case_images: PMC10874468_01
case_images: The 12-lead electrocardiogram on admission (case 1). The 12-lead electrocardiogram shows wide QRS complexes with alternating QRS axis- RBBB- blue star, LBBB-black star;  suggestive of bidirectional ventricular tachycardia.
case_images: cureus-0016-00000052531-i01.jpg
case_images: PMC10874468_01_cureus-0016-00000052531-i01.jpg
case_images: FIG1
case_images: The electrocardiogram on admission showed bidirectional ventricular tachycardia (VT) (Figure 1). The electrocardiogram on presentation shows a wide complex tachycardia with changing QRS morphology alternating beat to beat (RBBB and LAFB alternative with RBBB and LPFB morphology), with complete atrioventricular (AV) dissociation suggestive of bidirectional ventricular tachycardia (Figure 1) which degenerated into to ventricular fibrillation (Figure 2) and caused the cardiovascular collapse.
case_images: Electrocardiogram in the monitor during the cardiovascular collapse. Monitor electrocardiogram showing, bidirectional ventricular tachycardia (black and blue arrow) terminating as ventricular fibrillation (black star).
case_images: cureus-0016-00000052531-i02.jpg
case_images: PMC10874468_01_cureus-0016-00000052531-i02.jpg
case_images: FIG2
case_images: While stabilizing the patient, he had a sudden cardiovascular collapse, and the electrocardiogram on the monitor showed bidirectional VT terminating into ventricular fibrillation (Figure 2). The electrocardiogram on presentation shows a wide complex tachycardia with changing QRS morphology alternating beat to beat (RBBB and LAFB alternative with RBBB and LPFB morphology), with complete atrioventricular (AV) dissociation suggestive of bidirectional ventricular tachycardia (Figure 1) which degenerated into to ventricular fibrillation (Figure 2) and caused the cardiovascular collapse.
case_images: PMC10874468_02
case_images: The 12-lead electrocardiogram on admission (case 2). A 12-lead electrocardiogram shows no relation between p waves and QRS complexes. The white arrows point to the series of P waves, some of which are marching through and distorting the QRS. Two QRS complex morphologies are noted. A narrow QRS complex with 100 ms duration at 1520 ms cycle length and another wide QRS complex of 130 ms at a cycle length of 1440 ms.
case_images: cureus-0016-00000052531-i03.jpg
case_images: PMC10874468_02_cureus-0016-00000052531-i03.jpg
case_images: FIG3
case_images: The 12-lead electrocardiogram is shown below (Figure 3). There are two morphologies of the QRS complex in a bigeminal fashion; a narrow complex QRS which is likely the junctional escape rhythm that occurs at a longer cycle length of 1520 ms, and a relatively wide QRS complex with RBBB left axis, which is a ventricular ectopic occurring at a cycle length of 1440 ms (Figure 3).
case_images: Flowers grown in the garden of case 2. Oleander (Nerium oleander) flower (black star) grown in her garden.
case_images: cureus-0016-00000052531-i04.jpg
case_images: PMC10874468_02_cureus-0016-00000052531-i04.jpg
case_images: FIG4
case_images: On probing history further, it was found that she recently started growing new flowers in her garden (Figure 4).
case_images: Inset of lead II above with step ladder diagram below. Step ladder diagram explaining the sequences of events of atrial activity (black dot), junctional rhythm (orange dot), and ventricular ectopic (Blue dot). . The step ladder image is the author's own creation.
case_images: cureus-0016-00000052531-i05.jpg
case_images: PMC10874468_02_cureus-0016-00000052531-i05.jpg
case_images: FIG5
case_images: Interestingly, the junctional rhythm is not inhibited by the ectopic, likely due to an entrance block in the junctional foci as demonstrated in the step ladder diagram (Figure 5).