Cardiac question

[Doczilla]

I would have to be convinced that the palpitations and nausea are in fact from some sort of arrhythmia. Any of the antiarrhythmics we would give in this case could potentially complicate the picture or worsen the arrhythmia. I would not give an antiarrhythmic in the prehospital setting for someone with palpitations and nausea. If the patient's pacemaker has an AICD function, this would make me even less likely to administer an antiarrhythmic drug. The history is complex enough (and complaint ongoing for long enough) that I am shying away from wanting to "fix" the problem right away. I know that's not the question you asked (which Bieber answered very intelligently), but the thread has strayed into treatment territory.

'zilla

[ambodriver]

I would have to be convinced that the palpitations and nausea are in fact from some sort of arrhythmia. Any of the antiarrhythmics we would give in this case could potentially complicate the picture or worsen the arrhythmia. I would not give an antiarrhythmic in the prehospital setting for someone with palpitations and nausea. If the patient's pacemaker has an AICD function, this would make me even less likely to administer an antiarrhythmic drug. The history is complex enough (and complaint ongoing for long enough) that I am shying away from wanting to "fix" the problem right away. I know that's not the question you asked (which Bieber answered very intelligently), but the thread has strayed into treatment territory.

'zilla

i concur. If the patient in this scenario is normotensive as you said I would shy away from any medicine based treatment. Too much could go wrong.

As far as determining whether the above pt.'s rythm is VT or not, a 12 lead could help paint that picture.

I'd be looking at axis deviation and other suggestive signs in a 12 lead.

[azemt2007]

after looking at everyone's great considerations and your patien'ts family member's awesome history, I would conclude this: First you identified the patient's underlying rhythm as A-Fib. That being said, ami is not a med i would choose since the side effects to this patient are by far greater risk than the benefits. I would consider cardizem or verapamil if there was witnessed runs of vtach/sinus tach. Again that is making you read the ekg a bit closer as you stated the qRs complexes are wide. Keep in mind, this patient has lost her atrial kick so having a degraded ejection fraction is not surprising, especially as time from surgical repair increases. Furthermore, palpatations are often mimicked by abarencies within the A-Fib, often from re-entry type pathways. Additionally, her heart failure is in both ventricles, so she probably has an enlarged heart creating a much larger surface area for the conduction, slowing conduction volicity, resulting in wider than normal qRs complexes. My suspicion is that she has mitral regurgitation to the degree that she can actually feel it. In combination with her A-Fib, this will definitely allow the myocardial cells to become irritable. I would suspect this lady is toward the point of needing a VAD or transplant.

[Kaisu]

Keep in mind, this patient has lost her atrial kick so having a degraded ejection fraction is not surprising, especially as time from surgical repair increases.

"Atrial kick" is so off the mark in this patient. The patient was in afib BEFORE the surgery, with EJ of 61%. The EJ is now 34%.

Additionally, her heart failure is in both ventricles

What makes you think this?

so she probably has an enlarged heart creating a much larger surface area for the conduction, slowing conduction volicity, resulting in wider than normal qRs complexes.

Duh ? really?

My suspicion is that she has mitral regurgitation to the degree that she can actually feel it.

Did you read the post? She had mitral valve repair 2 1/2 years ago.

In combination with her A-Fib, this will definitely allow the myocardial cells to become irritable. I would suspect this lady is toward the point of needing a VAD or transplant.

She's 82 years old. Are you seriously suggesting VAD/transplant?

Thanks for playing

I think the general consensus here is that treatment with ANY antiarhythmics is contra-indicated based on this patient's history. I refer you to the posts from the MDs. This is a patient that you DON'T mess around with, especially as the patient is asymptomatic during your contact time with them. Take them to the ED, where their treatment is probably limited to admission(possibly) and a cardiac consult(without a doubt)

As a newbie to the forums, it would behoove you to read ALL of the posts in what is already a dead thread prior to posting.

[azemt2007]

First of all, I'm not a newbie to the forum as I haven't posted in a while (especially after the start of charging for the chat), if you noticed, I joined in april 2007. Secondly, I never referenced the surgery she had when i stated she had lost her atrial kick from the afib, which would cause a lower ejection fraction by itself. Third, I did read the post hence when I said, "...degraded ejection fraction is not surprising, especially as time from surgical repair increases," basing that statement on the fact that she did have surgery and just quite possibly, she has a recurrence of the original problem. Fourth, yes she is 82 years old and it is not uncommon for someone of 80 y/o to have transplant or vad, one in particular, Carrol Shelby (of the car fame) had his done late 70's or early in his 80's. Fifth, I never suggested treating this patient in the field, merely speculating since brainstorming is always fun and educational. I never claim to know all the answers, hence I used the terms I suspect, not I know. Finally, as an elite member of the forum and fellow arizonan, I would have figured you would be more polite in posting rather than mocking someone who took an interest in your post, albeit dead (whatever the hell that means since the prior post was 10 days previous to mine).

[Eydawn]

Yea.... I don't get where you hopped on him. His statements actually helped me to think through more of what was going on with this lady, since cardiac is something I haven't had a chance to sink my teeth into yet. I thought his statements were reasonable, and the treatment idea in line with what the general consensus seems to be, which is no antiarrhythmics for this one.

Also, a thread isn't "dead" until we've hit 17 pages and someone starts swearing at the troll, or it's locked, or it's been SEVERAL MONTHS. 10 days is nothing; some of us don't check the forum every day all the time... so when we float in and out, we find threads that most folks are done with, but we might not be yet.

