The Evolving Patient (ECGs!)

[fiznat]

This is one of my coworker's patients, so please forgive any omissions. I will find things out if need be.

56y/o male patient with complaints of syncope presents with the following ECG:

Vital signs are:

BP: 142/76

HR: As shown

RR: 20

Another glance at the monitor:

Whoops.

Vital signs remain unchanged. At the radial artery the paramedic can feel a regular pulse at about 80.

12 Lead:

Again vitals are unchanged, again the radial pulse says 80 BPM and regular. The patient is without change in any other aspect of presentation. He does not seem to notice what the monitor is saying.

The patient denies any past medical history, meds, or allergies.

Discussion points:

What do you call the rhythm?

How do you consolidate the ECG, vitals, and unchanged presentation?

What about the radial pulse?

What is your treatment plan?

[AZCEP]

It's Vtach. Wide-fast-similar appearance to the ventricular ectopy.

The patient is perfusing 80 times per minute, even with a much faster heart rate. The chambers aren't filling fast enough to allow for a pulse with every complex.

O2, IV(s), start a fluid bolus, "Expert Consultation" per AHA, consider some antidysrhythmic. Transport time will be the deciding factor on whether this patient needs immediate treatment.

[fiznat]

Are you sure about the VT? I was a bit split on the issue but I see a few things that point the other way:

1. Rightward axis. This is not common in VT if I remember correctly. In fact, I think it should be the other way around.

2. No concordance in the chest leads. Actually the progression seems to be fairly normal in that the deflection is away from V1 and towards V6, suggesting a downward path of depolarization. It could still be VT, but the origin would have to be fairly superior.

3. The minor abbarancy in the QRS morphology might suggest that this is in fact an atrial rhythm with LBBB?

Figure you are 10-15 mins away from the nearest appropriate hospital.

Any other thoughts?

[p3medic]

Looking at the initial strip, it appears there may be a delta wave associated with the sinus beats, which makes me wonder about an aberrantly conducted svt in the setting of un-diagnosed WPW, although I would love to see 12lds of his normal rhythm. The arrythmia by itself I'd call a "wide complex tachycardia" I know, its a cop out, but there you have it. If pressed, I don't think its V-tach, but a little amiodorone never hurt anyone....

[fiznat]

This is the closest I've got to a "regular" 12 lead from this patient:

[danielir]

The initial rhythm is ventricular trigeminy.

As far as the other one, I agree that the ectopic focus must be high up in the ventricles, but its definitely VT. The ectopic origin, being high in the ventricle, as well as this patients lack of medical hx may account for his ability to compensate so well, hence his maintaining BP and mental status. Those 80 beats that are perfusing may be enough to maintain homeostasis....for now.

Nevertheless, this patient did have a syncopal episode, for one reason or another, and I prefer to aggressively treat VT w/ pulses. Hi-con O2, IV, and a dose of your favorite antidysrhythmic. (In NYC amidarone is now in protocol) I would definitely monitor him closely and if he became hypotensive, AMS, or otherwise unstable I would cardiovert.

I would initially avoid a fluid bolus unless you could tell me that the patient has no other complaints and clear L/S. I'm sure the experts will correct me if I'm wrong, but the initial trigeminy and syncope may be a signs of impending failure, plus with his stable pressure he doesn't really need it.

[emt322632]

Was this the point in the ride where y'all hit every bump in the road? There's the simple explanation!

Seriously I'm thinking trigeminy that degraded into v-tach. The v-tach just occurred so that could be the reason why his vitals remained unchanged. I'd go the same way as everyone else here, consult med control if unsure. O2, IV, continuous ECG and some amiodarone.

[fiznat]

I think Amio is going to be a pretty popular choice amongst most of us since it makes determination of the origin of the rhythm less important...

I'd really like to nail down the reasons why people think this is VT or not VT.

[p3medic]

There is no evidence of av dissociation, there are rs complexes in the precordial leads, there is no complex with greater than 100m/sec from the beginning of qrs to nadir of s wave and no morphologic criteria in v1 or v6.....looks to me to be an svt conduted with LBBB, at least thats my reasoning.

[rdenman26]

I would called the the first trace ventricular bigemany. Second wide complex tachycardia.

O2 and IV access, regular monitoring of ECG, pulses BP etcetc. FAX ecg to recieving hospital and rapid transport. As the patient remains alert with peripheral pulses just monitor and reassure. Of course the fact that not all the QRS complexes have a pulse attached if significant. If the patient became, more unstable; reduced LOC, SOB, CP etc and rate is over 150, I can give amiodarone 150mg over 10 mins. UK resus council guidelines for unstable wide complec tachy are cardioversion and referal to expert advise. But at the moment UK paramedics cant do sync cardioversion.

I have seen this sort of dysrythmia converted by speed bumps (do you have those in the US?). Had one VT pt loose consciousness and pulse, gave pre cordial thump whilst mt crew mate was pulling out the defib pads. He came round pretty quick, did the same in hosp. They shocked him so quick he must have still been semi-conc judgeing by the scream and how much he jumped.

Still the point Im trying to make is these patients can become very ill very quickly so dont piss about.