Medical Scenario III

[Sdiver]

Okay gang, get out your calipers .....

Your patient is a 63 yo female, "sick". She looks pale. She responds to verbal stimuli, but does not seem alert or oriented. Her HR is as shown, BP is 86/60. Her friend called 911 because she was acting "confused this morning". The friend tells you she has not been feeling great for a couple of days, but seemed worse today. Other hx is unknown.

What is the rhythm?
What is your treatment?

[Trapper John]

Which lead on the ECG are we looking at?

First, impression is A-fib (absent P wave with irregular HR ~160 bpm). Patient needs a full cardiac workup. Transport to ER with IV NS slow drip (10 gtt/min) just to have a line open. (Bet ya thought I was gonna say Dextran :D). O2 nasal cannula. Transport semi-reclined. Aspirin sublingual wouldn't hurt to prevent clotting and possible occlusive stroke.

[adal]

Agree with Trapper. Be ready if she converts. I've had this convert simply by moving them from bed to gurney. If she has been this way for a few days (greater than 24 hrs) you could be getting ready for PE or stroke.

[Sdiver]

Which lead on the ECG are we looking at?

Lead II

Don't have a 12-lead. Sorry. :(

[Trapper John]

Lead II

Don't have a 12-lead. Sorry. :(

Ok thanks! Sticking with AF.

[PedOncoDoc]

Which lead on the ECG are we looking at?

First, impression is A-fib (absent P wave with irregular HR ~160 bpm). Patient needs a full cardiac workup. Transport to ER with IV NS slow drip (10 gtt/min) just to have a line open. (Bet ya thought I was gonna say Dextran :D). O2 nasal cannula. Transport semi-reclined. Aspirin sublingual wouldn't hurt to prevent clotting and possible occlusive stroke.

I agree with your assessment of the rhythm, but I am worried that she already had a thromboembolic stroke given her altered mental status.

[Trapper John]

I agree with your assessment of the rhythm, but I am worried that she already had a thromboembolic stroke given her altered mental status.

Agree. Probable TIAs. My question for you, Doc, is TPA indicated here?

[Sdiver]

First, impression is A-fib (absent P wave with irregular HR ~160 bpm). Patient needs a full cardiac workup. Transport to ER with IV NS slow drip (10 gtt/min) just to have a line open. (Bet ya thought I was gonna say Dextran :D). O2 nasal cannula. Transport semi-reclined. Aspirin sublingual wouldn't hurt to prevent clotting and possible occlusive stroke.

Just wondering here, you've got your IV set up for TKO but yet she's hypotensive. Would you consider a fluid bolus and if so, how much?

Also, would you consider cardioverting as an option and if so, how? (Adel, this is for you as well. :) )

Oh and BTW .... How much ASA and O2 are you giving? #attentiontodetail ;)

[Sdiver]

I agree with your assessment of the rhythm, but I am worried that she already had a thromboembolic stroke given her altered mental status.

True she may have had a thrombus break loose due to the a-fib, but she's also had poor cardiac output for the past x2 days. This could be the cause of her "confusion and disorientation".

[MR2]

Your patient is a 63 yo female ;)

[Trapper John]

Just wondering here, you've got your IV set up for TKO but yet she's hypotensive. Would you consider a fluid bolus and if so, how much? No, not hypovolemic shock.

Also, would you consider cardioverting as an option and if so, how? (Adel, this is for you as well. :) ) OK that one is outside of my wheelhouse. I'm in learning mode here, so teach me ;)

Oh and BTW .... How much ASA and O2 are you giving? #attentiontodetail ;) 80 mg ASA, 2L/min O2 :p

[PedOncoDoc]

Agree. Probable TIAs. My question for you, Doc, is TPA indicated here?

TIA can only be diagnosed in hindsight - if symptoms last for <24 hours without residual neurologic sequelae. I would consider this an acute thromboembolic stroke until proven otherwise.

If she seemed confused this morning, the stroke could've happened overnight, so it may not be outside of the therapeutic window for TPA. Then again - I coudln't tell you the last time I took care of an acute stroke in an elderly patient with AF, so I'm not sure on SOPs here.

I think a baby aspirin is 81mg (not 80), and (getting on my pediatric high horse here) never give aspirin to a pediatric patient unless advised to do so by a cardiologist.

[Trapper John]

TIA can only be diagnosed in hindsight - if symptoms last for <24 hours without residual neurologic sequelae. I would consider this an acute thromboembolic stroke until proven otherwise.

