EMS responded to a 76 year old female, feeling lightheadedness with palpations and also had fainting episodes, witnessed several times by ourselves the crew on scene...
On our arrival the patient looked pale, had a GCS of 15, the patient's husband stated that his wife had been experiencing the same symptoms 2 days ago and had attended the Emergency Department, but was later discharged shortly after without a diagnosis.
The patient was given 100% oxygen via non re-breather mask, with a Spo2 of 100% on it... Sats 91% before that on air... Patient is not C.O.P.D.
This lady has a long history of heart disease, and is normally hypertensive with medication. Also you will see from the ECG strips, the patient has a pacemaker in situ... But is the pacemaker behaving itself...??? What's your opinion on this patient, please discuss your treatments and interventions also.
Please note that on the strips, that the patient became very hypotensive at times during her fainting episodes she was experiencing, due to that reason, this patient was kept supine... so all the observations taken, were in the supine position.
We have 8 ECG's here, taken at different time intervals, whilst the patient was in our care, and you will see the patient's 12-lead ECG, that was taken in the Emergency Department... so kindly make reference to which ECG you have made a comment about...
THIS PATIENT DID HAVE A PULSE, NOT IN CARDIAC ARREST!
ECG-1
ECG-2
ECG-3
ECG-4
ECG-5
ECG-6
ECG-7
ECG-8
We have here above 8 ECG's captured from the patient, taken at different time intervals, whilst the patient was in our care, and you will see the the last ECG, being the patient's 12-lead ECG that was taken in the Emergency Department... so kindly make reference to which ECG you have made a comment about...eg:
ReplyDeleteECG-1
ECG-2
ECG-3
ECG-4
ECG-5
ECG-6
ECG-7
ECG-8
Please click on which ECG you want to enlarge and you can just comment as a Anonymous user if you don't have a google or other relevant account...
ReplyDeleteMany Thanks
Jason (Admin).
Atrial flutter
ReplyDeletecomplete heart block followed with runs of vt
ReplyDeleteECG 4
ReplyDeleteWith Hx of pacemaker, I would say that there is a failed pacemaker, causing VTach with possible bundle branch block
Just my 2c worth. Still learning 12 leads
ECG 1 2 3 Probably an AV dissociation, followed by CHB in ECG 3...
ReplyDeleteECG 4 Runs of monomorphic VT
ECG 7 trigger beat (junctional) initiating VT
ECG 8 VT
monomorphic VT in ECGs 4,7, and 8. Tx priorities: establish large iv access and begin NS fluid boluses. Pt is very symptomatic in an unstable rhythm, therefore would attempt cardioversion beginning at 100J. would consider amiodarone 150mg bolus followed by 1mg/min drip after successful conversion depending on resulting rhythm
ReplyDeletePt having AF then VT. Probably paroxysmal AF with pacer set to DDD with atrial therapies on. During VT, atrial sensing is blanked enough to trick the device into thinking pt came out of AF and went back in, so atrial ATP bursts are delivered. I can't think of anything else that could make this pacer fire so quick. Be carefull cardioverting this pt though, you'll cardiovert both the VT and the AF so they could stroke out on you.
ReplyDeleteI completely agree with the presumptive dx of AF c runs of VT. I do not see anything representative of CHB, AV Dissociation, nor A Flutter.
ReplyDeleteThere are only 2 irregularly irregular rhythms (AF and VF) so the primary inderlying rhythm is AF, with LBBB. The patient at ECG 6 goes regular, with a wide/bizarre QRS, which indicates a lower junctional rhythm with no atrial activity. Bet the VT spooked you. I had a patient do that to me on route to hospital-woke me up very well indeed! All (UK) paramedics can do if hoof them into hospital, probably in this case to do a spot of pacing (or cardioversion), as this lady's pacemaker is clearly buggered! I'm guessing you are a tech/paramedic. Read up on external manual pacing. Very occasionally very useful. Hannah.
ReplyDeletePacemaker mediated tachy...
