Wide and Fast (ECG)

[fiznat]

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

Generally it means:

1. The patient has symptoms related to the tachycardia.

2. The patient is not in shock.

There is definitely some flexibility here, but my opinion was that while this guy was surely in trouble, at the moment he was not "unstable" per-se. By the way, you can assume that the given BP is accurate, and is verified by multiple reassessments throughout the call.

but we're obviously having circulation compromise issues severe enough to cause the diaphoresis and tachypnea.

I got diaphoretic and tachycardic the other night when I ate some hot wings!!

Your initial impression before you involved the machines was 'Holy Shit!" That all spells trouble in my book.

True, but that is a subjective evaluation. If I'm going to make this guy ride the lightning I feel I would need something objective as well. More than what I saw. That's my opinion anyways. I'm fully aware that other people would feel differently- that's part of the reason I posted this here!!

[DartmouthDave]

Hello,

Late to the threat.

Reasonable stable. So, Amiodarone 150mg followed by 1mg/min. With pads on just in case. Transport.

From what it is worth I typically use the following system to try an see if a WCT is VT. Many of these points have been already raised.

1. Cardiac Hx?

2. Risk factors?

3. Old CAGB scar?

4. ICD (Internal Cardiac Defib...a square lump under the skin on the upper left or right chest)

5. Axis?

6. BBB?

7. Rate?

8. Variance of rate and QRS. Slows down with fluid? Dose the QRS change with rate?

9. How long has the patient felt unwell?

Though rare, I have seen a few cases in which the an IVCD develops due to tachycardia. Last winter, a 80 year-old gentleman was brought in with a WCT that was refractory to defib. It turn out he was feeling unwell and was dehydrated (Hence my addition of point #8 & #9).

Cheers

Edited January 18, 2011 by DartmouthDave

[chbare]

Late in the game; however, I am not particularly confident in a definitive field diagnosis of the rhythm in question. I would be very cautious about pushing meds. Honestly, I would cardiovert at this point.

Take care,

chbare.

[Eydawn]

Chbare, what leads you to doubt the diagnosis? Can you let me in on your thought process?

Wendy

CO EMT-B

[chbare]

Is it ventricular tachycardia, is there an underlying atrial flutter, what will happen when I start altering ion channels with medications? This is basically what I'm thinking. The safest consideration in my mind is to consider csrdioversion.

Take care,

chbare.

[1EMT-P]

The fact that the patient has no past medical history & developed these symptoms suddenly is very concerning, if he were my patient I would start with 02, IV & monitor. The patient is symptomatic & has already had 12 mgs of Adenosine, which really didn't do much, so I would consider a trial of medications to see if we could slow the rate. Amiodarone 150 mgs IVP over 10 minutes or Lopressor 5 mgs IVP. I would apply the pads & if he started experiencing chest pain, hypotension or respiratory distress I would go with cardioversion starting at 100J. As of right now I would call this a WCT of Uknown Origin ( A-Flutter/SVT vs V-Tach). I would love to know what his lytes were, especially his Magnesium.

Edited January 18, 2011 by 1EMT-P

[DwayneEMTP]

Is it ventricular tachycardia, is there an underlying atrial flutter, what will happen when I start altering ion channels with medications? This is basically what I'm thinking. The safest consideration in my mind is to consider csrdioversion.

Take care,

chbare.

I'm with chbare on this. I believe that he needs treatment, (the pt, not chbare) though I know that I seem to feel that he's more seriously in need of that treatment than many here, and treatment should be considered from less invasive to more invasive and cardioversion would be the least invasive at this point, wouldn't it? A chance of success, also a chance of new diagnostic data and minimal physiologic change if it proves unsuccessful.

Of all of the treatment options available, it seems as if we're avoiding cardioversion for the same reason that people avoid EJs and nasal intubation, not because of logical treatment decisions but because of the medics comfort with the options available.

Amiodarone does seem like an odd first choice for a rhythm that hasn't been identified yet, doesn't it?

Dwayne

[fiznat]

ACLS considers cardioversion *more* invasive, which is why it is reserved for only the sickest of patients.

[D.P.Gumby]

ACLS considers cardioversion *more* invasive, which is why it is reserved for only the sickest of patients.

Why is that so? ( I ask of ignorance, not attempting to be a provocateur). By "more invasive" does the AHA really mean "more dangerous?" Especially in a case like this where the rhythm identification is difficult, I would have thought that there is more danger in administering medications that may cause harm if the ECG interpretation is incorrect.

[DwayneEMTP]

ACLS considers cardioversion *more* invasive, which is why it is reserved for only the sickest of patients.

Can you cite the source for these statement? I'm not doubting you, but I'm not able to place this hierarchy that you all keep mentioning in my head. Does ACLS even cover treatment of hemodynamically questionable patients with unknown rhythm disturbance?

Truly not being a dickhead, at least not on purpose. I'm just not sure how to argue these points, which I really, really want to do..grin, without knowing their source.

Thanks to all for keeping this discussion in the spirit intended. I'm truly not sure what is best, I'm only trying to argue what I believe I would do, and why. This conversation has been way overdue for me! It's reminded me to get back to revisit cardiology, that's for sure.

Dwayne

What made you choose drugs over electrical cardioversion?...

To those choosing drugs over electricity, I'm truly curious as to the answer to Mobey's question, and it's justification.

Dwayne