Tachycardia: Another EKG Case

[fiznat]

We were dispached to a SNF for an older male at a nursing home who's AICD has been discharging every few minutes. On arrival we find our patient jumping in his bed about once a minute as the AICD shocks. He says this has been happening all day- he is a DNR/DNI/Do Not Hospitalize, but he would like us to treat him today because "I just cant stand this damn thing shocking me." The man is without complaint except for the constant shocking. In between and right before shocks he denies pain, SOB, weak, dizzy, n/v, palpitations, and anything else I could think of.

82 y/o Male in apparant discomfort only during shocks

Hx: s/p CABG x 4, CAD, AICD (duh), CHF, Hypocalcemia

Rx: Lasix, Percoset, Klonopin, Wellbutrin, Risperdol, Ambien

NKDA

I wont list my whole assessment here but he was largely unremarkable. Lung sounds clear, no JVD, no distal edema, PEARRL, skin warm/pink/diaphoretic, no complaints, etc etc.

Vital Signs:

BP- 132/111

HR- varies

RR- 22

SPO2- 99% on RA

GCS- 15

On the monitor we see a lot of this:

In between AICD shocks, the rhythm would alternate quite a bit.

This strip is pretty tachy still, but he did slow down to about 140 or so in between AICD discharges.

I called the underlying rhythm a-fib with various, multifocal ectopy (the ectopy is more apparant in other strips). I simply called the faster rhythm a "wide complex tachycardia of unknown origin."

About once a minute the rhythm would widen and speed up to about 180-190, and the AICD would shock.

I gave the pt 4lpm O2 via n/c, started a line of NS @KVO. I then administered 150mg Amiodorone, mixed in 100cc NS and dripped over 10 minutes. Transport priority 1 to the ED.

Enroute I get a 12 lead. This is about 5-6 minutes into drug administration.

link to a bigger version: http://i62.photobucket.com/albums/h99/fizn...CT12leadbig.jpg

(might need to copy/paste that to avoid frames)

The last AICD shock was observed about 2 minutes into drug administration, and we never saw another - even after writing paperwork in the ED. The rate remained tachy, but not AS tachy I suppose. This 12 lead was at about as fast as it ever got. The complexes also seemed to narrow quite a bit. The patient said he felt the same but was greatful the AICD had stopped shocking.

In the ED the patient was given Lopressor for rate control, which in about 30-40 mins brought the rate down to about 100. The patient remained without complaint.

I wanted to discuss this call a little bit with you guys, especially my choice to administer Amiodorone when clearly I could have gone with a calcium channel blocker for the a-fib. I chose Amio because the rhythm appeared wide to me, and while I admit I probably should have done the 12 lead first, I knew that this drug is indicated for both atrial and ventricular rhythms so I beleived I had my bases covered. Rookie mistake not getting the 12 lead done first, I know. I understand that abbarancy on the a-fib could have explained the width, but that wouldnt quite explain how the width appeared to increase along with the rate, right before the AICD would discharge.

As usual, things seem much clearer after the fact. Looking at everything again the rhythm doesnt seem nearly as wide as it did on the call, although there is still some there. Id like to hear what you guys have to say.

[Roostmonkey]

We don't administer Amioderone as a drip here (yet), but I would have done the same thing if I saw that strip.

[ERDoc]

I will start by saying that I am using one of the computers at work, so clarity is not the best. Are you sure that is a wide complex? It almost looks like a narrow complex with ST elevations. Looking at the 12 lead, it looks like ST elevations in the inferior leads, with depressions in the lateral leads.

[OVeractiveBrain]

Im going with erdoc on this one. Lead III on the 3 lead looks scary. Compare it to II and aVF and they look narrow to me, with some tracings BETWEEN the QRS complexes, not within them. Lead III jumped out at me, and at first i assumed worst-case and went with wide-complex tach as well, though the irregularity as well makes me hesitate. With close inspection and a twelve lead (always get a twelve lead, especially in a stable patient, SHAME ON YOU!) I would have gone rapid afib and given 10mg of cardizem (our protocol) since he isnt already on a beta blocker (which is suprising). If he were, its 5mg of Lopressor q 5 min max 15mg for rate control.

Of course the amio wasnt a bad decision in this case. You werent trying to treat an arrythmia for necessity of perfusion, you were treating him for his pain. He wasnt symptomatic nor had any complaints (except that he was being shocked). The perfusion and half life of amio I guess couldnt hurt - youre slowing the rhythm so he doesnt get shocked anymore, and it will last. Amio is the wonder drug for rapid arrythmias, so its not a bad catchall, especially if you have even an inkling of wide-tach. I still would have gone with rapid afib, taken it on a two, and given him some cardizem/diltiazem.

I dont know if those are actually ST segment elevations. V1-v3 i think youre talking about, Doc. There arent any reciprocal changes that I can see, and life pack 12s (especailly in a moving ambulance) are notoriously unreliable for subtle changes (especially with the tracing bounching around so much). While it may be, I wouldnt go cardioverting or activating the cath lab.

Amio is given over 10 minutes. You can stand there and push it, or you can buratrol or smalll bag it and just let it drip in. One frees you to do other things, one is a bit more engaging. We unfortunately have only 250 cc bags as our smallest, and no buretrols to speak of, so were SOL for convenient drips as well (the 250 is bad, i know).

