EMS is called to the residence of a 41 year old female with chest pain.
Onset: Sudden while sweeping the floor
Provoke: Nothing makes the pain better or worse
Quality: Tightness
Radiate: The pain does not radiate
Severity: 8/10
Time: 20 minutes prior to EMS arrival
Past medical history: MI, Pacemaker/ICD
Medications: amiodarone
Vital signs:
RR: 22
Pulse: Very rapid
BP: 150/80
SpO2: Not registering
The cardiac monitor is attached.
A 12-lead ECG is captured.
The patient is placed on O2 via NRB @ 15 LPM and IV access is established.
What do you think the paramedics should do next?
Ok... Here goes...
ReplyDeleteACLS outlines the basics such as O2 and IV access already established. Regarding the SPO2 not reading, poor peripheral perfusion maybe but they are not the most accurate pieces of equipment. There are clearly no pacing spikes visible so you cannot rule out a failed pacemaker. I am however a little reserved calling this a wide complex tachycardia. In a few of the leads you can see a bit of notched effect. Is this not a Supraventricular Tachycardia with a bundle branch block? Either way, Amiodarone is indicated. As she is already on Amiodarone, my first point would be to confirm that her drug is not expired. As it has a maximum of 2.2g/24hrs there is room for use as an IV bolus (150mg over 10 minutes repeated if necessary). If successful, set an Amiodarone infusion of 1mg/min to maintain the rhythm.
I think the most important point here would be to seek expert advise if possible and transport to hospital in the most appropriate and time efficient way. On route, I would maybe place the cardioversion/pacing pad on her chest in case she worsens. I would not cardiovert now as her level of consciousness is enought to get a history and her BP is acceptable. Should this change, I would cardiovert without hesitation.
Agree/disagree?