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Please stop with this totally incorrect mantra. How are you going to treat the pt without knowing what the monitor says? Let's say that this pt in VTach is presenting with dizziness. Are we just going to assume that it is VTach and shock them? Are we going to shotgun our treatment and treat every possible cause of dizziness? So we'll shock the pt for VTach/VFib, push some adenosine for SVT (though the shock may take care of that), we'll give meclizine for vertigo, push tPA for their MI and ischemic stroke (hope this doesn't complicate their hemorhagic stroke or GI bleed which can both cause dizziness), give toradol, benadryl and compazine for the migraine, steroids for their MS, transfuse for their anemia, push an Amp of D50 for hypoglycemia, while at the same time giving insulin for the uncontrolled hyperglycemia, I could go on but I think you get the idea. That's pretty cost effective and safe for the pt, no? There is a reason we have the tools we have. They help us to do what is best for the pt. Anyone who has worked in medicine for any reasonable time (and I really question if you have), knows that you develop your differential diagnosis based in the history and physical exam. You then use the tools you have available (monitor, EKG, labs, radiology, etc) to narrow down your differential to a single diagnosis. You then treat what is wrong. "Treat the patient, not the monitor," is the gospel spoken by those who have no clue as to what practicing medicine means. Tom, I have to agree with the "newer" criteria. I find the Brugada criteria easier to use (one of the purposes of making a clinical decision rule). In practice I can see the "newer" rules being more difficult to use, resulting in a higher error rate. I had to read it several times before it started to make sense. I can see a medic pulling out his calipers while being bounced around on a bumpy road. It might be interesting to watch, lol.

Job13_5 - Thanks for chiming in. From an academic perspective there are things I like about this algorithm, but there are problems with it also. In the first place, can we honestly say it's simplified? Consider Fig. 7. Out of 453 wide complex tachycardias: 35 showed AV dissociation > presumed to be VT 127 showed an initial R-wave in lead aVR > presumed to be VT 156 showed atypical BBB or bifascicular morphology > presumed to be VT (Note: Requires the clinician to understand typical vs. atypical patterns.) Now we're down to 135 of the original 453. 44 have an initial voltage (in the first 40 ms of a bi- or multi-phasic QRS complex) greater than the terminal voltage (in the last 40 ms of the QRS complex) > presumed to be VT (Note: I am simplifying this criterion because the stipulations for selecting the right QRS complex are bewildering). Do you think this criterion will be correctly applied by anyone other than EPs? I don't. Even if by some miracle this final criterion is correctly applied in the field (and no other mistakes are made) 15 of the remaining 91 patients (16%) were misidentified as having SVT with aberrancy when in fact they were experiencing VT. Do you like those odds? 76 of the original 453 patients (17%) were correctly identified (by exclusion) as having SVT with aberrancy. So again, the burden of proof is entirely on the person who says a wide complex tachycardia is something other than VT. The most important criterion of all is "wide and fast" but sadly, that's the criterion more and more paramedics are willing to ignore. The default diagnosis for a wide complex tachycardia should always be VT. I have no quarrel with the idea that we should "treat the patient, not the monitor" but if that's your position then why do you feel the need to make the pronouncement that it isn't VT? Call it a wide complex tachycardia that is well tolerated by the patient and transport the patient to the nearest hospital. That's a lot better than killing the patient with a calcium channel blocker. Tom

Treat the patient not the monitor !!!!!!!!

NYC EMS gets 12$ an hour?!?!?!?! That is shocking....and an unlivable wage.