Heart rate: 310

[firedoc5]

My most humble apologies for being "counterproductive." I have sent a PM to the administrator requesting he remove all of my posts and delete my username in full. Congratulations on running off yet another member.

No reason for that. I've felt the same way about some of my posts. You just move on.

[Richard B the EMT]

For the most part, everyone has been behaving, even with this being an ALS level session, and my request for further information for myself at the BLS level, earlier on.

As I have commented in other strings, and now here: Tell someone they are wrong, and then explain how and/or why they are wrong, but don't tell someone they are wrong, and say it's because they're stupid. THAT is counterproductive!

Remember that the beatings will continue until morale improves!

[zzyzx]

I've enjoyed all the posts so far. Haven't seen anything counter-productive yet!

So we already know this is WPW + AF. Could a rate this fast be anything else? I was thinking ventricular flutter, but I figured that ventricular flutter would only last for a very short while before becoming VF, so you wouldn't be likely to see it in a patient like this.

Could AF produce such a rapid ventricular response without there being an accessory pathway?

[AZCEP]

I said that introducing a second scenario into this discussion would be counterproductive because it would confuse the issue of managing this particular situation. It does make for a good topic, but should be placed in a thread dedicated to it rather than added on to one that is unique to itself.

As for the case at hand, because of the AV node's function of slowing conduction between the atria and the ventricles an accessory pathway would almost have to be in effect to get a rate this fast. More importantly than specifically identifying the accessory pathway would be considering that it might be in action when you see this type of rhythm.

If we consider that the atria can fibrillate up to 700 times per minute, or flutter at 300+ per minute it becomes very apparent that there is something amiss with the physiologic brakes that the AV node provide.

[Ghettomedic351]

What exactly does this have to do with the scenario presented?

Nowhere is this situation discussing a narrow-complex tachycardia.

[AZCEP]

Yes, a 12 lead would be of benefit in this case but only after the rate is controlled to be able to see what type of atrial activity is present. A wide complex tachycardia with a rate greater than 300 needs to be considered to be due to an accessory pathway.

You will notice that no strip was produced of any lead, and I would still consider this to be due to an accessory pathway.

If learning is the intent, and not to deliver a war story that will detract from the original discussion, then by all means. EMS49393's case would be a good one for it's own thread. Placing it in amongst the discussion of a wide complex tachycardia of unknown origin would detract from the clarity needed for both cases.

[boneknuckleskin]

Can you clarify why you believe that a wide complex tachycardia at this rate in the hemodynamically solid patient must be aberrant AFIB/AFLU on a bypass tract?

[AZCEP]

The hemodynamic status of the patient is immaterial.

"Normal" cardiac physiology will tell you that the absolute maximum for atrial tissue during AF/Aflutter is 700 beats per minute. The conduction rate of the AV nodal tissue is 180/min in the "normal" healthy adult.

The only way for the rate to exceed the AV node's ability to conduct is through the use of an accessory pathway.

[boneknuckleskin]

And how did you rule out ventricular tachycardia/flutter as the cause of this wide complex tachycardia?

[AZCEP]

It is highly unusual for the ventricles to have a rate that high.