He is a recent addition to the Paramedicine 101 bloggers and has his own blog called My Variables Only Have 6 Letters.
46 year old male presents to EMS complaining of chest pain.
After sitting down on the gurney the gurney states, "My heart is jumping out of my chest!"
Onset: Sudden while doing yard work.
Provoke: Nothing makes the pain better or worse.
Quality: Heaviness and "jumping" sensation.
Radiate: The pain does not radiate although his hands are numb and tingling.
Severity: Not reported.
The patient is alert and oriented to person, place, time and event.
Skin: mottled, cool, diaphoretic.
Vital signs were assessed.
Resp: 18
Pulse: Too rapid to count
BP: 120/60
SpO2: Not reported.
Breath sounds: Clear bilaterally.
Capillary refill: 5+ seconds
BGL: 140 mg/dL
The cardiac monitor is attached.
A 12-lead ECG is captured.
What is your differential diagnosis?
What is your treatment plan?
*** Update 04/02/2010 ***
The treating paramedics gave 1.5 mg/kg lidocaine.
After administration of the drug the following rhythms were noted on the monitor.
Pay close attention to this rhythm change....
There is a critical clue here, and it has to do with the R-R interval.
Now take a look at a 12-lead ECG of the irregular rhythm.
Was lidocaine the best possible choice?
Is there a safe antiarrhythmic for a patient like this?
Is this patient at-risk for sudden cardiac arrest?
Why or why not?
GoGetter
ReplyDeleteDiagnosis: stable VT
Plan:
Amiodarone 150mg over 10min repeat as needed to max 2.2g/24h
prepare for synchronized cardioversion 100 J
atrial flutter with 1:1 conduction and rate related RBBB.
ReplyDeleteA Flutter with RBBB and 2:1 conduction, changed to 1:1 possibly because of AV shutdown with Lido and now conducting through an accessory pathway.
ReplyDeleteamio was a safer choice.Not all wide QRS tachys are VT.esp when the RBBB pattern is consistent in all leads, R-to-S nadir<100,etc.
try iv amiodarone..
ReplyDeletept at high risk to arrest..standay all emergency drug for resus and CPR....
pt must on continuos cardiac monitor..for close observations
I would say original rhythm was Vtach, scenerio doesnt state anything about length of CP, so I would treat him with Amiodarone 150mg in 100ml bag infused over 10 minutes, monitor closely, reassess in 5 minutes if pain persists go to sedation and cardioversion. Really need to reasses after rhythm change as well, may need to use cardizem 0.25mg/kg initial dose titrate to 0.35mg/kg.
ReplyDeletestable wide QRS tachy
ReplyDeletecould be SVT with aberrancy (no RS in precordial leads/RS < 100/ no AV diss/ triphasic V1
this could be Afib with aberrant conduction (WPW)
amio (no dig)
sudden death (maybe not)
correction - AF with aberrancy (not SVT)
ReplyDeleteVTach with a pulse
ReplyDeleteAmiodarone 150 mg infusion over 10-15 mins
Standby crash cart
Prepare for sedation if it needs cardioversion...
VT cardioversion amiodarone..........crash cart ready.
ReplyDeleteSVT with abbarent conduction, precipitated by fast AF! Pt is stable initially but with reduced CRT therefore suggestive of compensatory mechanisms. ? IV Adenosine with follow up of Amiodarone infusion
ReplyDelete*aberrant
ReplyDeleteStable wide QRS tachycardy, could be SVT with aberrancy (WPW). you can try with amiodarone!
ReplyDeletethis is atrial fibrillation in WPW
ReplyDeletethis is atrial fibrillation in WPW. So, xylocain is hazardous and can increase heart rate. class III and class Ia, I think is suitable in this case.
ReplyDeletethere is risk of VF by xylocain or any drugs act on AVN
ReplyDeleteThese are great records. I am a fan.
ReplyDeleteThe first tracing shows a wide complex, regular tachycardia at almost 300bpm or 200 msec. The morphology of the QRS is RBBB. Importantly the initial upstroke of the QRS is sharp which suggests a typical north to south (or high to low) activation through the his-purkinje system. PSVT is rarely this fast in an adult. The third tracing, after the lidocaine shows a change in the R-R interval. Specifically, the cycle length transiently doubles. This suggests atrial flutter. The final tracing shows typical isthmus dependent right atrial flutter. The atrial flutter cycle length is identical to the RR cycle length in the first tracing. The previously mentioned diagnosis of 1:1 flutter is correct.
Lidocaine did nothing. Amio is almost always ok. Adenosine would have transiently blocked the av node which would have provided a diagnosis. Laying the guy flat, giving oxygen, providing rest and reassurance would have likely sufficed in decreasing circulating catecholamines enough to enhance natural av node blocking effects. Given the normal BP, even a small dose of metoprolol would have worked in this case.
Great stuff,
JMM
Let me try.
ReplyDeleteI think this is a regular wide complex tachycardia with with heart rate about 250 bpm and typical RBBB pattern and right axis with visible inverted P waves in inferior leads and long RP interval
I think atrial flutterwith aberration with 1:1 conduction is the most likely and other possibilities like VT, atypical AVNRT or AVRT may be considered
here I may do carotid sinus massage to detect any variation in AV-conduction that may confirm the diagnosis of atrial flutter or give some drug like adenosin as a diagnostic (in case of atrial flutter) or therapeutic (if atypical AVNRT or AVRT).
After Lidocain was given the complex became narrow with no significant change in the rate. I think this excludes the VT and AVRT utilizing the Right bundle.
Then I would give verapamil or a beta blockerto terminate this tachycardia or at least slow the AV conduction.
After the tachycardia slowed down (we do not know if that was spontaneous or by certain drug or procedure), the present rhythm is atrial fibrillation. I think this makes the diagnosis of atrial flutter at the begining sound more logic.
SVT first trace need to treat with adenosine....
ReplyDeletelast ECG AF with RBBB ?due to AMI
wayne i agree with you entirely its SVT Tx adenosine if that doesnt work or the pt becomes compromised cardiovert then the last ECG is AF with RBBB Tx with dig or sotalol if pt is stable....?due to AMI
ReplyDeleteHow do you see on the first ECG the difference between atrial flutter with 1:1 conduction compared to VT?
ReplyDelete