FL_Medic Posted March 26, 2009 Posted March 26, 2009 My training captain has provided another one. Please provide your impressions. 87 y/o M c/o weakness & near syncope for the past 18-24 hours. Denies CP or SOB. HR matches monitor. 132/72 supine. Pale & clammy.
OHMEDIC187 Posted March 26, 2009 Posted March 26, 2009 (edited) I guess i'll give it try. At first glance it looks like a sinus rhythm with runs of V-Tach, occasional PVC and I also see a PAC in there. Looks like he is pretty ischemic with those sloped s-t segments. CAD. After looking at it for a while, maybe its just periods of s-t elevation? doubting the v-tach now. Edited March 26, 2009 by OHMEDIC187
Kaisu Posted March 26, 2009 Posted March 26, 2009 underlying is sinus with a sinus pause and an escaoe rythym - possibly junctional....
FL_Medic Posted March 26, 2009 Author Posted March 26, 2009 I haven't received the answer yet but I am going to post what I responded with. This was my emailed response: I don't think I am right, but why not try? Well, the first thing to ask would be if the patient has a pacemaker. Rhythm: There are at least three different morphologies that appear to be atrial, including a very wide complex, and one that appears to be ventricular. One ventricular morphology appear to have possible p waves with a very short pr-interval. One may even have the p buried in the R wave. Since the P waves vary in morphology as well I'd say this is some sort of atypical wandering atrial pacemaker. It's possible that this is an AV block but it doesn't meet any classic criteria. Side note: I think I even see some U waves in there Treatment: Treat the patient not the monitor. He is hypoperfusing. His rhythm may have PVCs but lidocaine would leave his HR far too slow. O2 would be initial treatment with continued supine/trendelenberg positioning. A 12-lead and family Hx would be good as well. I would feel for a mechanical pulse to see if those wide complexes are perfusing. It's possible that his pulse is slower than his HR and that BP is compensatory due to increased vascular resistance. I think that is probably the case, and if so, the patient should be treated per the symptomatic bradycardia guideline. Atropine, TCP, Dopamine, Epinephrine. The treatment goal here is to get the SA node back to it's position as the lead pacemaker. Hope I'm right, but if not I would treat with diesel fuel.
OHMEDIC187 Posted March 27, 2009 Posted March 27, 2009 Man, I keep going back to those wide complexes being two Salvo runs, a pvc and a couplet on the second strip. Although, that would be too easy. Im probably way off. Im curious what the answer is!!
AZCEP Posted March 27, 2009 Posted March 27, 2009 SR with junctional, possibly AIVR, escape beats. O2/IV/12 lead/transport
FL_Medic Posted March 27, 2009 Author Posted March 27, 2009 (edited) THE ANSWER Sinus Bradycardia with ventricular escape beats. You can see a slowing SA nodal discharge rate util no p-wave is seen. The ventricular complexes are late cycle, not premature like a PVC. The patient should not be treated with antidysrhythmics. O2, Fluid bolus, positioning. If still unresolved treat with Atropine then Pace if unchanged. The wide complexes with p-waves are fusion beats. Fusion beats are common when ectopic site fires while ventricles are already being activated from primary pacemaker. Unfortunately this patient was treated with Amiodarone. Edited March 27, 2009 by FL_Medic
CharleeFoxtrot Posted March 27, 2009 Posted March 27, 2009 Unfortunately this patient was treated with Amiodarone. I've have said junctional escape as well and considered atro/pacing. Amiodarone??? D'oh!!!!!
akroeze Posted March 28, 2009 Posted March 28, 2009 I'll be man enough to admit that I might have treated that patient incorrectly. Obviously I don't know for sure what I would have done but salvos of V-tach was my thought process.
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