Ventricular Tachycardia input

[fiznat]

Good case!

My question is, with the patient's presentation (pretty much stable although the tachyness and SOB complaint is a little worrysome), why do anything at all about that rhythm? Sure its funky and wide and could be SVT/VT whatever, but if the patient is presenting okay, I think I would hesitate to go after an unknown rhythm and potentially upset this otherwise fairly stable patient. Isnt this one of those "treat the patient, not the monitor," IV/O2/Monit. patients they keep telling us about in class?

Also as far as the SVT/VT rhythm, could you start off with some vagal maneuvers and see what that does for ya first? Amio would be nice, but you guys are just like my service. Too expensive a drug or something, I guess. With the drugs that you had on hand, assuming you would do anything at all, I think you were correct with the lido. You have to assume that it is VT in this situation anyways, bieng that it is probably potentially the more dangerous rhythm.

[stcommodore]

I have as much experence as your little toe but during a ER rotation I saw a patient sustain runs of VT. He clearly was unstable, looked like crap, etc etc but it was a learning experence none the less. I believe he was in a SVT they tried to break with Adenosine and when the rate dropped the salvo's of VT would kick in. Oh and feel free to feel special hitting an IV like that, but only a 20?(jk)

[Asysin2leads]

Fiznat, you are absolutely right in that if the patient is asymptomatic, treating the monitor is not a good idea. However, I have one case that haunts me to this day of the mostly symptomatic patient with a bit abnormal EKG. Actually, I wrote it up and posted it here a while back, but basically, I had a 50 y/o male who was complaining only of mild dyspnea (when found he was sitting chatting with police comfortably) with a heart rate of 165 and a hx of Asthma, showing an SVT on the monitor. The only treatment initiated on scne was IV access and high flow O2. En route (a transport time of less than 5 minutes), his heart rate went up to 175, and he complained of increased difficulty breathing. I tried to break it with Adenosine, no luck. Two minutes later, after coming through the doors of the ER, he was in cardiac arrest. He was revived, and it was found the SVT was from an active MI. This is part of the reason why I personally am a bit more aggressive in treating arrhythmias with out a great deal of associated symptoms.

[Just Plain Ruff]

I've had patients like that too and was surprised to say the least.

I've also taken care of a 101 year old woman with 3rd degree heart block with a rate of 30 who's only complaint was being a little tired and when her friend checked her pulse she called us.

We put a pacemaker in her at the transferring hospital and she lived 2 more years. Amazing that we would see this woman driving herself to the market and church and always say, man if I looked that good at 101 I think i might want to live forever

[AZCEP]

The key point is that this is a stable tachycardia. Leaving it alone is not necessarily right or wrong. The patient's condition allows you to take a bit more time in making a better decision on what needs done. It does not preclude you from having to treat the rhythm, you just get more time to think about how you are going to proceed.

The adult heart does not tolerate these kinds of rates too well. Decreased filling, increased oxygen demand, decreased supply all lead to collapse. The compensation that the patient is exhibiting should be considered in the treatment decision, and "expert consultation" should be sought. Trouble is the "expert" in the transporting unit is often forced to deal with many other variables than just the origin of the rhythm.

[redwolfef6]

Excellent case study.

I am inclined to agree with Tomcbad...valsalvas and then Adenosine. Should be able to see the Flutter waves. I actually was involved in a case (during my clinicals) on a man with a very rapid tachyarryhthmia. The Doc had me given him 6mg (x2) of Adenosine. The rate slowed and showed a 2 to 1 Atrial Flutter. After that he got Diltiazem.

As far as SVT with aberrant conduction vs. V Tach... should normal to left axis and good R wave progression (V1- V6) for SVT.

[firefighter523]

Asysin2,

Valid concern, I agree 100% with you to treat the VT, however, this is the down and dirty way that I remember it. The ONLY way you can DIAGNOSE VT is to look on the 12 lead at leads 1 and AVF. Since VT indicates extreme right axis deviation, it will show negative deflection in both of the QRSs. If she was stable, I would do a 12 lead if you think you could get away with it. Or do like you did and treat the VT.

Kudos, my friend!