Tom B. Posted May 24, 2009 Posted May 24, 2009 As ERDoc stated, debating the specific focus of the escape rhythm is academic when considering the pre-hospital treatment of a symptomatic patient. However, for the sake of mental masturbation, why not discuss the possible focus of the escape rhythm? Again, I point to the axis. Right shoulder axis deviation is still suggestive of a ventricular rhythm; however, this patient clearly does not demonstrate right shoulder axis deviation. As people have stated, the right shoulder finding is not always the case; however, it still provides evidence against a ventricular rhythm. As ERDoc stated, the rate is around 40, this is ~the upper limit for a ventricular escape (not including accelerated rhythms), and the ~ lower limit for a junctional rhythm. So, yes I would agree, it's a hard call when you have a wide complex escape rhythm with a rate that could go either way. In my case, I am using the axis as a tie breaker. Take care, chbare. I don't see how it provides evidence of anything. Most cases of VT present with other than right superior axis. Why should ventricular escape rhythms be any different? In my world, wide complex rhythms are ventricular until proven otherwise, and rate, axis, and QRS morphology are not sufficient evidence. Tom B.
chbare Posted May 24, 2009 Posted May 24, 2009 I don't see how it provides evidence of anything. Most cases of VT present with other than right superior axis. Why should ventricular escape rhythms be any different? In my world, wide complex rhythms are ventricular until proven otherwise, and rate, axis, and QRS morphology are not sufficient evidence. Tom B. You asked, I gave a sound description of may stance, and you are free to disagree. Take care, chbare.
FL_Medic Posted May 24, 2009 Author Posted May 24, 2009 You asked, I gave a sound description of may stance, and you are free to disagree. Take care, chbare. But an educated discussion is what this is, and even the great chbare may learn something here. This is why the AHA doesn't have a V-tach(with a pulse) protocol, they instead use the term wide-complex tachycardia. Considering it ventricular until PROVEN otherwise, might be the safest route. Remember we are trying to prove that it isn't ventricular not prove that it isn't atrial. I say this because if you start by considering it to be the worst possible case and work up, you will be on the right side of treatment more times than not. I think too many medics try to make a case for a rhythm to be of "normal" conduction for some reason. If you look at my previous post, I gave a case for it to be LBBB. Also stated that the borderline QRS, just around 120ms is expected abarency with a complete HB. I am just saying, consider Tom's stance. I use the Bob Page method for determining the origin of wide complex rhythms. Seems to work pretty well. If you go to Tom's blog though, he has another good tutorial on the same topic. I would say it is a good read for all levels of clinicians.
chbare Posted May 24, 2009 Posted May 24, 2009 But an educated discussion is what this is, and even the great chbare may learn something here. This is why the AHA doesn't have a V-tach(with a pulse) protocol, they instead use the term wide-complex tachycardia. Considering it ventricular until PROVEN otherwise, might be the safest route. Remember we are trying to prove that it isn't ventricular not prove that it isn't atrial. I say this because if you start by considering it to be the worst possible case and work up, you will be on the right side of treatment more times than not. I think too many medics try to make a case for a rhythm to be of "normal" conduction for some reason. If you look at my previous post, I gave a case for it to be LBBB. Also stated that the borderline QRS, just around 120ms is expected abarency with a complete HB. I am just saying, consider Tom's stance. I use the Bob Page method for determining the origin of wide complex rhythms. Seems to work pretty well. If you go to Tom's blog though, he has another good tutorial on the same topic. I would say it is a good read for all levels of clinicians. I agree this is an educational discussion; however, people are going to disagree based on how they look at this XII lead. As I stated, I am not arguing against looking at this as ventricular until proven otherwise. However, I stated for the sake of mental masturbation, I am using axis as a tie breaker. We disagree on our assessments and go about our way without resorting to personal attacks, creating yet another hostile and pointless argument. In addition, where have I ever called my self "the great chbare?" Where have I sated that I cannot learn anything? Clearly, I am capabable of learning and have incorrect assessments, ideas, and concepts. Remember the paced rhythm strip tease? I initially missed that one. I am quite sure you can look at my other posts and find where I had the wrong idea or thought. I considered his stance and think it is a sound one. However, I continue to disagree. We disagree, not a big deal. Take care, chbare.
Tom B. Posted May 24, 2009 Posted May 24, 2009 Absolutely, and no hostile or pointless argument is desired. Thanks for the discussion! Tom B. I agree this is an educational discussion; however, people are going to disagree based on how they look at this XII lead. As I stated, I am not arguing against looking at this as ventricular until proven otherwise. However, I stated for the sake of mental masturbation, I am using axis as a tie breaker. We disagree on our assessments and go about our way without resorting to personal attacks, creating yet another hostile and pointless argument. In addition, where have I ever called my self "the great chbare?" Where have I sated that I cannot learn anything? Clearly, I am capabable of learning and have incorrect assessments, ideas, and concepts. Remember the paced rhythm strip tease? I initially missed that one. I am quite sure you can look at my other posts and find where I had the wrong idea or thought. I considered his stance and think it is a sound one. However, I continue to disagree. We disagree, not a big deal. Take care, chbare.
FL_Medic Posted May 24, 2009 Author Posted May 24, 2009 I agree this is an educational discussion; however, people are going to disagree based on how they look at this XII lead. As I stated, I am not arguing against looking at this as ventricular until proven otherwise. However, I stated for the sake of mental masturbation, I am using axis as a tie breaker. We disagree on our assessments and go about our way without resorting to personal attacks, creating yet another hostile and pointless argument. In addition, where have I ever called my self "the great chbare?" Where have I sated that I cannot learn anything? Clearly, I am capabable of learning and have incorrect assessments, ideas, and concepts. Remember the paced rhythm strip tease? I initially missed that one. I am quite sure you can look at my other posts and find where I had the wrong idea or thought. I considered his stance and think it is a sound one. However, I continue to disagree. We disagree, not a big deal. Take care, chbare. I apologize for saying that. I didn't mean it as an insult. I consider you one of the more educated I have discussed with and read posts from, that's all. I do remember that post, and point taken.
HellsBells Posted May 25, 2009 Posted May 25, 2009 Just to play devil's advocate, how do you know the rhythm is supraventricular in origin? As the discussion has proven in its evolution since my post, I can't say for sure that it is or isn't with absoulte certainty.
Fifthkid Posted May 25, 2009 Posted May 25, 2009 (edited) sorry my error can't seem to be able to delete this now Edited May 25, 2009 by Fifthkid
chbare Posted May 25, 2009 Posted May 25, 2009 I apologize for saying that. I didn't mean it as an insult. I consider you one of the more educated I have discussed with and read posts from, that's all. I do remember that post, and point taken. No worries, it's all good! Take care, chbare.
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