If she seemed confused this morning, the stroke could've happened overnight, so it may not be outside of the therapeutic window for TPA. Then again - I coudln't tell you the last time I took care of an acute stroke in an elderly patient with AF, so I'm not sure on SOPs here.

I think a baby aspirin is 81mg (not 80), and (getting on my pediatric high horse here) never give aspirin to a pediatric patient unless advised to do so by a cardiologist.

Thanks for the info Doc! Yeah, 81 mg (not 80 mg). Rounding error :p

I have often wondered why the 81 mg aspirin was called "baby aspirin" anyway. I always thought it contra-indicated in children under 2 yo (maybe even 3 yo)?

[PedOncoDoc]

Thanks for the info Doc! Yeah, 81 mg (not 80 mg). Rounding error :p

I have often wondered why the 81 mg aspirin was called "baby aspirin" anyway. I always thought it contra-indicated in children under 2 yo (maybe even 3 yo)?

We worry about Reye syndrome if children receive ASA while having viral illness - so it is not used in children <12 if recovering from varicella or flu-like illness. ASA is only used in children with a clear cardiac indication or an acute thromboembolic stroke. ASA can be used at any age (no absolute age cutoff), but we are very careful about dosing.

Back to the scenario: Looking at current ASA guidelines, I would administer 325mg x1 with plans for a baby ASA daily thereafter.

[adal]

Doc I,
Generally the only rhythm that is irregularly irregular is AF. Even the SVT's are regular for the most part. At least in my train of thought, there would be some sort of pattern to it.

A 12-lead would be nice. ;)

Our protocols for ASA are 324mg PO. 4 x 81mg.

O2 until SPO2 above 92-94%.

[Trapper John]

The R-on-T of the ECG has rattled the cobweb cage of school knowledge, bringing back the image of a paroxysmal SVT. The low BP and lack of alertness are S&S, but usually more abrupt and episodic.

Is it possible for a paroxysmal ventricular tachycardia patient to exhibit these over such a time? :confused:

I'm no cardiologist Doc, but I did sleep at a Holiday Inn Express, and I'm sticking with AF. If memory serves VT ECGs show a fusion of the QRS - T wave complex. Also broadening of the QRS complex. We see a T-wave here (not pretty) but may be a function of the conditions (2 lead ecg) field conditions, patient moving, etc. Also, I think the rhythm in VT is regular and faster. This patients rhythm is irregular. No broadening of the QRS. All things considered and the absent P wave -just MO - this is more consistent with AF than VT.

Final point: IF this were VT the ambulance run would be to pick up a body. ;)

[Trapper John]

Our protocols for ASA are 324mg PO. 4 x 81mg.

O2 until SPO2 above 92-94%.

Thanks, Adal, for the lesson. :lifter

So can you explain the cardioverting to me as well? That's a new one on me.

[Trapper John]

It is like defibrillation, however the monitor times the shock with the rhythm so that it will happen within a specif part of the rhythm. If and that is a big if I remember correctly it happens during the QRS complex to avoid the T wave.

Thanks BrushOkie. BTW, interesting assessment. I learned a few things.

Why do you select D5W in this case instead of NS? From your questions, it looks like your thinking dehydration. Wouldn't D5W exacerbate dehydration?

With your assessment I understand the atropine. Good call IMO. If you are correct.

Doesn't heart block lead to bradycardia? Don't see that here so I am curious. I briefly thought about atropine in this patient, but dismissed it. Thought it too risky. Could you expand on your reasoning a bit? I find this interesting.

[NurseTim]

Cardioversion would be no bueno if she has been in afib for >24 hrs due to possibility of loosening a clot in the right atrial appendage. But she is symptomatic. There is a list of criteria for thrombolytic therapy that I don't recall off the top of my head.

I agree with Trapper John. If possible, TEE just prior to cardioversion to ensure no thrombus in the appendage.

Her ventricular rate is tachy so I don't think I'd give atropine.

[PedOncoDoc]

EKG. 2nd degree heart block Type II. Starts off 4 even then drops to two even? Notice how some of the QRS complexes are even but there are intervals where a QRS is dropped. This is headed to a 3rd degree heart block .

I disagree with your assessment - the p-waves are not well visualized and with 2nd degree heart block you have progressive lengthening of the PR interval and finally drop a beat - this doesn't fit that pattern.

Given that this has likely been going on for >24 hours I agree with deferring cardioversion for now.

