Tom B. Posted January 7, 2010 Posted January 7, 2010 I'd like to clarify one extremely important point. A borderline wide complex tachycardia should be considered a wide complex tachycardia, particularly when the T-wave is deflected opposite the terminal deflection of the QRS complex. Wide complex rhythms are ventricular until proven otherwise. Having said that, heart failure is a common indication for an ICD, and bundle branch blocks and atrial fibrillation are common manifestations of heart failure. Atrial fibrillation is the most common reason for an inappropriate ICD shock. However, sometimes patients with an ICD are taking oral antiarrhythmics that slow down VT to below the lower rate limit for antitachydysrhythmia therapy. So correct rhythm interpretation is very important. Regardless, if ICD shock number 5 doesn't convert the patient to sinus rhythm, it's doubtful that ICD shock number 6, 7, or 8 is going to convert the rhythm. So if you can document the pre-shock rhythm is essentially the same as the patient's baseline rhythm at the time of initial evaluation (with the exception of rate) then I wouldn't hesitate to deactivate the ICD with a ring magnet. You can always remove it. I wrote a 3-part series on inappropriate or ineffective ICD shocks HERE. It includes a case study similar to the one you mentioned as well as brand-specific instructions for applying the ring magnet. Tom P.S. Would you mind scanning the ECGs and posting them so we can take a look?
P_Instructor Posted January 8, 2010 Author Posted January 8, 2010 Will try the scanning, but don't hold your breath. Further, since there was the LBBB, whether the QRS was slightly widened or not, and the faster heart rate, what would you do? Option to look at the worst of the evils, the potential of significantly wide QRS and fast (VT) and the defibrillator going off. Would adenosine actually work in this case if there were reciprocal pathway causing the tachycardia? Could adenosine slow the rate down enough to realize the true underlying rhythm? Should antiarrythmic medications be given to stave of potential VT? Which med: Lido, Amio, or another??? How about doing the smart thing and running the EKG and 12 Lead at 50mm instead of 25mm standard? Ah haaaaa..............
Tom B. Posted January 8, 2010 Posted January 8, 2010 Will try the scanning, but don't hold your breath. Further, since there was the LBBB, whether the QRS was slightly widened or not, and the faster heart rate, what would you do? Option to look at the worst of the evils, the potential of significantly wide QRS and fast (VT) and the defibrillator going off. Would adenosine actually work in this case if there were reciprocal pathway causing the tachycardia? Could adenosine slow the rate down enough to realize the true underlying rhythm? Should antiarrythmic medications be given to stave of potential VT? Which med: Lido, Amio, or another??? How about doing the smart thing and running the EKG and 12 Lead at 50mm instead of 25mm standard? Ah haaaaa.............. There's a world of difference between a confirmed LBBB and a wide complex tachycardia with LBBB morphology. In the absence of an old ECG for comparison, a wide complex tachycardia with LBBB morphology is VT until proven otherwise. Running an ECG at 50 mm/s may help pick up irregularity suggestive of AF or it may not. Either way you should leave your calcium channel blockers in the drug box. A slight widening of the QRS complex during faster rates is not unheard of, but it also poses the possibility of electrolyte derangement as someone else mentioned earlier in the thread. I'm afraid that doesn't help us pinpoint the exact diagnosis. By all means let's look at the worst of the evils. Right now you have a conscious patient with a pulse. That's a good thing. Monkeying around with antiarrhythmics? Maybe a good thing. Maybe a bad thing! The first rule of medicine is "do no harm." If the patient had no ICD, would you be shocking? Would you be pushing antiarrhythmics? If not, then I see no reason to consider those options simply because an ICD is present. I think this is a perfect example of a case where the paramedic should show restraint. Capture a 12-lead ECG. Monitor the rhythm. Consider deactivating the ICD. Start an IV. Draw labs. Supportive care. If you must give an antiarrhythmic, give amiodarone. Tom
streethealer535 Posted January 8, 2010 Posted January 8, 2010 How about doing the smart thing and running the EKG and 12 Lead at 50mm instead of 25mm standard? Ah haaaaa.............. I was thinking as I read through this thread what about trying to vagal... it might not work but if it slowed the rythem enough to reconize something it my help. I guess running at 50mm might help but then I have never seen and EKG done like this is it easy to read and understand in relationship to the vertical lines on the tracing? ~street
SANDMEDIC Posted January 8, 2010 Posted January 8, 2010 Consider causes of such a rhythm. 1. Electrolyte imbalance. 2. Fever/ recent illness/ surgery. Verify no signs/ symptoms Weakness-Fatigue-dizziness-etc If Medical control received the 12 Lead see what the Doc thinks. After all that's why some carry that fancy ECG transmission monitor for these days. (Amongst other reasons of course) Not sure I would toy around with immediate cardioversion, although Amiodarone (150mg over 10 minutes) would be my choice if I had to choose an aggressive route. Would definitely like to see the 12 lead. Oxygen, rapid transport and being ready & aware of any changes in the 12 lead or patient status. I would discretely place the Multi-function pads. My 2 Cents
P_Instructor Posted January 8, 2010 Author Posted January 8, 2010 I was thinking as I read through this thread what about trying to vagal... it might not work but if it slowed the rythem enough to reconize something it my help. I guess running at 50mm might help but then I have never seen and EKG done like this is it easy to read and understand in relationship to the vertical lines on the tracing? ~street Vagals were attempted without success of even slowing down the rhythm. Just double the time factor per box. Try it sometime. Consider causes of such a rhythm. 1. Electrolyte imbalance. 2. Fever/ recent illness/ surgery. Verify no signs/ symptoms Weakness-Fatigue-dizziness-etc If Medical control received the 12 Lead see what the Doc thinks. After all that's why some carry that fancy ECG transmission monitor for these days. (Amongst other reasons of course) Not sure I would toy around with immediate cardioversion, although Amiodarone (150mg over 10 minutes) would be my choice if I had to choose an aggressive route. Would definitely like to see the 12 lead. Oxygen, rapid transport and being ready & aware of any changes in the 12 lead or patient status. I would discretely place the Multi-function pads. My 2 Cents No imbalance. No fever/illness/surgery. Absolutely no symtoms other that being hyped up from argument, but not starting to relax. Medical Control got on line while 2nd 12 Lead being received. Concurred with what I thought. Forget the cardioversion, not needed as of now. Requested the Amio over 10 and MC confirmed that would be what he wanted and granted the order. Patient only slowed down to 146 range, always asymptomatic, oxygen and transport. No other changes during transport and upon arrival ER. Workup produced only minimal findings, however, there were records of previous hx. AF. Thanks for the comments, ideas, opinions. Just a little fun to see what others thought.
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