Wide and Fast (ECG)

[fiznat]

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?

This isn't something that I can quote directly, just a perspective that I take from the entirety of the ACLS algorithm. ACLS tells us that if a patient is unstable, we must cardiovert immediately. If not, however, it is preferable to further analyze the rhythm and administer medication. To me, that says that the *right* medication is less dangerous and invasive than cardioversion. If that weren't the case, why wouldn't we just forget about meds entirely and cardiovert everyone?? That whole idea gets messed up if you give the wrong med, of course...

A bit from ACLS:

Unstable and symptomatic are terms typically used to describe the condition of patients with arrhythmias. Generally, unstable refers to a condition in which vital organ function is acutely impaired or cardiac arrest is ongoing or imminent. When an arrhythmia causes a patient to be unstable, immediate intervention is indicated. Symptomatic implies that an arrhythmia is causing symptoms, such as palpitations, lightheadedness, or dyspnea, but the patient is stable and not in imminent danger. In such cases more time is available to decide on the most appropriate intervention.

My impression of this patient is that he fits the definition of stable/symptomatic, NOT unstable. If we agree on that and we want to stay within the boundaries of ACLS, we need to talk about drugs.

This conversation has been way overdue for me! It's reminded me to get back to revisit cardiology, that's for sure.

Yeah this patient was something of a wake-up call for me. You'll see..

Edited January 18, 2011 by fiznat

[tcripp]

Yeah this patient was something of a wake-up call for me. You'll see..

Ahem. I'm ready for more information. What other details can you provide?

[DwayneEMTP]

Fair enough brother....

But having said that, I would have given him ASA and welded him. Just putting that on the table so I can see how big of an asshole I would be later...

Hey, and what the hell does fiznat stand for?

Dwayne

Also, though you may have become tachypneic and diaphoretic from eating chicken wings, wouldn't that also make the anxious, diaphoretic chest pain with with a decent blood pressure and h/r stable? And would you also consider this pt stable despite knowing that the odds are that he's in big trouble?

Does anyone have any idea what level of hemodynamic compromise is necessary to cause the level of diaphoresis that is mentioned in this pt? I've only seen it in severely ill patients, hemodynamically challenged from either cardiovascular pathologies or trauma, so perhaps my inexperience with it in regards to pts not so sick is pushing me off into the ditch? Has anyone seen this level in a pt that is not critical from something?

Ok...I guess I saw it once in a guy that vagal'd down secondary to a mombo shot of Rocephin. But otherwise...Well, you see my point.

Dwayne

[island emt]

Well from my past exposure to folks with similar signs & symptoms they have an unknown etiology of arrhythmia , so do we want to start the guessing game of which medication to use when we don't truly have an identifiable diagnostic rhythm? Cardioversion after a mild sedation is less invasive and more likely to cause less harm than

choosing the wrong drug to maybe slow the rate.

Good discussion Fiznat

[Bieber]

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

Dwayne

I chose amiodarone because, honestly, like chbare said, a definitive diagnosis of the rhythm is unlikely in the field and ACLS's recommendation is always, when in doubt, treat as V-tach. I also chose amiodarone because, and perhaps I need to review cardiology, I personally don't see enough there in that strip to make me think so much that it's something other than V-tach that I would be comfortable NOT treating it as V-tach in the field; and maybe part of that is inexperience. Also, the wide QRS complex makes me think that if this were atrial flutter, that there might be an accessory pathway present and to my knowledge amiodarone is the recommended treatment for such arrhythmias.

None of this means that electricity is contraindicated, and I certainly don't see any problem with cardioversion regardless of what the actual rhythm is and I agree it is probably the safest choice. However I don't think amiodarone would be deleterious to the patient in this scenario and to be honest I AM hesitant to light somebody up if I can avoid it. Perhaps the correct treatment would be to cardiovert, and I'll defer to your guys' experience, but that's my rationale behind the amiodarone.

[fiznat]

Okay, here it is. (big breath)

I gave Cardizem to this patient, and it was a big mistake.

I was convinced, incorrectly it seems, that this was 1:1 a-flutter with an abbarency. I came to that conclusion based on the flutter waves that I thought I saw with the trial of adenosine. In addition, I did not believe I was looking at VT as the axis is leftward (VT should be extreme rightward), there is no precordial concordance (as seen in VT), the morphology looks asymmetrical and abbarant (not VT), the rate is awful high for VT, and the patient was somewhat young. I think, although I wasn't consciously recognizing it at the time, that the auto interpretation on the 12 lead pushed me towards this decision as well. I try not to let that happen but in retrospect, if I'm honest, I think it played a role.

