Ventricular Tachycardia input

[Asysin2leads]

This all comes from two very specific cases I have worked on, I'll give you the short synopsis on the second.

Pt. is male 45 y/o male found sitting on bus AOx3 reporting asthma attack. pt. sts he has been having difficulty breathing over the past few days, particularly at night, worse on exertion, described as tight feeling in chest like an asthma attack, chest pain denied, 6/10 on severity, has used albuterol inhaler several times without relief.

PMH: Dx Asthma, reported history of IV drug use.

PE: perrl, conjunctiva pink, negative cyanosis, negative JVD, trachea midline, negative accessory muscle use, lungs clear, slightly diminished, negative incontinence, PMS present x4in extremities, negative edema, pulse rapid, weak. Skin: Normal, dry.

VS: BP 130/80, HR 160, RR: 20, SP02: 96 on room air, GCS: 15

EKG: I don't have a copy of it, but just take my word for it, this guy had a rhythm that looked like classic ventricular tachycardia. Wide complexes, if it was on a test you'd say "that's easy" and check ventricular tachycardia as the answer.

TxN: Administered 02 10lpm via NRB, obtained IV access 20 gauge in L AC. (Just to make sure that everyone knows how cool I am, I'll reiterate, I succesfully put an IV in on one shot on an IV heroin user while kneeling on the floor of a bus.)

So, now we come to medication choices. The problem is I think way too much to be a good shiny soldier/medic. As mentioned before, I had one case before that was similar, a rhythm that looks like what you could point out from across the room as v-tach, but a patient presentation that just does not fit. From the previous patient I knew that an SVT with a variancy can mimic v-tach on the monitor, and I had a strong suspicion that this was what was going on with this guy. However, since would still fall under out wide complex tachycardia protocol, I administered a bolus 1.5mg Lidocaine, I really would have like Amiodarone, but the FD decided to buy me $2500 PPE rather than update our meds.

We're supposed to follow up with the 1-4mg/min lidocaine drip, but I was so sure that the guy was not in ventricular tachycardia, and he was complaining about the effects of the drug, (mostly ringing in the ears), that I made the decision to not continue the protocol treatment. If I had my way, I would have given him 0.25mg/kg diltiazem, but I knew there was no way I was going to convince telemetry of what was going on.

At the ER, it was found that after slowing his rate down, the guy actually was in 4:1 Atrial flutter. I was right. The dilitazem would have worked and the lidocaine was not indicated. Score one for the nonconformist paramedic.

Okay, so here's my question. Given the impaired pumping function of the heart in a person in true ventricular tachycardia, is it possible, or at least likely, to have a person who is in true ventricular tachycardia to have normal skin, normal respirations, and a normal BP? In my mind, v-tach is secondary to v-fib, as in, you're heart isn't working right, you are pale, cool, diaphoretic, possibly without a palable BP. I need to have some people who have more experience in treating v-tach than I do to way in on how the patient's present; have you ever had a v-tach patient (confirmed by ER diagnosis) that was walking around with this life threatening arrhythmia?

[Scaramedic]

I have had pts who have looked good and were in confirmed V-tach with a long history of episodes of V-tach also. Are they picture perfect like you described? No not really, looked good yes, but RR was increased and they were extremely weak. Non ambulatory on arrival, been walking around the fairgrounds sudden onset weakness and that good ole fluttering feeling in their chest kind of thing. I believe for some the body can compensate temporarily for the decrease in cardiac function, but your right for the most part they are catching the train to V-fib. If you were thinking SVT did you consider vagal maneuvers? That might have slowed the rate down long enough to see that A-flutter.

On a side note, I am going to assume you do not have 12-lead capability, whats wrong FDNY spend too much money on those snazzy new boots to go with your PPE gear?

Peace,

Marty

:joker:

P.S. Good job on the IV, I personally hate sticking junkies. =D>

[AZCEP]

Asys,

Thank goodness that not all paramedics look for the patient to present like the book tells them they should.

I've had a number of patients present with VT and not have any other associated symptoms. No shortness of breath, no diaphoresis, nothing. As a routine, I check a pulse with my initial contact, otherwise it would have been much longer until I decided to put the monitor on. :roll:

One question, if the patient you describe had their rate slow and you could identify atrial flutter after the lidocaine, wouldn't that mean that the lidocaine was effective at controlling the ventricular rate? Oh well, you don't have to convince me that you did the right thing. Sounds like the patient improved from here.

