P_Instructor Posted January 7, 2010 Posted January 7, 2010 Called to residence for patient who's implanted defibrillator has gone off 5 times. You arrive and find elderly female sitting in lounge chair, conscious/alert/pink/warm/dry. Was arguing with family member and defibrillator goes off 5 times. Has no complaints of pain or discomfort. History of diabetes, cardiac. Only significant Rx is Coumadin. BP 130/90, HR tachy at 140-150, RR 14 non-labored. Patient completely asymptomatic. Oxygen per EMS PTA. Monitor placed show tachy undeterminable rhythm, not narrow, not significantly wide, rate 150. 12 Lead performed reveals undeterminable rhythm except for LBBB. Loaded to rig. IV established and oxygen continued, perfusing well, BP now 110/80 (normal BP low 90's). Opinion: What would you do......Adenosine, Amiodarone, leave alone, or what else to help you determine rhythm? Patient continues to have rates is 150 range, defibrillator has high and low settings.
chbare Posted January 7, 2010 Posted January 7, 2010 I would leave it alone. Let the doc interrogate the device and do a workup. Check the sugar enroute. Take care, chbare.
P_Instructor Posted January 7, 2010 Author Posted January 7, 2010 Sugar good. Medical Control contacted with confirmation of 12 Lead. While on phone with RN who is getting MC, you notice that it appears the QRS looks slightly more widened. Second 12 Lead performed reveals wider QRS, still LBBB. This confirmed by MC as he get on phone when second 12 Lead successfully transmitted. BP now 96/66, RR 14, HR still 150. Transport time will be 15 minutes. Any requests?
treaux Posted January 7, 2010 Posted January 7, 2010 (edited) I agree with chbare. Kinda need more info to determine the basis of his tachycardia as well. Any flu symptoms, dehydration, etc that might point you away from cardiac? His rate isn't fast enough to be causing symptoms, and there's no reason to think of conversion unless you can see a clear picture of SVT. If he's asymptomatic then treat him as so and simply transport to the appropriate facility. Oops, just saw the update. Edited January 7, 2010 by treaux
chbare Posted January 7, 2010 Posted January 7, 2010 You want to consider potential electrolyte imbalance. I would want to look at the XII lead, med list, and obtain additional history before charging down the blast em with the antiarrhythmic of the month pathway. Take care, chbare.
P_Instructor Posted January 7, 2010 Author Posted January 7, 2010 I agree with chbare. Kinda need more info to determine the basis of his tachycardia as well. Any flu symptoms, dehydration, etc that might point you away from cardiac? His rate isn't fast enough to be causing symptoms, and there's no reason to think of conversion unless you can see a clear picture of SVT. If he's asymptomatic then treat him as so and simply transport to the appropriate facility. Oops, just saw the update. Yup, still asymptomatic, but could this change into anything else. What is the cause.....maybe just the heated argument with family member, but could this develop into something else? You want to consider potential electrolyte imbalance. I would want to look at the XII lead, med list, and obtain additional history before charging down the blast em with the antiarrhythmic of the month pathway. Take care, chbare. Nothing significant except the coumadin. Patient not specific on cardiac history other than defibrillator. Was just seen at physicians office 2 days ago and everything checks out normal.
HERBIE1 Posted January 7, 2010 Posted January 7, 2010 If his QRS was widening, I'd assume his device is ready to fire again. Check with medical control and see about a loading dose of the antiarrythmic of choice. Asymptomatic or not, if you can prevent his defibrillator from firing it seems prudent. Whether or not it may be effective-due to potential underlying problems- is another story. I'd increase fluids if you have reason to suspect hypovolemia. Wondering if the patient may be infarcting due to a thrombus affecting the conduction system- noted that Pt is on coumadin.
P_Instructor Posted January 7, 2010 Author Posted January 7, 2010 If his QRS was widening, I'd assume his device is ready to fire again. Check with medical control and see about a loading dose of the antiarrythmic of choice. Asymptomatic or not, if you can prevent his defibrillator from firing it seems prudent. Whether or not it may be effective-due to potential underlying problems- is another story. I'd increase fluids if you have reason to suspect hypovolemia. Wondering if the patient may be infarcting due to a thrombus affecting the conduction system- noted that Pt is on coumadin. Perfusion good/adequate. Request from MC will be posted later. What else can be done to determine the specific rhythm is this case? Why the coumadin? Looking for more opinions.
chbare Posted January 7, 2010 Posted January 7, 2010 History assessment. Why are we taking coumadin? (Atrial fibrillation, valvular disorder, etc.) History of WPW or LGL? Take care, chbare.
treaux Posted January 7, 2010 Posted January 7, 2010 (edited) Also to throw into the mix, does the pt have a magnet for emergency de-activation of his AICD? Try disabling it to see what the underlying rhythm is that's causing it to fire. Make base for permission (at least where I work) and apply defib pads in case you need to manually defib or cardiovert. Then treat appropriately to the pt and/or the rhythm I'm not clear on how you cannot determine the rhythm when you say you have a QRS and it's widening. Are you just missing the p-waves? Is it regular? I'd also consider a sedative if this was precluded by anxiety and due to the pacer firing. Edited January 7, 2010 by treaux
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