The case occurred six years ago so certain details are missing. However, there is more than enough here to discuss the most relevant points about the case.
The patient was a 12 year old male whose only complaint was palpitations.
The patient's pulse was extremely rapid. However, he appeared to be perfusing adequately and the blood pressure was stable.
A 12-lead ECG was captured.
And another.
Online Medical Control was contacted and the treating paramedic was advised to watch the patient's blood pressure and cardiovert if the patient became unstable.
The patient converted after the ambulance went over a bump. Unfortunately, a post-conversion 12-lead ECG was not recorded.
At the time, Mr. Sullivan was a new paramedic. He states that his co-workers felt that he should have given adenosine, since a 12 year old "could not be in VT." He also mentions that he's gotten different interpretations from each doctor he's shown it to.
The case has been bothering him ever since.
What do you think is the best field treatment for a patient like this?
What do you think of Online Medical Control's advice?
What do you think is wrong with this patient?
In V1, V2, and V3 it certainly looks like v-tach, but the other leads (esp. the inferior ones) make it look more like a wide-complex tachycardia, but not necessarily v-tach. Very interesting for a 12 year old regardless.
ReplyDeleteDELTA waves- WPW
ReplyDeleteLeads 1 and V3 will show you that there is V A association and the QRS's look more narrow to me (V4-6). I am thinking an SVT is the likely arrhythmia (AVNRT?).
ReplyDeleteI think it SVT, should treat with adenosine..not VT..V1,V2,V3 looks like VT, but the other leads are different...should be SVT, treat with IV adenosine...
ReplyDeleteSVT(AVRT)DUE TO WPW
ReplyDeleteVT is in all leads not just a few. SVT I would think and great move on calling MC depending on the service you work with makes a huge difference as far as tx goes. Very interesting for an adolescent
ReplyDeleteAgree with Delta waves due to WPW vs. re-entry SVT
ReplyDeleteSVT wt aberrancy
ReplyDelete1) any pMHX
ReplyDelete2) onset and duration
3) is this kid really thin?? or fat??
4) any drug abuse
5) if pressure is fine two avenues of treatment a) versed and cardiovert
b) chemistry would be ACLS WIDE COMPLEX TACH of unknown origin. Capnography, SPo2,
6) I am going to go with SVT with aberrant conduction
why, delta waves and a dx of WPW should be done when the Rate is in a " normal range" There is way too much crap going on... for a proper dx you have to SLOW the rate. rate reduction and l-12 , and Chemistry with tox panel. Then I would give you an exact dx, this could be LGL too
7) always go with : when in doubt call the MD.
I forgot to mention.. if the pt is not in distress.. ie B/p perfusion problems...leave it alone and drive to er.. safely and don't stop for coffee
ReplyDeleteIf you like Fluid bolus.. but I would not be aggressive with chemistry with this kid. Prep for cardioversion and monitor thats it.