Overactive

[fiznat]

Yeah doc, thanks for the benefit of the doubt, but it isnt your computer screen. The more I look at it, the less wide it seems to me-- the rhythm did change quite a bit, but to be perfectly - painfully - honest here I think i got a bit carried away thinking this was wide complex after seeing a few runs that appeared wide either because of apparant ST elevations (in the 3 lead only), or possibly from some other abbarancy.

There were a lot of runs like this, too:

But even those are probably not truly wide-- it almost looks like there are pacer spikes there though the LP12 didnt pick them up.

I dont know. I was on the fence about it, so I chose a medication that worked to cover both. I should have done a 12 lead first (shame on me), but I was eager to help with this guy's pain and (initally) skipped a necessary step. Especially with a questionable rhythm like this. I didnt get called out in the ED or anything, the doc actually said I did a good job, but on closer inspection I really think I probably could have done better.

Dustyn-- we have buritrols and 250 cc bags, but it so happens that our buritrol was broken on this call. We went to use it and found out the chamber had a crack right down the side of it. Instead, we just took a 250 cc bag and let out all but 100 cc from it, then mixed in that. It doesnt have to be exact, just some NS to dilute the mixture and drip in. She had crap veins and I only got a #22 gauge, but even still we had no problem dripping the mixture in within 10 mins.

[FL_Medic]

I think you did good, it worked didn't it. Amiodorone is second line Tx for stable A-fib with RVR, and first line if they have WPW. It does have that nasty side effect with it's long half life, but in this case it isn't too much of a concern. I would say always do a 12-lead before treating A-Fib with RVR, because you really want to make sure that you don't give Cardizem to someone with WPW. But since you didn't do a 12-lead, Amio was the right choice. This is a good call to learn from, and a really good post.

[FL_Medic]

Yeah doc, thanks for the benefit of the doubt, but it isnt your computer screen. The more I look at it, the less wide it seems to me-- the rhythm did change quite a bit, but to be perfectly - painfully - honest here I think i got a bit carried away thinking this was wide complex after seeing a few runs that appeared wide either because of apparant ST elevations (in the 3 lead only), or possibly from some other abbarancy.

There were a lot of runs like this, too:

But even those are probably not truly wide-- it almost looks like there are pacer spikes there though the LP12 didnt pick them up.

I dont know. I was on the fence about it, so I chose a medication that worked to cover both. I should have done a 12 lead first (shame on me), but I was eager to help with this guy's pain and (initally) skipped a necessary step. Especially with a questionable rhythm like this. I didnt get called out in the ED or anything, the doc actually said I did a good job, but on closer inspection I really think I probably could have done better.

Dustyn-- we have buritrols and 250 cc bags, but it so happens that our buritrol was broken on this call. We went to use it and found out the chamber had a crack right down the side of it. Instead, we just took a 250 cc bag and let out all but 100 cc from it, then mixed in that. It doesnt have to be exact, just some NS to dilute the mixture and drip in. She had crap veins and I only got a #22 gauge, but even still we had no problem dripping the mixture in within 10 mins.

S-T changes can make a QRS look wide at first glance. You need to look at all the leads you have available. In a 12-lead, or even a 3-lead print out the QRS complex in the same realm of time are the same. I know that may sound confusing, so I will try to explain.

lets pretend this is a 3 lead strip

V1 - p QRS T

V2 - p QRS T

V3 - P QRS T

They will be the same duration, even if they appear different. The isoelectric line, and the j point will be lined up with the other complexes in the same verticle line. So the easiest way to tell if it is wide is to look at the other leads and compare your points. Also the 12-lead gives ya the QRS duration, so in the future make sure you do 12-leads and all stable arythmias my man, and you will be practicing good medicine.

[AZCEP]

Rate related BBB's are pretty common in the patient with a significant cardiac history. As the rate speeds up, the bundle branches are less able to tolerate the increasing stimulation, and the QRS's become wider. When the rate slows down the BBB disappears. Pretty cool to watch happen, if you can notice it at the time.

Amiodarone was a reasonable call for this patient. It's not real good at rapid rate control, as the calcium channel blockers are, but it can be effective. It tends to take a long time to take effect, and the patient needs to be able to tolerate the tachycardia while waiting for the drug to work. Amiodarone is a pretty safe choice for tachycardias, but it's not really the best choice for all of them.

For the interpretation, when you have a period that slows down, you can see an irregularity in the R-R intervals. By itself, this should lead you to atrial fib/flutter. As the rate speeds up, and the QRS's widen, they also become more regular. A tachycardia this fast tends to be atrial in origin. When you see a rate of 300+, it almost has to be atrial.

Good call for you to learn on.

[OVeractiveBrain]

You know, it never occured to me that you could let some of the fluid of a 250 cc bag BEFORE adding the medication to concentrate the drug. What a brilliant idea! BRILLIANT (cheers guiness)

Overactive

[als_medic_uk]

Paroxysmal supraventricular tachycardia, [with Atrial flutter; if you check the pulse you will find that it is slower than the ECG reading because not all of the electrical impulses become contractions in the ventricles]. It sounds like atrioventricular nodal reentrant supraventricular tachycardia and that would cause the internal defibrillator to go off, as this tends to stop and start, it is the palpitations that are uncomfortable. You can correct the arrhythmia by using a vagus nerve stimulation maneuver [does'nt always work]. The pharmacon of choice would be adenosine or verapamil. But remember this person is already undergoing cardioversion, not of choice.

Digoxin or propafenone would be amognst many long term antiarrhythmic drug treatments.

Regards.