[Trapper John]

BO- This is getting interesting. I still say AF. The key for me is the irregular HR. VT is regular. Also, age and patient history and presenting symptoms.

Why lidocaine in a patient that is already hypotensive? Aren't you risking BP crash?

(I just have a bias against drugs in cardiac cases unless we are in a primary care facility and have the drugs and other support apparatus available to correct a mistake. Don't like to do anything that I can't also correct if wrong)

Epi & dopamine seem very risky in this patient too. Are you looking for BP elevation. I am concerned about emboli in the brain. Wouldn't Epi or dopamine exacerbate this problem? IMO these are too risky unless you are thinking renal failure? Don't think we are there yet. But maybe I'm just being too conservative.

Really interesting case.

[NurseTim]

The QRS complexes SVT, so 6mg adenosine. And warm up the Lucas device.
For the hypotension, I'd order a 500 cc NS.

Edited for wrong initial dose.

[Sdiver]

Great discussion so far guys. That's the "beauty" of ECG strips, everyone sees a little something different.

The only one that EVERYONE can agree on just by glancing at it is, Asystole. :D

Trap: sorry I didn't get back to you sooner, but as has been answered, Cardioversion is like defibrillation but at a lower setting, usually at 100 joules. You can also cardiovert using chemicals, (adenosine, adenocard, ect.). It's actually pretty wild when the Pt. is still awake and talking and you tell them you're going to have to shock them. My old medic partner had to do that once, with a Pt. in SVT (rate 230) and after attempting a vagal maneuver and x3 rounds of adenosine, the only thing left was to hook him and press the flashing light.

Answers to Brush's questions are in BOLD ....


A few questions.
How confused ie spontaneous eye open? Babbling or speaking but confused? She answers questions appropriately, but her speech is very sluggish.
Is she Short of breath? No
Lung Sounds? Clear and equal bi-lat
Depandant Edema? Non noted
What is her neuro like ie weakness on one side or pupils uneven? Equal grip strength, although weak in squeezing, but no obvious defects noted. Pupils: PERRL at 4mm
Can you find her meds around the house? She keeps saying they're "over there. Neither you or her friend can find them.
What is her capillary refill? Slightly sluggish
Does she appear dehydrated ie tenting of skin? No


Here's a refresher on counting rates using the "boxes".
If you can, find a QRS, where the R wave lands on one of the darker lines. Then count to the right, the darker lines, or .2 seconds apart. (Small box ='s 0.04 seconds. 5 small boxes x 0.04 sec = 0.2 seconds) 5 large boxes = 1 second.)
With the R wave on a dark line, count the dark lines till it comes up to another R wave, counting 300, 150, 100, 75, 60, 50, 43, 37.
But remember, the pattern needs to be regular.

Looking at the strip posted above, if you look at the 9th complex from the left, it falls on a dark line. Use the formula above (and below) to get your rate.

[Trapper John]

BO- You don't scare me, you have only pointed out why cardiac cases scare me. Give me a straight up trauma case any day. :D

When I went back to school and was studying pharmacology and we got to the heart, well right then and there I decided that there was no way in hell I was going to be a cardiologist! You guys in the civilian first responder world see a lot of these cases I am sure. It is a very fine line you walk and that is really, really tough especially in the field. A tip of the ol' beret to each of you. ;)

SDiver- This one has given me some homework to do. Learned a few things and will learn more. Thanks for this post. :lifter

I'm sticking with my initial Dx and Rx plan with the correction of the ASA (324 mg sublingual - thanks to Adal). Not sure if cardioverting is indicated here, but as I said I need to do some homework on that one.

[Trapper John]

SDiver- Are you going to post the answer to this one? Will there be prizes like the last time? I'm willing to give BrushOkie the nipple ring I got from the last one.

BO - It'll look good on ya and the chicks think it's hot! :D

[MR2]

BO - It'll look good on ya and the chicks think it's hot! :D

There you go, bringing up ole snaggletooth again.

[Trapper John]

There you go, bringing up ole snaggletooth again.

Can't get her off your mind, huh? What's been seen can't be unseen.:D

[longrange1947]

K OD? :munchin :D

[Sdiver]

SDiver- Are you going to post the answer to this one? Will there be prizes like the last time? I'm willing to give BrushOkie the nipple ring I got from the last one.

