Wide and Fast (ECG)

[Bieber]

Hmm, can I change my answer to symptomatic and stable? I guess that's pretty much what I implied in my treatment, in any case. O2, IV, patches, try to calm the patient and go ahead with the lidocaine bolus followed by a drip if no rhythm changes with O2 and relaxing him.

Edited January 17, 2011 by Bieber

[Kiwiology]

He is obviously distressed but not significantly haemodynamically compromised right now. I'd quickly get an amiodarone drip into him and go with that while starting toward hospital, if the rhythm converts then no further treatment is required. That said, should his blood pressure or haemodynamic state become any worse then I would cardiovert him.

[tcripp]

Interesting rhythm strip. On your initial, I would have called it v-tach with pulses or even v-flutter - I do not see torsades (TDP). The patient appears to be stable (his blood pressure is currently holding) so I'd have some one apply the pads while I went for the drugs.

Now, going with what I think I know instead of doing any further research, I'd be pulling out and administering 150mg of Amiodarone over 10 minutes. I'd also be preparing my valium/versed if I need to cardiovert. (Brief memory from school actually taught us, whichever we can get to quickest (drugs/electricity), use because the patient will not stay this way for long.)

Now...what is interesting that I didn't see coming was the 12-lead ekg interpretation of "A-Flutter". So...hmmm...go with my initial instinct or with the monintor's interpretation? Or, just use electricty and call it good?

Thanks, fiz for the brain stumper...

[fiznat]

Okay, I'll move this forward a little bit.

12 mg of adenosine barely touched the rhythm. There as a brief period (maybe 5 or 6 beats) where the space between each QRS widened and I could see what I thought were flutter waves. Could have been p-waves though, but they did seem to have that f-wave appearance to them. Unfortunately, though I printed this out, I never got this section back in the code summary when I printed later so I don't have a copy to show you. You'll have to just go with what I say haha.

I also did notice:

-The mean QRS axis is to the left.

-The precordial leads are not concordant

-The QRS morphology looked asymmetrical and aberrant to me

-I feel I can see atrial activity (especially with the adenocard, but also on the original strips)

Does this change anything?

Edited January 17, 2011 by fiznat

[Tom B.]

It means that 1:1 atrial flutter is a strong possibility. It also means that the patient may have an accessory pathway.

[tcripp]

Any change in your patient's presentation after the first dose?

2nd dose of adenosine and then ready for diltiazem...while still being prepared for the cardioversion.

[fiznat]

Any change in your patient's presentation after the first dose?

2nd dose of adenosine and then ready for diltiazem...while still being prepared for the cardioversion.

No change in presentation, or rhythm really. After that initial slowdown, the rate came right back up and it was as if I had never done anything. I didn't give a 2nd dose of 12 mg adenosine. I know that ACLS tells us to, but dammit it never ever ever has worked for me and I feel it isn't worth the time, effort, or patient's discomfort. Slap my wrist, but I didn't do it...

You can assume for the rest of this case that we are doing the other basic stuff. Oxygen, IV access, pads in place, fluids wide open....

Cardizem. There's the tricky part. Are we sure enough about this flutter to give cardizem? Let's hear what people have to say about that....

Edited January 17, 2011 by fiznat

[tcripp]

Cardizem. There's the tricky part. Are we sure enough about this flutter to give cardizem? Let's hear what people have to say about that....

For me...yes. It's used refractory to adenosine...

Of course...there is always a little jolt...

[Bieber]

I think I would hold off on anymore adenosine or diltiazem. If I'm seeing some flutter or P waves, then I'm thinking more and more that this is an accessory pathway issue and I want to avoid any AV nodal blockers. I'd rather go with amiodarone, diltiazem and adenosine might shut down the normal conduction pathways and pre-excite the accessory pathway.

[DwayneEMTP]

I'm not sure what the ACLS definition of symptomatic/stable is?

But I'm going to stay with unstable for now. He's not mentally altered, and that's awesome, but we're obviously having circulation compromise issues severe enough to cause the diaphoresis and tachypnea. I'm really not all that impressed with his vitals to tell the truth as we're only dealing with one set. This guys is diaphoretic, tachypneic, and anxious. Your initial impression before you involved the machines was 'Holy Shit!" That all spells trouble in my book.

What would I do? Punt to my basic partner..he's smarter than I am.. :-)

Dwayne