Atrial vs Ventricular origin of wide complex tachycardia

[Kaisu]

Quite some time ago, I posted about a patient with episodes of a wide complex tachycardia and how difficult it was to determine the origin of the tachycardia. I found this on a facebook posting by a medic practicing in the Philippines.

http://circ.ahajournals.org/content/119/24/e592.full

I find it quite interesting and am soliciting your comments. Have you ever used the Lewis Lead configuration? Any comments?

Thanks

[paramedicmike]

Have never used it. In fact, I've not heard of it before now. It looks interesting, though. I'll need to do more reading on the matter.

[paramatt_]

I've used it a few times. I was able to pick up an SVT where absent P waves were hard to distinguish. With that being said, I've also had just as good, if not better, results in using V1 and turning up the gain. Intresting concept though

[Kiwiology]

Interesting.

Not sure it makes a difference, since the 2011 CPG update all tachycardias causing significant haemodynamic compromise get cardioverted regardless of their origin but interesting none the less ...

[craig]

Have to agree with my mate from across the dutch....

[Kiwiology]

Have to agree with my mate from across the dutch....

Winning

[craig]

Winning

Did that make you feel better kiwi?........:-)

[Kaisu]

I like to understand what's going on. Uncontrolled afib in a patient with a history of afib has me thinking differently from a patient with a new onset of vfib. I agree that the treatment protocols will have you treating both the same in regards to stable vs. unstable, medication vs electricity. Given hemodynamically stable yet symptomatic patients, I think a trial of a calcium channel blocker is indicated for the first patient before zapping them, whereas the second patient is getting amoidarone or possibly electricity first.(it depends). This has to to with sustainability of the first rhythm as opposed to the highly unsustainable vfib.

Maybe I'm off base here, but I like to know everything I feasibly can about what is going on with the patient, and in my simple mind, knowing where the dysrhythmia is originating is valuable information.

Smart people correct me. I always like to learn.

Edited February 24, 2013 by Kaisu

[Kiwiology]

Did that make you feel better kiwi?........:-)

Nah I was being a little bit smug

I like to understand what's going on. Uncontrolled afib in a patient with a history of afib has me thinking differently from a patient with a new onset of vfib. I agree that the treatment protocols will have you treating both the same in regards to stable vs. unstable, medication vs electricity. Given hemodynamically stable yet symptomatic patients, I think a trial of a calcium channel blocker is indicated for the first patient before zapping them, whereas the second patient is getting amoidarone or possibly electricity first.(it depends). This has to to with sustainability of the first rhythm as opposed to the highly unsustainable vfib.

Maybe I'm off base here, but I like to know everything I feasibly can about what is going on with the patient, and in my simple mind, knowing where the dysrhythmia is originating is valuable information.

Smart people correct me. I always like to learn.

Nothing wrong with it but there are more important things to do if the patient is crook, get a look at the rhythm and determine that its very fast and the patient is having haemodynamic compromise and there's your sell on cardioverting him. Once you have fixed him up you can have a nosey I suppose.

[Aprz]

Tried it on myself after I read http://sixlettervariable.blogspot.com/2011/02/highlighting-atrial-activity-on-ecg-s5.html (Christopher's blog from ems12lead), and I felt like I failed.

I tried it first without normal lead placement, and I was like "Pff.... the p-waves are small and I can see the ventricular activity big time." I then placed the leads in the normal spot to compare, and I had big time sinus arrhythmia/vagal down to a junctional rhythm I think, lol, which I confirmed by pulse palpation. It was weird... That's the only time I tried it.

Edited February 24, 2013 by Aprz