ReplyDeleteECG-1 capured vernticular paced beat and follow by AF with controlled venricular response
ReplyDeleteECG-2 AF with PVC
ECG-3 AF
ECG-4 monomorphic VT
ECG-5 second degree AV block mobitz type 2 followed by 1 degree AV block
ECG-6 first degree AV block
ECG-7 monomorphic VT
ECG-8 moomorphic VT
i would do chest x-ray to see the lead placement of the pakemaker. obtain a history of date the lady last change of battery. do an interogation of pacemaker. cos either one of this cos will cos dysfunction of pakermaker.
during the monomorphic VT , i would start on infusion admiodarone with a trancutaneous pace maker beside the patient as tha patient would have sick sinus syndrome the induce the VT. if patient is stable and BP holding.
if not i would plan to put on transvenous temporary pacemaker before start on onfusion admiodarone. to prevent patient go to severe bradycardia and for override pacing as well.
lady is having VT with retrograde p waves that the pacemaker is sensing in DDD mode. No mode switch on.
ReplyDeletehad pt with same thing i ran multiple 12 leads pt converted from vt to nsr 12 leads confirmed nsr but duing vt called it undetermined rhythm however I captured 12 lead during nsr that had pvc with same morpholgy as the vt which confirmed vt for me and pt was awake and complain of feeling weak bp was 120/60 no flutter in chest no pain cardiolgist met us and she was rushed to have pacemaker reset and
ReplyDeleteDefinately not PMT. No one sets max track @ 150 on a 76 y/o and VA conduction during VT is not a factor on patients in AF. No indication that pacing capture is compromised so no need for temp line. Mode switch is on or you would see rapid pacing in all strips not just during VT. During VT, pacing @ 300 BPM? No pacers with V ATP but even if, they would be set to pace @ 80-88% of tachy cycle length. Only explanation for rapid pacing is atrial therapies being delivered to treat AF. Pacer is fine, patient's rhythm is the problem..
ReplyDeleteConsidering the QRS width I would get a potassium level ASAP. In the meantime, broad complex rhythms are ventricular until proven otherwise! Interesting case.
ReplyDeleteTom
the ecg in 8 looks like VT due to the v lead concordance, the underlying rhythm looks like af so i suggest that the pacemaker is a single chamber and looks like set to 60bpm, and is sensing/pacing appropratly, another example of a patient having a pacemkaker and medics immediatly thinking that this is the problem, what did the pacing check reveal???? needs to go on some anti arrthmics
ReplyDeleteThe primary underlying rhythm is:
ReplyDeleteDemand pacemaker, this is based on intrinsic rhythm... Atrial Fibrillation with premature ventricular or (aberrantly conducted complexes), with complete Left Bundle Branch Block, the ECG shows Left Axis Deviation, also nonspecific intraventricular block... with possible lateral infarct??? this is a abnormal ECG... any comments or further discussions on this case, or the runs of non-sustained ventricular tachycardia ???
probably a vvi with base rate 60. pacemaker function ok capturing, occasional fusion beats which may be wrongly mistaken as malfunction. also during vt the pacemaker unlike an ICD may undersense vt so occasional pacing spikes. rapid spikes during vt probably artifact. baseline rhythm mostly AF with slow ventricular response that also ivcd s/o underlying conduction system disease. many such patients have vt for cause of syncope, which is probab the case here. also check electrolytes
ReplyDeleteECG 8. Has no-one commented upon the fact that there are pacing spikes evident on the T waves? This is not a normal phenomenom. Firstly, the device must be identified and interrogated to find exactly what parameters have been programmed. Secondly, the VT must be controlled, either with pharmaceuticals or by DC Cardioversion. Once back in NSR, then the pacemaker can be programmed appropriately. If not possible, then box changed to a more appropriate device.
ReplyDeleteas in my last comment sensitivity of pacemaker works in a diff way than an icd which has automatic gain contol/ similar features that make the icd detect even fine vf. pacemaker may undersense a vt some times like in this case and always will undedetect vf. the pacemaker may be interrogated but the likilyhood is pm function is normal. reqs workup for cad and dep on it revas and prob upgradation to icd
ReplyDeleteaf ? lead away from ventricle wall treat vt risk of emboli being dislodged as af has been going on over 48 hrs if concious vt drugs ? lignocaine lay pt on left side to see if ppm starts to caopture chest xray
ReplyDelete