Case Study with EKG's: Transient Tachycardia

[crazycanuck]

The rate from digoxin toxicity is not necessarily slow though it may be primarily what people see. Dig can make the rate do anything, like magic...bad magic --or good magic depending on how much of it you eat.

From EMedicine reference link http://www.emedicine.com/emerg/topic137.htm

* Cardiovascular findings on physical examination relate to the severity of CHF, dysrhythmias, or hemodynamic instability.

o Digoxin toxicity may cause any dysrhythmia. Classically, dysrhythmias that are associated with increased automaticity and decreased AV conduction occur (ie, paroxysmal atrial tachycardia with 2:1 block, accelerated junctional rhythm, or bidirectional ventricular tachycardia [torsade de pointes]).

o Premature ventricular contractions (PVCs) are the most common dysrhythmia. Bigeminy or trigeminy occurs frequently.

o Sinus bradycardia and other bradyarrhythmias are very common. Slow atrial fibrillation with very little variation in the ventricular rate (regularization of the R-R interval) may occur.

o First- and second-degree AV block, complete AV dissociation, and third-degree heart block are also very common.

o Rapid atrial fibrillation or atrial flutter is rare.

o Ventricular tachycardia is an especially serious finding.

o Cardiac arrest from asystole or ventricular fibrillation is usually fatal.

[fiznat]

V-Tach it is not. Irritable foci for sure. Bundle Branch playing tricks again.

I don't know how you could possibly be so sure about this. Since the 12 lead doesn't capture the rhythm in question, we are really comparing opinions based on a 3 lead view only which, to be honest, really doesn't allow us to make diagnoses with such certainty. It is a regular, wide complex tachycardia of unknown origin.

The bottom line as always, treat the patient, not the rhythm, right?

I agree. I'm not sure I would have done ASA and NTG, but I think we are all in agreement that this patient was more or less stable, and probably didn't require overly aggressive treatment.

The fun of this though is to imagine if the patient were perhaps a *little* less stable and presenting with the same rhythms. Then you would need to make a decision...

[AZCEP]

Management of the stable patient tends to be a bit more complex than the unstable. With stability comes the decision of treating or not, gathering more information or going with what you have.

When the patient turns unstable, the decision becomes much easier.

[goofymedc8]

Fiznat...

Indeed it is fun...especially if you imagine your pucker factor increasing 100-fold if this pt was unstable with a 20-minute drive to the ER! Oh what FUN that would be!

Drag the medic kit out kiddies...It's time to see what we learned...