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%.

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. ;)

Thanks, Adal, for the lesson. :lifter

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

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.

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.

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.

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.

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.

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 ....

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.

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.