The Evolving Patient (ECGs!)

[fiznat]

Obviously the guy is getting Amiodorone, but we're after the fact now - monday morning quarterbacking as it may be - and now we have the chance to determine the rhythm in detail. I'm still not so sure that this is VT, and I was hoping we could get a few of our resident docs to weigh in on the subject.

Interestingly enough, the medic who gave me this case did NOT give amio. His defense was that the patient remained stable as far as vital signs + mental status and was without complaint, so he "didn't want to mess with it." He got yelled at in the ED though, and I'm pretty sure I wouldn't have made the same choice.

[Just Plain Ruff]

I think that I'd have called and discussed it with the receiving physician. The patietn seems stable right now so you can make the call.

Tell the doc that you are leaning towards amio but it just doesn't look like v-tach to you. Ask if he wants lido or amio or does he want you to wait and let them look at the patient.

I think most docs would be willing to discuss this with you. Remember, ACLS suggests expert consultation so you would be doing the expert consultation you know.

The physician at the hospital might want to get the cardiologist who's on duty in on the case too right away. Then you have more expert consultations.

Either or I'd have probably given amio and gone from there.

[p3medic]

The Zebra was thrown out there as something to consider. I am all in favor of considering the 5 differentials of a regular wide-complex tachycardia: 1. VT, 2. VT, 3. VT 4. VT, 5. SVT with aberrancy. Symptomatic wide-complex tach is MOST safely tx as VT until proven otherwise. The management is essentially the same, cardioversion for unstable patient, amiodorone for the rest. Just my opinion of course.

As for the lack of LBBB, I don't follow, slow it down, drop some p waves in front of those complexes, and it looks exactly like a LBBB. Wide, QS in V1, monophasic R wave in v6....am I missing something?

[fiznat]

I think that I'd have called and discussed it with the receiving physician. The patietn seems stable right now so you can make the call.

I've never actually done this before, called a doc with an ECG and asked for advice. I imagine it would be really hard to describe the ECG over the radio to the point where the doc's determination would be THAT much better than mine. What do you do, sit there and say "...the deflection of the QRS in V1 is negative. It is approximately .17s in duration. There is some minor slurring on the terminal aspect of the wave.... blah blah..." I dont know, I've never done that before so maybe it works more smoothly in real life. It just seems like it would be difficult to describe in words an ECG like this, that clearly combines a whole host of pertinent nuances.

The Zebra was thrown out there as something to consider. I am all in favor of considering the 5 differentials of a regular wide-complex tachycardia: 1. VT, 2. VT, 3. VT 4. VT, 5. SVT with aberrancy. Symptomatic wide-complex tach is MOST safely tx as VT until proven otherwise. The management is essentially the same, cardioversion for unstable patient, amiodorone for the rest. Just my opinion of course.

As for the lack of LBBB, I don't follow, slow it down, drop some p waves in front of those complexes, and it looks exactly like a LBBB. Wide, QS in V1, monophasic R wave in v6....am I missing something?

I agree about the LBBB... I cant figure out why people seem to be absolutely sure this is a ventricular rhythm, except that the tachy bit "looks sorta like" the ectopy in the previous ECGs. There are a number of factors (perhaps more factors) that suggest that the rhythm may in fact be atrial in origin. ...It is tough to tell, and while I can't say with absolute certanty that this is not VT, I also can't say that it is definitely one or the other. Either the evidence isn't there, or I just don't know enough to decipher it. In any case, I don't think any of the points made thus far are enough to say with absolute certainty what the rhythm truly is.

As far as dealing with wide complex tachyarrhythmias, I agree with you that we have to assume VT unless proven otherwise, but that doesnt mean that VT is the more common rhythm-- only that it is the more dangerous. That is an important point, and aside the fact that amiodorone takes the necessity out of making this decision, imagine for a second that we've got enough time and that determination of the rhythm is an important step in the treatment path. It isn't, as we all know, but it is interesting to consider.

