffuse paresthesias, and dizziness. She was in her convert to mmol/L, multiply by 1). Troponin was undetectable. The
normal state of health until an hour after drinking a home-brewed patients condition rapidly deteriorated and she developed mul-
tea containing leaves and roots prescribed by a Chinese herbalist. tiple different rhythms with widened QRS morphology and inter-
She had normal mental status and vital signs. Seventeen minutes mittent pulselessness requiring cardiopulmonary resuscitation. She
after arrival, the patient complained of feeling worse. An ECG was was intubated and cardioversion was attempted. In consultation with
obtained (Figure 1). the cardiology and electrophysiology services, multiple interven-
Question: What are the pertinent electrocardiogram (ECG) tions were attempted without success, including adenosine, amio-
findings, and what is the likely cause? darone, lidocaine, diltiazem, and verapamil. After 3 hours of at-
tempted resuscitation, venoarterial extracorporeal membrane
Interpretation oxygenation was instituted. After 12 hours, her cardiac rhythm con-
The ECG shows bidirectional ventricular tachycardia at a regular rate verted back to normal sinus. Her clinical course was complicated by
of 158 bpm. There are 2 distinct QRS complexes that are alternat- multiorgan failure resulting from the prolonged resuscitation. Labo-
ing beat to beat. The QRS complex labeled 1 displays RBBB with left ratory analyses of her initial serum and urine, and samples of the tea
anterior fascicular block (LAFB). There is an RR in lead V1, a slurred she drank on the day of presentation, were positive for aconitine.
S wave in lead V6, and left axis deviation, as evidenced by a nega-
tive QRS in aVF and a positive QRS in lead 1. The QRS complex la- Discussion
beled 2 displays right bundle branch block (RBBB) with left poste- Aconitine and other related alkaloids are highly potent cardiovas-
rior fascicular block (LPFB). There is an RR in lead V1, a slurred S wave cular and neurological toxins and belong to the Aconitum plant spe-
in lead V6, and extreme right axis deviation as evidenced by a posi- cies. In Europe and the United States, toxic effects typically occur
tive QRS in aVL and a negative QRS in lead I. P waves are present after inadvertent ingestion of the wild, unprocessed plant.1 In tra-
after each QRS. The R-P interval (start of QRS to start of P wave) is ditional Chinese medicine, aconite roots are typically used after pro-
0.16 milliseconds. cessing, and are prescribed for the treatment of arthritis, general
pains, and other conditions.2 The plant processing involves soak-
Clinical Course ing and boiling to hydrolyze the aconite alkaloids into less toxic de-
Laboratory studies conducted 10 minutes after patient arrival were rivatives. However, faulty processing after harvest or medicinal
only notable for a white blood cell count of 11 300/L (reference preparation may result in higher-than-intended toxin concentration.3
I aVR V1 V4
II aVL V2 V5
III aVF V3 V6
VI
II
V5
This patient presented with multiple rhythms, including a pat- Take-Home Points
tern of bidirectional ventricular tachycardia, a form of fascicular left
ventricular tachycardia which alternates conduction down the left Bidirectional ventricular tachycardia is a form of fascicular left ven-
anterior and left posterior fascicle. With fascicular VT, the QRS can tricular tachycardia, which alternates conduction down the left an-
be as narrow as 100 milliseconds, possibly owing to a junctional ori- terior and left posterior fascicle.
gin with spread of activation over the His-Purkinje system, al- Fascicular ventricular tachycardia can present with narrow QRS
though typically it is wider.4 In addition, there was ventriculoatrial complexes.
(VA) retrograde conduction, illustrated in lead V1 (Figure 2A). To con- Retrograde P waves may be present in ventricular tachycardias.
firm the presence of a retrograde P wave rather than misinterpre- Bidirectional ventricular tachycardia suggests a toxic effect from
tation of a portion of the QRS complex, examine the P wave in other aconite or digoxin.
simultaneously recorded leads (Figure 2B). While a retrograde P wave Aconite alkaloids have a high affinity for cardiac fast sodium chan-
can also occur with AV junctional tachycardias, it may be present with nels, causing premature excitation of myocytes.