It's funny you should mention this Trap. It's still being discussed over on my other board. Some of the replies have been, shall we say .... interesting. Some of the strip interpretations have ranged from A-flutter, to SVT, but the majority of them are saying A-fib c RVR. (Sorry Brush, you're the only one reading a 2nd degree block.)

But yes, as I said above, the majority of the interpretations are A-fib c RVR.
Treatment would be,O2 4L, IV NS, fluid bolus 250cc to get B/P up (and that might bring back rate to sinus), if not look at cardioversion.

I'll let ya know what's determined once it's posted.

K OD? :munchin

Oh look, a late entry. :p

SooooOOOOOoooooo Hyperkalemia. Part of the "H's and T's" protocol .....
http://www.rcpals.com/downloads/oct42006/HowtousetheHsandTsinACLSandPALS.htm

..... anyone else seeing peaked T's ????

and go .......

[longrange1947]

Hey, old SF medic, usually stay out of these, my memory is not that good anymore. :D

[Sdiver]

Hey, old SF medic, usually stay out of these, my memory is not that god anymore. :D

A little Freudian slip there LR ??? ;) :p

[Trapper John]

The T-waves in this patient are highly irregular. May be fused P waves or U waves or both. Definitely not hyperkalemia. May be hypokalemia. Has the patient been having diarrhea? On diuretics?

May also be fused P wave and now were back to BrushOkie's heart block (probably Stage 1).

What are the chances of both hypokalemic and stage 1 heart block?

Will IV KCL (bolus, 1100 mg) be differentiating? If so I would monitor the T waves to see if a normal T wave appears. If not then we may be dealing with heart block and IV lidocaine (50 mg IV bolus) would be indicated.

I am still leaning more towards AF with hypokalemia.

[Trapper John]

How about a digitalis OD

Did you see Foxglove in her garden? :D

[Sdiver]

SDiver- Are you going to post the answer to this one? Will there be prizes like the last time?

It's funny you should mention this Trap. It's still being discussed over on my other board. .....

I'll let ya know what's determined once it's posted.

Well, they posted a Dx today .....

Revisiting this strip from last week... The majority of responses called for either cardioversion or rate control for our sick patient... However, she was in septic shock, and needed several liters of fluid before the rate returned to a normal range. Determining treatment for patients in AFib w/RVR is not easy!

She must've had an underlying condition of HTN, because her MAP (Mean Arterial Pressure) wasn't below 65 .... (although, <65 is what we use to call a Sepsis alert.) .... so her lactate must have been out of wack.

MAP formula ..... Systolic X's 2 plus diastolic divided by 3

86(2) + 60 / 3 .... 172+60 / 3 = 77.3 MAP

Trap .... Your prize, along with everyone else's is ...... Greater Knowledge and Understanding. (looks like you're stuck with that nipple ring) :D

[Trapper John]

Thanks for this one. Very interesting. And, yes I did learn a few things on this one too.

One question: If she was in septic shock wouldn't she have presented with fever?

Brush Okie, I know you really wanted my nipple ring. Maybe next go around? :D

[MR2]

I do believe it was the nipple ring that caused the underlying sepsis.

Doom on you whosoever reuses a nipple ring.

[Trapper John]

I do believe it was the nipple ring that caused the underlying sepsis.

Doom on you whosoever reuses a nipple ring.

Ooops :eek:

[Patriot007]

Systemic Inflammatory Response Syndrome or SIRS is a syndrome characterized by at least 2 out of 4 criteria.

1. Temperature- greater than 38 (100.4 F )or less than 36 (96.8 F)
2. Heart Rate- greater than 90
3. Respirations- greater than 20
4. White Blood cell count- less than 40000 or greater than 12,000

SEPSIS- is SIRS criteria (atleast 2 of 4) plus a presumed source of infection.

Therefore- A septic patient can be hypothermic, normothermic, or hyperthermic.

Blood pressure is not a criteria to define sepsis. In fact, early in sepsis in healthy individuals blood pressure is usually normal. They are still compensating well enough to maintain a normal BP. Also you can have elevated lactate ( an indication of inadequate tissue perfusion or SHOCK) with a normal blood pressure.


When you have sepsis plus low blood pressure that is not responsive to fluid boluses alone you have SEPTIC SHOCK.

[Trapper John]

Systemic Inflammatory Response Syndrome or SIRS is a syndrome characterized by at least 2 out of 4 criteria.

