Wide and Fast (ECG)

[fiznat]

Hmmmmmmmmmmm good questions Mobey!

Why is (or isn't this) ventricular tachycardia?? What criteria do we have to evaluate the ECG?

[mobey]

Hey.... where did my other reply go??

Anyway. I suck at these VT vs abberant SVT ECG's. Looking forward to being schooled.

I could google Brugada's and whatnot, but to be fair, I don't use them in the field because I am not proficient at it.

The complex is VERY wide >140ms, No LBBB is apperant (pos V1), no discernable P waves.

I am gonna go with VT.

The reality is, 150mg amiodarone or sync cardioversion, depending on pt stability, is indicated in either rhythm, so my treatment will not be wrong. HOWEVER: that is not good enough for me!

I do want to be better at this!

The problem I have, is I do not see these in the field, so it is hard to remember any complex formula. Hope I can learn some simple tips from ya'll

[Tom B.]

Cool ECGs, fiznat!

Since the village elders are keeping their opinions to themselves I'll simply offer a couple of clues.

The 2010 AHA ECC Guidelines say "go right ahead" with adenosine for a patient like this but I wouldn't be comfortable doing it even though it could prove to be diagnostic in this case.

There's only one antiarrhythmic I'd consider and few EMS systems carry it because it's expensive and difficult to administer correctly (dosing and end points).

"Wide and fast" is VT until proven otherwise in my book right up until the rate pushes (or exceeds) 250. Then I'm forced to consider another possibility because that's a bit fast even for VT (although it could be so-called ventricular flutter).

Electrical cardioversion for unstable patients allows caregivers to avoid the potentially deleterious consequences of selecting the wrong antiarrhythmic which in some cases can be fatal.

For stable patients I'm a big fan of "supportive care and transport".

Tom

[William A. Ritchey]

First impression is OH CRAP!! Pads would be a good idea and I agree with others on that. I would call it Wide Complex Tachcardia boarding on V Tach. With the HR AT 235 sweating and dipharitic you have here an UNSTABLE patient. I would t go straight to synchronized electrical cardioverson. 150 mg of amiodarone if the patient is stable. Adenocard would be a bad bad deal as to prove the diagnostic is SVT. If you stop he heart with Adenocard it will most likely kill this patient.

Would want a MD opinion (if time permitted) but would be prepared for this guy to crash w/o notice. If he is not in Vtach now he soon will be. Haul butt to the hospital and treat the patient!! If stable it would be supportive care. I do not agree with others here that this patient is in anyway stable.

Edited January 17, 2011 by William A. Ritchey

[Bieber]

Wide and fast I'm going to call it V-tach until proven otherwise, though I'd like to print out a strip to make sure it's not a pacemaker deal. Patient said no history, but I want to check anyway. I'm going to call him unstable due to the poor skin condition and shortness of breath, however since his blood pressure is okay I'm going to slap the patches on and try to get an IV and bolus in 1 mg/kg lidocaine and be ready to cardiovert if he doesn't make it that long.

[fiznat]

Would you guys really call this patient unstable?

BP 128/82

GCS 15

No pain

Sweaty

Pale

Nervous

Mild SOB (still speaking full sentences, no increased WOB)

Remember the alternative isn't "stable" as in "everything is fine." We're talking about the ACLS definitions of unstable versus stable/symptomatic, which is a different animal alltogether.

Some things we consider in this VT/Not VT decision:

-QRS Axis

-Precordial concordance

-QRS morphology

-Visible atrial activity

-Rate

-"Diagnostic" treatments

What do we think?

**I do have an opinion on this, and I do have an end result, but I'm biting my tongue on purpose because I think the discussion on this is more important than the actual answer.... Please feel free to chime in with what you think--- this could be your next patient!!!

Edited January 17, 2011 by fiznat

[island emt]

Ok Fiznat: Dwayne made me wait. :-}

What was the Pt doing when this started?

Has he had any previous episodes of this?

Does he have any other co-morbidity's? diabetes, hypertension?

O2, load up & head to ER, En-route Iv access with a little bolus, get him stripped down & dried off enough to get the pads on .

Be prepared for this rate to change drastically.

For now it's a wide complex tach with a perfusing rhythm and anxiety making him worse. Calm him down to the best of your ability and have the electrical therapy ready to cardiovert

Might even have a go at him trying a vagal maneuver to see if it has any effect.

Next :::

[Kiwiology]

What made you choose drugs over electrical cardioversion?

If we can break the rhythm with some amiodarone its less cardiotoxic and invasive than cardioversion. If however, he went down the crapper I'd be giving him the juice therapy pretty quick!

[fiznat]

What was the Pt doing when this started?

Has he had any previous episodes of this?

Does he have any other co-morbidity's? diabetes, hypertension?

I answered most of these questions in the original post... He hasn't had any previous episodes of this.

O2, load up & head to ER, En-route Iv access with a little bolus, get him stripped down & dried off enough to get the pads on .

Be prepared for this rate to change drastically.

For now it's a wide complex tach with a perfusing rhythm and anxiety making him worse. Calm him down to the best of your ability and have the electrical therapy ready to cardiovert

Might even have a go at him trying a vagal maneuver to see if it has any effect.

Haha sounds good. Don't think anyone will argue with you as far as that stuff goes. What's next???

If we can break the rhythm with some amiodarone its less cardiotoxic and invasive than cardioversion. If however, he went down the crapper I'd be giving him the juice therapy pretty quick!

So I can take from this your vote is that he fits into the ACLS "symptomatic/stable" category?

Edited January 17, 2011 by fiznat

[mobey]

Absolutly stable/symptomatic.

Pale and sweaty with mild SOB does not fit criteria for unstable in either my opinion or ACLS books.

BP is good, no significant chest pain.

I am happy.