Not so good....

[zzyzx]

This call was run by an a helicopter crew and was posted on FlightWeb. Thanks to Mike McKinnon for letting me steal it.

You are called out for an “unknown medical.” A fire medic is already there, and the first thing that happens when you walk through the door is that he hands you this EKG:

http://img102.imageshack.us/img102/3325/ekg28wm.jpg

:shock: :shock: :shock: :shock:

The 50 y/o patient is sitting in a chair. He’s pale, cool, diaphoretic. He’s already on an oxygen mask. His chief complaint is feeling dizzy when he stands and mildly short of breath. No chest pain.

History: patient only knows that he has heart problems.

Meds: digoxin, Lasix, ASA

Allergies: none

He has clear bilateral lung sounds with a sat of 98% and a RR of 20.

His BP is 82/56.

So what’s up with this guy’s EKG?

What are the appropriate treatments?

“Don’t worry, sir. You’ll be just fine. Don’t hesitate to call us back if anything changes.”

[mobey]

I am quite sure i am wrong but i will be the first to say V-Tach because I am interested to find out how I can tell it isn't.

BLS treatment

High flow O2

Call ALS

load and go unless ALS will arrive soon in which case i would...

Get the best Hx I could

Put the Pt. in position of comfort

Clear away furniture

Have AED handy & set up BVM out of sight

Get meds and health card rounded up

keep reassessing pulse & BP every 3 min or so

Talk about fire trucks with the Firemedic and twiddle my thumbs waiting for ALS!

My guess on ALS Tx, Amiodarone (1st choice), or Adenosine (2nd choice)??

[Just Plain Ruff]

Get your epi and the tube ready, he's gonna code if you don't start to fix what's wrong.

[sagigl]

hi all!

to my opinion we're watching an unstable rapid a.fib.

it might sometimes be mistaking with VT but not on this case because of the irregularity.

bls treatment should include laying the patient down or at least getting his legs on a chair if he's got trouble to breath lying. off course- oxygen, opening an i.v. and waiting for als with resuscitation gear standing by.

als treatment will include anestesia with ketamin 2mg/kg and midazolam 3 mg and synchronized cardioversion with 100J.

anamnesa and physical examination should be completed before but apparently this is the direction.

"if it's wide, fast and funny looking- shock it!!"

[gvandellen]

Unstable Afib, IV, Maybe sedate, Shock 50J BiPhasic, (cross fingers)...He's on Dig, Lasix, and ASA so there is a cardiac history to suggest Afib.

[Mateo_1387]

Get your epi and the tube ready, he's gonna code if you don't start to fix what's wrong.

I agree, be prepared for the worst. To fix his rate problem I would start an amio drip, 150 mg of 10 minutes, and also give a fluid bolus.

As far as the rythm, the patient appears to go from a sinus tach, to v tach, to possibly a fib, if i saw a twelve lead at a slower rate i'd expect to see a LAFB and probably another block.

[Dustdevil]

Irregular rhythm.

Rate around 300.

Delta waves.

Dig among his regular meds.

You might want to re-think the V-tach thing.

We're definitely headed towards cardioversion, but I am hesitant with pre-existing a-fib without anticoagulants. If his vitals are remaining stable, I would lean towards holding off until we can get to the hospital.

[akroeze]

I'm sticking with my usual Dx.... all patients are suffering from Syphilis until proven otherwise.

[unknown]

This is what a flight Nurse had to say.....

Its an accelerated idioventricular rhythm. IV, O2, amiodarone IV and if that doesn't work cardiovert.

[Dustdevil]

This is what a flight Nurse had to say.....

Its an accelerated idioventricular rhythm. IV, O2, amiodarone IV and if that doesn't work cardiovert.

Please tell me that was an OB nurse. :?