I started with 15 mg Cardizem, which did nothing. Next I transmitted the 12 lead to the ED and consulted with a physician. I recognized the rhythm was wide and that our standing order is Amiodorone for this scenario (if its not flutter), but I wanted to discuss with the physician- especially since the first Cardizem didn't work (I was hesitant to give a 2nd dose). I was ordered to follow up with another 10 mg of Cardizem (??). That didn't do anything either. In the ED they gave mag and amiodorone with no effect. Cardiology consult eventually decided to cardiovert, which worked immediately. The post cardioversion rhythm had delta waves, and a pattern (not an expert on this part at all) that the cardiologist identified as an orthodromic reentry mechanism/WPW.

For those who are unfamiliar, giving Cardizem (calcium channel blocker) to patients with WPW is absolutely contraindicated and quite dangerous. The patient turned out to be fine, but the cardiologist said that I "really dodged a bullet," and "got really freaking lucky."

Turns out I was right that there was an atrial origin, but dangerously wrong about the rest. I consider a big lesson learned for me. There is no reason I should have been messing around trying to identify an atrial origin/abbarency. Wide + fast should have just been amiodorone (or procanimide), and that should have been that. I stand by my decision not to cardiovert immediately, but I recognize that I made a pretty big error in my drug choice.

Anyways, there it is. I've been a medic for 5 years now, I've done lots and lots of bad calls, but I'm still making mistakes and learning hard lessons every now and then. I thought I'd pass it on so hopefully people can give these things some thought before this happens to someone else! Thanks for playing!

[DwayneEMTP]

Your honesty should be the gold standard that we judge all scenarios by here.

I beat you on this one Fiznat!

But because I'm smarter than you? Of course not, anyone that's been here for more than a week knows that's not true, but because I was scared. I would have tried cardioversion simply because I can come back from that if it's in error having created almost no physiologic changes if my decision was in error. Also the ASA for, hopefully, obvious reasons.

Do YOU still believe that the medications were the less invasive choice of initial treatment for this patient?

I would still like to hear your opinion, not the ACLS opinion, but your logic for choosing drugs instead of electricity. I'm just not getting your committed stance on that. I certainly respect it, but don't understand it.

Do you know what they medicated with post conversion, if at all?

Thanks for sharing brother. I don't think you realize your value to the City...It's massive.

Dwayne

Edited to fix a typo. No significant changes made.

Edited January 19, 2011 by DwayneEMTP

[chbare]

Thanks for sharing bro. As I stated, I was not totally confident and would have been hesitant to give any medication. I would have still cardioverted, but I really appreciate you sharing this with us. Definitely a good case.

Take care,

chbare.

[Bieber]

Thanks for sharing, Fiznat. That was obviously a tough call for you and I know how hard it can be to share it with the rest of us, but like you said we all make mistakes and we grow from them, and hopefully we all do what you have and share them with our peers so we can ALL learn from it. Glad to hear the patient turned out all right.

[uglyEMT]

Does anyone have any idea what level of hemodynamic compromise is necessary to cause the level of diaphoresis that is mentioned in this pt? I've only seen it in severely ill patients, hemodynamically challenged from either cardiovascular pathologies or trauma, so perhaps my inexperience with it in regards to pts not so sick is pushing me off into the ditch? Has anyone seen this level in a pt that is not critical from something?

Well I have nothing to add to this thread twords the OP but I can answer this question for Dwayne.

Dwayne to have the level of diaphoresis that was mentioned the patient needs a heart rate over 120. Once the body senses the high heart rate the chemicals begin fireing (dont know which ones, still learning my cardio) and one of the side effects is sweating. So as long as the body is sensing a high heart rate the higher it is the more profuse the sweating.

Here is a perfect example. Personel example so i can give you the indepth to it all.

When I was 24 I came back from a long trip (drove florida to NJ in one shot) without much movement. Well the next day I started feeling a little "off". Then I got "heartburn" a few hours went by and I just brushed it off. Hell I'm 24 and invincible right? The heartburn didnt go away and I began getting anxious. I couldn't sit still and when I did I was just sweating like I ran a marathon. I finally gave up and went to the ED myself. Turns out I threw a PE that developed in my leg. My heart rate upon arrivial at the ED was 157 BP was sky high. I went from waiting room (which was packed) to a bed in less then 3 minutes. I thought the nurse was going to crap herself when she looked at my vitals. Within a few minutes of that I had pads placed on me and several IVs running. Felt ominus sitting there with a LP12 (at the time I just called it the shock box) in between my legs waiting for the line to go flat. I thought the last thing I would hear is BEEEE. At the time I wasnt even dreaming of being an EMT and most of my medical knowledge was from ER (the tv show). I never realized just how bad off I was until now. Now that I am an EMT and work closely with Medics I realise how close I did come. The one thing I did remember from all this was the sweating, no matter what I did I couldn't stop. The Docs said that was the one sign that should have had me at the hospital immediatly. I asked why and thats when he said it means my heart rate is sustained over 120 and my body is trying everything to slow it down and as a result I sweat.

Now that I talked about it I will go research more and find out exactly the pathology so i can give an even more accurate answer for you Dwayne. Just wanted to get this down before I lost track of it, I will get better information though as I know anticdotal evidence is not the best.