[rdenman26]

[quote="fiznat

I've never actually done this before, called a doc with an ECG and asked for advice. I imagine it would be really hard to describe the ECG over the radio to the point where the doc's determination would be THAT much better than mine. What do you do, sit there and say "...the deflection of the QRS in V1 is negative. It is approximately .17s in duration. There is some minor slurring on the terminal aspect of the wave.... blah blah..."

Ihought you guys had telemetry if you needed to discuss an ECG, ETC. If I had an ECG i needed advise about I can fax it to the reciving hospital CCU for advise. I thought you guys had beed doing that for years.

We are restricted on what we can do for a patient like this. We cant cardiovert, and we can only use the amiodarone on the unstable patient. This is contry to national resus council guidlines. When I have to have such a patient under my care for 45 mins, it can get a little worrying.

[fiznat]

Ihought you guys had telemetry if you needed to discuss an ECG, ETC. If I had an ECG i needed advise about I can fax it to the reciving hospital CCU for advise. I thought you guys had beed doing that for years.

Some do, some dont. Things are pretty fragmented here- protocols/equipment/standards of practice tend to vary widely by region. We don't have telemetry at my service, which is fine by me since I cant imagine using it all that often anyways considering our average transport times.

We are restricted on what we can do for a patient like this. We cant cardiovert, and we can only use the amiodarone on the unstable patient. This is contry to national resus council guidlines. When I have to have such a patient under my care for 45 mins, it can get a little worrying.

Yikes

[HellsBells]

Some do, some dont. Things are pretty fragmented here- protocols/equipment/standards of practice tend to vary widely by region. We don't have telemetry at my service, which is fine by me since I cant imagine using it all that often anyways considering our average transport times.

This is a little off topic, but...

What kind of transport times do you have? Do you have cath labs or thrombilytic treatment at any of your receiving hospitals? We have a cardiac protocol where any ST elevation or LBBB gets transmited to hospital right away, so if they require it they bypass the ER and go right into the cath lab. Our service is Urban with transport times less than 10 min (usually), but this protocol works very well.

[Just Plain Ruff]

2 things to discuss here

I will transmit the ekg if I'm at all uncertain as of the interpretation - I'm rarely uncertain enough to transmit it. But all MI's get one sent.

2nd thing -

Transport time

urban settings go from 10 mins to 20 or so minutes to the appropriate facility

Rural setting - 20 minutes to 1 hour transport time and thats just to the closest facility which may or may not have a cath lab. Add on an additional 20-45 minutes to fly the patient to the appropriate cardiac facility.

Urban responses have it easier since it seems like every hospital in an urban area has at least a cath lab. Rural hospitals may or may not have a cath lab and the three rural areas I've worked did not have cath labs - our patients had to go to a receiving facility 60 minutes away.

[fiznat]

What kind of transport times do you have? Do you have cath labs or thrombilytic treatment at any of your receiving hospitals? We have a cardiac protocol where any ST elevation or LBBB gets transmited to hospital right away, so if they require it they bypass the ER and go right into the cath lab. Our service is Urban with transport times less than 10 min (usually), but this protocol works very well.

Our coverage area includes a major(ish) city/urban area, and a number of the surrounding towns. The longest transport time I have done (with lights + sirens, without is much longer) was perhaps 15-20 mins if that. We have 4 major hospitals within our primary service area, all of which have cath labs. Of those 4 hospitals, only one allows us to activate the lab from the field, which is a decision that we make as paramedics based on our assessments and our own interpretations of the ECG. This is actually a new program which is just getting started. If it works well, I imagine we will have this capability at most if not all of the other local hospitals. We dont have telemetry capability at all.

[jjones1418]

Slow it down and drop some P's in front of it?

So you're saying it's a LBBB if you slow it down and drop Ps in front of it.

That's like saying "we would've won the game, but they scored more points than us."

It's not the case. The rhythm is what it is - A wide-complex tachycardia at a rate of 215. It matches the morphology of the ectopic foci, which we know is a PVC. I'm goin with VT.

This could be as simple as lead placement, as in the leads are on the chest and abdomen, instead of the limbs. It may be why the axis of this looks different.