[Ridryder 911]

When I started working in CCU, I rapidly learned that many patients have V-tach for several hours, and not be very symptomatic as well. Although, I would not recommend it, I have seen different modalities on treatment of such.. mainly do nothing. Yes, it is a different awakening to see a person in sustained V-tach, and not immediately treat it... Sometimes the most appropriate treatment is the etiology, such as electrolytes therapy etc... if they are not hemodynamically compromised..

R/r 911

[Asysin2leads]

All right. so, the consensus is that you can be in true v-tach and still look some what normal, its good to know. To answer a few questions, the rate didn't slow after the lidocaine, it slowed after a calcium channel blocker was given in the ER. The fact that lidocaine had no effect on the rhythm also made me believe that the rhythm was not ventricular in nature. We do have 12 lead capabilities, and I spend much time enjoying reading and interpreting and passing them around the station. This guy's rhythm was such a mess that the 12 lead was good only for making a med list.

So, for field diagnosis and treatment, besides the patient's presentation, which apparently can't always definitively rule out ventricular tachycardia, any ideas for making a differentiation between v-tach and a sneaky SVT with a bundle or variancy or other oddity that like to pop up just to make my life more interesting? The ER doctor also made the recommendation that you use Amiodarone if you are on the fence, the reason being I assume because the prolongation of the cardiac repolarization cycle will effect both the ventricles and the atria, so either way you'll do some good. However, I supposed you need to weigh in the added risk of throwing a clot if there is an underlying atrial flutter.

So lets say we give the guy diltiazem instead and it turns out that he was actually in a stable ventricular tachycardia. If the guy is hemodynamically stable but in a ventricular tachycardia, how bad are talking in terms of effects? Would it just be better to risk throwing a clot using Amiodarone than risk dropping the patient's blood pressure couple with ventricular tachycardia?

Will Stephanie tell Ted that she's having Elian's baby?

[AZCEP]

Well, without going into all of the mechanisms that Amiodarone works on, it will work on atrial and ventricular rhythms. The danger with using a calcium channel blocker on a ventricular rhythm is due to the way they will slow conduction through the AV node. If the rhythm is ventricular in origin, and using a retrograde reentry mechanism through the AV node, the blockage of this conduction will create VF, almost instantly.

The risks of converting AF/Aflutter to sinus with amiodarone is a valid concern, but typically requires higher doses than the 300 mg that most will use. 150 mg x2 doses reduces this possibility some.

As for the identification of the rhythm, the most reliable method is the frontal axis, but this is far from perfect. Your patient's history could help guide you, but this patient didn't really have any of the classic risk factors. When you are on the fence, and feel that you need to do something, the fastest, most reliable treatment is cardioversion. Even that, apparently, caused some issues with your patient. Just maybe he would have responded better if it had been done earlier, but maybe not. :roll: :oops: :shock:

[chbare]

Asysin2leads, hard case. I tend to agree with AZCEP and what the doc told you. I would be very hesitant to give a calcium channel blocker unless I was certain the rhythm was Fib/Flutter for the same reason AZCEP stated. Sometimes you can tell that the rhythm is very irregular and this can help differentiate A-fib from V-Tac. (sometimes) Hell, it even states in the ACLS guide line that "Expert consultation is advised" when you come across a stable wide complex tachycardia.

Take care,

chbare.

[Spock]

This is a great brain teaser. I have also seen several patients in V-tach who were pretty much asymptomatic. A narrow complex tachycardia with abberency will look very much like V-tach but if you look very closely at the EKG strip you will see a small notch usually on the downside of the rhythm. That is your clue that the "classic" V-tach is probably a horse of a different color. Still, I would not have had the brass to give a calcium channel blocker in the field for this patient. The nice thing about amiodarone is that if you look at the ACLS text you will find is is indicated at some point for just about every abnormal rhythm except bradycardia or blocks. To bad this was not an option.

Ringing in the ears after lidocaine indicates toxicity.

Live long and prosper.

Spock

[tomcbad]

any thoughts of using adenosine? It might slow down the rhythm so you can get a better look. A 12 lead would have given you the electrical axis and you could probably confirm vtach. This is probably not in your protocols, but could help you diagnois vtach.

Tom

[mediccjh]

If I had my way, I would have given him 0.25mg/kg diltiazem, but I knew there was no way I was going to convince telemetry of what was going on.

What's wrong, you didn't want to talk to Dr. Silverman so he can ask for your full patient presentation and start off with "Well, I think this patient needs.... instead of ...."?