Just my thoughts.

Wendy

CO EMT-B

[DwayneEMTP]

...yes she is 82 years old and it is not uncommon for someone of 80 y/o to have transplant or vad...

I know almost exactly nothing about transplants, but when you mention 'transplants' I'm assuming you mean a heart transplant. Is it truly not uncommon for someone in their 80's to get a new heart? I've not run across many transplants in any demographic, but this seems intuitively unlikely. Interesting though..

...I [was] merely speculating since brainstorming is always fun and educational...

+5

...I never claim to know all the answers, hence I used the terms I suspect, not I know...

Azemt, I thought your post was well thought out as well. It also made me walk a whole different path mentally than I had started on.

If you could, would you mind breaking your posts up into paragraphs a bit? Not busting your balls Brother, it's just way easier to read in parts.

Dwayne

[Kaisu]

I did not notice when you joined the forum. My reference to you as a newbie was based on your post count.

You made the statement “Keep in mind, this patient has lost her atrial kick so having a degraded ejection fraction is not surprising” . It is difficult to ascertain exactly what you meant because your punctuation and formatting is rather poor. I interpreted this statement to mean that you felt a 34% ejection fraction is unsurprising to you based on loss of “atrial kick”.

I was irritated in what I perceived as poor logic, as the patients EJ without the “atrial kick” was 61% prior to her developing heart failure. It irritated me because to me, it was extraneous statement with no contribution to make to the original question.

I must admit to being irritated by the term “atrial kick”. I am generally irritated by attempts to simplify cardiology with catch phrases. Here in Arizona, I hear more than my fair share of them from medics.

I was irritated at your statement “My suspicion is that she has mitral regurgitation to the degree that she can actually feel it “ primarily because she had mitral valve repair (with replacement valve) and in my mind, that had fixed that. Your second posting led me to research the recurrance of mitral valve issues after surgery and low and behold, I found that that is indeed a possiblility (albeit a low one), thus you educated me. That being the case, this patient with proven mitral valve regurgitation did not “feel it” as palpitations prior to the surgery. These palpitations are new.

Your statement “Additionally, her heart failure is in both ventricles, so she probably has an enlarged heart creating a much larger surface area for the conduction, slowing conduction volicity, resulting in wider than normal qRs complexes “ irritated me because there is no evidence that this patient has both left and right heart failure and I found the explanation of enlarged heart creating wide complexes condescending. I would have thought that this is self evident to anyone with any understanding of cardiac pathophysiology.

Your statement “Furthermore, palpatations are often mimicked by abarencies within the A-Fib, often from re-entry type pathways” irritated me because it is my understanding that this is what one of the most common causes of palpitations are. My original posting was trying to differentiate between this type of palpitation and the other main (and more dangerous type) ventricular re-entry pathways.

I was irritated by your statement “ami is not a med i would choose since the side effects to this patient are by far greater risk than the benefits “ first because I have run into a strange and deep rooted prejudice against amiodarone here in Arizona. It seems to be based on old medics teaching new medics old stuff and a refusal to change. I have tried to trace this prejudice and think it may have something to do with the AZ heat and Amiodarones sensitivity to it. Needless to say, I have tried to counteract this to no avail. Secondly, I was irritated because the consensus among the MDs contributing to this thread was to avoid all medications in this case.

Your followup to this statement to consider calcium channel blockers was extremely irritating to me as 1 – medications are contraindicated and 2 – the whole problem in the first place was the difficulty in determining whether this was atrial or not... thus going to a treatment based on the issue that was indetermined in the first place was irritating as hell (I'm getting irritated now :-) )

Your statement “Again that is making you read the ekg a bit closer “ was irritating it implied that I was not reading the ecg clearly, when I had made it clear that I could not obtain an ecg because the episode was over and second, earlier contributors in the thread make it pretty clear that even reading the ecg closely makes this a difficult differentiation.

I referred to the thread as “dead” not based on how many days it had been inactive, but dead in the sense that there appeared to me very little to add to it. I perceived your post as one not adding an iota to my original question, and felt it was a post to show off a lot of cardiac terminology and little practical application to my question. I now appreciate that perhaps the world does not revolve around my naval, and that your post was helpful to others.

In summary, I was irritated by your post. As for being an elite member, this is something that has been bestowed on me by the number of posts and should not be taken as an indication of the quality of my contributions. You can see that my reputation rating is pretty low, and that is because a lot of my posts are stupid one liners looking for a laugh.

I very rarely make the effort to respond in as much detail to any post as I have to this one, and its only because you had the cojones to post the followup taking me to task for my rudeness. For my rudeness, I apologise.

Edited to fix the freaking formatting... what gives with that anyway

Edited December 3, 2011 by CrapMagnet

[HellsBells]

CrapMagnet, it sounds like you were irritated. Is that true?

[mobey]

I was irritated in what I perceived as poor ......

I must admit to being irritated by the term ......

I was irritated at your statement “My suspicion is that she has .......

....... resulting in wider than normal qRs complexes“ irritated me because.......

Your statement “Furthermore, palpatations are often mimicked by abarencies within the A-Fib, often from re-entry type pathways” irritated me because it is .......

I was irritated by your statement “ami is not a med i would choose since the ......

Your followup to this statement to consider calcium channel blockers was extremely irritating to me as.......

......as hell (I'm getting irritated now .......

Your statement “Again that is making you read the ekg a bit closer “ was irritating it implied that I......

In summary, I was irritated by your post. As for being an .......

I am amazed by the amount of power az has over you!!

....and a little irritated