1. Temperature- greater than 38 (100.4 F )or less than 36 (96.8 F)
2. Heart Rate- greater than 90
3. Respirations- greater than 20
4. White Blood cell count- less than 40000 or greater than 12,000

SEPSIS- is SIRS criteria (atleast 2 of 4) plus a presumed source of infection.

Therefore- A septic patient can be hypothermic, normothermic, or hyperthermic.

Blood pressure is not a criteria to define sepsis. In fact, early in sepsis in healthy individuals blood pressure is usually normal. They are still compensating well enough to maintain a normal BP. Also you can have elevated lactate ( an indication of inadequate tissue perfusion or SHOCK) with a normal blood pressure.


When you have sepsis plus low blood pressure that is not responsive to fluid boluses alone you have SEPTIC SHOCK.

If Sepsis is at least 2 of the 4 criteria listed above, one of which is unavailable to a first responder, then from an EMTs POV its at least 2 of the three (WBCs not available) So, what conditions that an EMT responds to do not meet conditions 2&3 above? (Other than dead ones and opiod alcohol poisoning. :D) Should these be Dx as Sepsis? As a DDx tool for first responders - I think this is of very limited value.

Just my $0.02 worth.

[PedOncoDoc]

If Sepsis is at least 2 of the 4 criteria listed above, one of which is unavailable to a first responder, then from an EMTs POV its at least 2 of the three (WBCs not available) So, what conditions that an EMT responds to do not meet conditions 2&3 above? (Other than dead ones and opiod alcohol poisoning. :D) Should these be Dx as Sepsis? As a DDx tool for first responders - I think this is of very limited value.

Just my $0.02 worth.

Agreed - a physiologic pain response will get you a heart rate >90 and repiratory rate >20. That does not equate with SIRS.

Hell - running 5 miles will give you SIRS by those criteria. :munchin

[Patriot007]

If Sepsis is at least 2 of the 4 criteria listed above, one of which is unavailable to a first responder, then from an EMTs POV its at least 2 of the three (WBCs not available) So, what conditions that an EMT responds to do not meet conditions 2&3 above? (Other than dead ones and opiod alcohol poisoning. :D) Should these be Dx as Sepsis? As a DDx tool for first responders - I think this is of very limited value.

Just my $0.02 worth.

Agreed. Often times in medicine definitions arise from the need for standardizing conditions for the purpose of research and are not that helpful to the ones who first reach patients at Death's door and do initial stabilization. This is one of the challenges of field and emergency medicine as when the dust settles there will always be someone standing there in a controlled environment with more stable vitals, a full set of labs, and a CT result with a diagnosis saying "duh stupid!".

Remember, rapid afib for some patients is their sinus tachycardia. If you are sick or stressed and have afib, your afib just beats faster, just like your heart does. There are times when this will get the patient in trouble but often times rate control is contraindicated if you are blunting the patient's normal physiologic response E.G. sepsis, dehydration, hemorrhagic shock.

I've seen and given rate control in several instances where it was hard to pick up on an underlying cause. It happens. It is one of the perils of treating an undifferentiated patient without the luxury of time. It is our job to try to minimize this risk by doing the best quick review of systems that we can (including bystanders) AND realizing when an intervention is not needed just as much when it is needed.

[Trapper John]

Agreed. Often times in medicine definitions arise from the need for standardizing conditions for the purpose of research and are not that helpful to the ones who first reach patients at Death's door and do initial stabilization. This is one of the challenges of field and emergency medicine as when the dust settles there will always be someone standing there in a controlled environment with more stable vitals, a full set of labs, and a CT result with a diagnosis saying "duh stupid!".

Remember, rapid afib for some patients is their sinus tachycardia. If you are sick or stressed and have afib, your afib just beats faster, just like your heart does. There are times when this will get the patient in trouble but often times rate control is contraindicated if you are blunting the patient's normal physiologic response E.G. sepsis, dehydration, hemorrhagic shock.

I've seen and given rate control in several instances where it was hard to pick up on an underlying cause. It happens. It is one of the perils of treating an undifferentiated patient without the luxury of time. It is our job to try to minimize this risk by doing the best quick review of systems that we can (including bystanders) AND realizing when an intervention is not needed just as much when it is needed.

Agree 100%. A good case for "less is sometimes more". As I said earlier, this is particularly true for cardiac cases IMO. Pharmacological intervention in these cases scare the crap out of me. No margin of error and when it goes badly it really goes badly very fast. Very unforgiving of error.

Thanks for the post. Learning here. :lifter