Atrial vs Ventricular origin of wide complex tachycardia

[Kaisu]

Thanks for the link Aprz.. and.. hahaha

You know, Craig and Kiwi.. you guys upset me a little. I post what I think is interesting and potentially useful information and you two hit me with "whatta ya want that crap for, just follow the protocol."

OK - no question, I may be a wee bit sensitized to this but I run in an area where protocol monkeys run the show. They don't want to understand any more than they do and consider someone who does a threat. I have learned to eat shit and smile.

Come on fellows - can you not admit that there is the potential in the field for some patient benefiting from you knowing how to do this?

[chbare]

Thanks for the link Aprz.. and.. hahaha

You know, Craig and Kiwi.. you guys upset me a little. I post what I think is interesting and potentially useful information and you two hit me with "whatta ya want that crap for, just follow the protocol."

OK - no question, I may be a wee bit sensitized to this but I run in an area where protocol monkeys run the show. They don't want to understand any more than they do and consider someone who does a threat. I have learned to eat shit and smile.

Come on fellows - can you not admit that there is the potential in the field for some patient benefiting from you knowing how to do this?

In spite of underlying guidelines, exercises in mental masturbation like this evoke curiosity and the spirit of exploration. Only through asking questions and seeking answers do we arrive at solutions, guidelines and so on. I am not sure making the differentiation will be all that useful when considering the guidelines, but the exercise of considering it may be helpful and the possibility in its self is worth the consideration.

[Kaisu]

One real benefit of mental masturbation is the esteem it evokes in other members of the healing profession, specifically ED docs and RNs. When one of the cranium spankers brings a patient into the crowded and understaffed ED they listen. Used judicially, when a frontal lobe wanker gives them the "this guy is circling the drain" look, they attend.

[rock_shoes]

One real benefit of mental masturbation is the esteem it evokes in other members of the healing profession, specifically ED docs and RNs. When one of the cranium spankers brings a patient into the crowded and understaffed ED they listen. Used judicially, when a frontal lobe wanker gives them the "this guy is circling the drain" look, they attend.

Precisely. It's all about giving the receiving staff a reason to respect you. If they respect you, your patients receive better, more timely, care.

Thank you for posting Kaisu. I'll give this a go the next time I have a hemodynamically stable patient with a wide complex tachycardia.

[craig]

Thanks for the link Aprz.. and.. hahaha

You know, Craig and Kiwi.. you guys upset me a little. I post what I think is interesting and potentially useful information and you two hit me with "whatta ya want that crap for, just follow the protocol."

OK - no question, I may be a wee bit sensitized to this but I run in an area where protocol monkeys run the show. They don't want to understand any more than they do and consider someone who does a threat. I have learned to eat shit and smile.

Come on fellows - can you not admit that there is the potential in the field for some patient benefiting from you knowing how to do this?

thanks Kaisu

You must have pretty thin skin

All I said in my post was that I agreed with my mate from NZ

I have no problem with anyone doing things to better themselves or for better patient outcomes....however as kiwi stated current standards state that unstable wide QRS get the electrical treatment. In no way do I think that paramedics that just "run on protocols alone" and either don't want to or refuse to further their outlook and understanding a detriment to our profession.

At this current moment, the standing is electrical is used for unstable wide QRS....hanging around on scene doing things that are not required seems a little silly if you are talking about better patient outcomes.

Also if you do this at a scene with a stable patient, and them take them to the hospital, what do you tell the doctor..."ahh we did this.....and we found this....so the patient must have this........" what will most ER doctors think about you as a paramedic then.....that's his role for that ...think he might think this upstart paramedic might be over stepping the mark.

Saying that I am all for further advancement of trading, skills and understanding of A&P

[Kaisu]

Where did I state I was hanging around on scene? I work for a transport company and that's what I do - transport. Secondly, is every wide complex tachycardia an unstable one? Where did you get the impression that I advocate hanging around diddling while Rome burns?

and as far as my skin goes - the less you know the better....

[Jaymazing]

I think this topic is spinning into the ditch.

The Lewis lead is a hand tool, if used correctly and in the right circumstances, to acquire an extra piece to the puzzle when met with an interesting case. What I think people are trying to suggest here isn't that it's pointless to broaden your knowledge of ECG's, cardiology, or patient care, but are instead suggesting that there is in fact a delicate balance that must be maintained when applying these non-standard practices to standard-care.

What Kiwi and Craig are saying is a valid and reasonable response to the concept of modifying chest leads in the prehospital setting, and I do not believe that their remarks were meant to shut you down. While no, you did not suggest the act using this configuration on unstable patients, we should remember that many tachycardic rhythm's in which atrial activity cannot be accurately defined are statistically unstable by their very nature, and current studies suggest that recognizing distinguishable, organized atrial complexes is an act that often times delay's treatment (even if it wouldn't delay your treatment).

I have't had any clinical use for the Lewis lead in my career, but I look forward to the day it helps me diagnose a tricky rhythm so that I can show off to my partner. I fear I've yet to impress her...

[systemet]

Come on fellows - can you not admit that there is the potential in the field for some patient benefiting from you knowing how to do this?

Hi Kaisu,

I think this was an excellent post, that provided novel information that could potentially impact my patient care. I'd like to thank you for posting it, and raising the level of discussion.

I think I agree with some of the other points made, as well, that cardioversion remains the most appropriate choice in an unstable patient -- although there are definitely different degrees of unstable, and some of them might allow time for a 12-lead and an attempt at a Lewis lead, especially if sedation is being employed.

Given the high frequeny of VT versus WCT with aberrancy in the adult population (about 9:1), I'd be very reluctant to give a beta-blocker or Ca2+ channel blocker to a WCT. The new ACLS guidelines support giving adenosine to undifferentiated WCT, and this would be my first approach if I found P waves in the WCT. This is an approach that I think has a reported 80-90% conversion rate for SVT. Unless I was looking at an extremely prolonged transport time, in the stable patient I would be tempted to withhold antiarrhythmics beyond adenosine until the ER.

All the best everyone!

[Job13_5]

I've used the Lewis lead quite a bit prehospitally. It's been very useful. For example, the other day I had a patient with a narrow irregularly irregular rhythm in the 150's. A standard set of leads was unhelpful in determining if it was sinus with frequent PACs, MAT, or AF. A Lewis lead helped amplify atrial activity, showing associated p-waves of only two morphologies.

I can't think of an instance when it's changed my treatment plan, but by using it, I have been able to be more definitive about rhythms, and I can only imagine that that will eventually lead to a change in course.

[medic113]

Kaisu,

Had never heard of Lewis leads until your post. I retired out of 9-1-1 after 35 years and am now doing strictly inter-facility (ER in non-cardiac cath hosp to cath center, non-hemorrhagic CVA's to get their brain cath'd and such) so everyone is already diagnosed. While in the ER the other day picking up another patient, there were 2 ER docs discussing a patient with SVT and they were discussing if the P was in the T or not. I proposed the Lewis leads (which only 1 had ever used in the past), they tried it and it worked. Bottom line is there were P waves as
determined by using the Lewis method (and the Docs think I’m brighter than I really am!).

Thanks!

Matt