Medical Scenario III
 

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?

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.

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.

Lead II

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

Ok thanks! Sticking with AF.

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?

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 ;)

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".

;)

80 mg ASA, 2L/min O2 :p

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)?

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.

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.

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

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

K OD? :munchin :D

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.

Oh look, a late entry. :p

SooooOOOOOoooooo Hyperkalemia. Part of the "H's and T's" protocol .....
http://www.rcpals.com/downloads/oct4...CLSandPALS.htm

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

and go .......

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

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

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.

Did you see Foxglove in her garden? :D