V-Tach or Not?

[medic001918]

Stupid question, but are there P waves? it kind of looks like there are but it's hard to tell. Also if it is, could it possibly be 2:1 AFib with an aberrancy?

You mean an a-flutter with 2:1 conduction? Not trying to split hairs, but the "fib" in a-fib is not a distinguishable p-wave to count as a conduction, whereas a-flutter has the distinct flutter wave that can be counted. Without having the strip physically in front of me, it looks like it's fairly regular to me, which would decrease my suspicion of a-fib (but not a-flutter since a-flutters with consistent conduction such as a 2:1 or 3:1 may retain regularity).

It's hard to tell from the poor image, but it looks like it could be an SVT with a bundle branch block? You said you didn't get the chance to do a 12-lead because this took you by surprise, but I'd like to see what the strip looks like from before the tachycardia set it. Does it look to be a narrow or wide QRS when the rate is controlled? If it's wide, then there is a strong possibility of a bundle branch block and I'd lean more towards the SVT. If it's narrow and then developed a wide complex tach, I'd go more with V-Tach. It's difficult to tell without seeing a 12-lead on this patient.

One thing I'm curious about, how much distress was the patient in while you were treating for pulmonary edema? I know it's in our protocols (and generally good practice) to obtain a 12-lead on patients complaing of shortness of breath. If the patient was in severe distress, it changes the priorities a little. But if this was a patient in mild/moderate distress, a 12-lead would be expcted of us.

So how did you treat this patient and why? I'm thinking there's a medication that is carried by many services that works on atrial and ventricular rythems...Amiodarone wouldn't be a bad choice for this patient depending on the rest of the story. It's hard (if not close to impossible) to base a treatment off of an EKG alone.

Shane

NREMT-P

[chbare]

I would still like to know this patient's medication and medical history. From the strips, it looks like I is upright. If you do an axis assessment based on leads I,II,III, you can tell that this is not right shoulder deviation. This leads me to suspect something other than ventricular tachycardia. A 12 lead would be quite helpful. Did the receiving facility do a 12 lead? Are you able to get any follow up?

Take care,

chbare.

[AZCEP]

I'd agree with you chbare. The quick axis determination from these leads would point to something other than VT, but we can't really rule it out with this strip.

Shane made a number of good points in his post also. Seeing this rhythm at a slower rate would be very beneficial. A-fib, a-flutter, MAT, rate related BBB are all possibilities. We just can't know for sure from this strip.

Amiodarone, Procainamide, maybe even a beta blocker would be useful to control the rate. Treating the shortness of breath angle might cause more problems though.

[Medic26]

The patient presented SOB increasing over last several hours "with a vengance" according to the patient. He was anxious and rammy with expiratory wheezes in the apex's with crackles in the bases bilaterally, rate was 28, initial B/P was 120's over 90's with no relief from his nebulizer's. The patient was vague and basically could not provide a very good history. He did complain of diaphoresis, dizziness and nausea on and off over last few hours. This patient has COPD and CHF history, also was told that he is in need of a heart transplant but is not a candidate due to other existing medical conditions. I was not able to get any follow up on this patient nor do I know what the hospital's 12-lead was after we got there, we had another call waiting and didn't make it back that night.

Please explain your interpretation of this strip.

[medic001918]

Please explain your interpretation of this strip.

What else are you looking for? A number of experienced posters have commented on the strip and how those answers were arrived at, and more importantly why the answers aren't definitive. Let us know what you're looking for, and we'll try to help. It seems as though quite a few people have offered an interpretation of thise EKG and explained what they've seen (with axis deviation, etc).

AZCEP, I was going to mention procainimide but I know it's been recently removed from the ACLS guidelines and effective July 1,2007 they're taking it out of our protocol entirely. But if you have it, it's certainly a viable choice along with the beta blockers.

Was the patient tachycardic like this upon your arrival? Or did it set in after you got there? If the patient had that kind of a rate when you showed up, a 12-lead should have taken precedence over other intervention to ensure that the shortness of breath isn't due to a cardiac problem. The shortness of breath of a cardiac problem needs distinctly different treatment than someone with that of a respiratory etiology as I'm sure we can all agree on.

Shane

NREMT-P

[kkidfall]

Medic:

Yes I did mean A-Flutter, haha thanks. I worked all night and was sitting in bed half awake looking at it.

[Just Plain Ruff]

I'm confused, I'd have done a 12 lead on this patient. this should have had a 12 lead done but............... that being said, i was not there but my medical director would have taken one look at this call and report I wrote and I'd be in their office explaining why a 12 lead was not done.

this rhythm actually demanded a 12 lead since you were admit you were unable to interpret it in the field. Now that's not a completely bad thing, this rhythm as pointed out by our esteemed colleagues here is a difficult one to interpret. Without the 12 lead we are shooting in the dark.

The 12 lead would have given many additional clues to interpretation not excluding that nice little interpretation written out in black letters on the printout. (don't rely on it fully or exclusively though).

Treatment would be dependent on what the interpretation of the 12 lead shows.

I'm not trying to critique your handling of this patient (well actually I am playing armchair quarterback) but I think 12 lead would be in my top 3-4 items that I'd have wanted to get done before dropping this patient off in the ER.

One other thing, Say I'm your medical director and I reviewed this run. I notice no 12 lead. I call you in the office and ask you one question. "What is your justification of not getting a 12 lead on this patient?" What is your response? If you wish you can reply back to me in a pm. I've been down this road and this question before so I'm speaking from experience.

That's my 2 cents, take it as it is given or give me my change.

take care. This is one of those cases that the patient turned out ok on but it could have been worse, look at it as a learning experience.

[AZCEP]

Shane, You are right in Procainamide being de-emphasized, but it still appears for wide complex tachycardias. Just waaayyy down the list.

With the new information, I'd suggest that this patient has overused their MDI and is suffering the consequences. Assuming it was albuterol, I'd suggest using some magnesium as your anti-dysrhythmic of choice. The electrolyte situation is probably contributing and it may work a bit better than a blocking agent.

That aside, see if you can get the patient to perform an effective Valsalva or consider some Adenocard. With the rate where it is, I'm betting this is A Fib/flutter. I wasn't there, so I can't say for sure, but was the rate changing frequently? The strip seems to have some irregularity in it, but the rate causes the R-R interval to look constant.

If you don't have 12 lead ECG's available to you, which many LP12 users don't, this single patient could be your impetus to get them. If you do have them, and had a short ETA, not doing one is reasonable. Your ETA would have to be less than 2 minutes, but that is a possibility.

Don't feel that we are trying to bash your management. As Ruff stated, I too have been down this discussion route with medical control several times. Your ACLS guidelines will help to support your decision to achieve "expert consultation", but you didn't quite get all the information that you could have.

[scottymedic]

AZCEP if you look at the strip, its actually from a Zoll monitor. I am not familiar with Zolls myself as we are all Lifepak here, but do they do the 12 lead option prehospitally?

I'm gonna be a goober (hey i do it ooh so well ) and I would have thought that it is vt. Wide bizzare QRS complex, rate is a little slow, but it is over 100. Good oxygen sats, seems your treatments brought his sats up nicely

Scotty

[Medic26]

The reason I asked is this cardiologist took one look at the patient and a 2 second glance at the monitor strip and said "your wrong" and walked out of the room. He didn't have any patient history, vitals or nothing else but he was able to make the determination. I posted this strip to see if I had missed something, wide complex, bizaar, unifocal tachycardia.......yeah maybe I should have done a 12-lead but I didn't have time. I suppose that some of you are perfect but me.....I make mistakes and have oversights on occasion.