Medical Scenario III

[Trapper John]

Originally Posted by DocIllinois

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?

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]

Originally Posted by adal

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

O2 until SPO2 above 92-94%.

Thanks, Adal, for the lesson.

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

[Trapper John]

Originally Posted by Brush Okie

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]

Originally Posted by Brush Okie

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.

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 ....

Originally Posted by Brush Okie

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.

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.

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!

[MR2]

Originally Posted by Trapper John

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

There you go, bringing up ole snaggletooth again.

[Trapper John]

Originally Posted by MR2

There you go, bringing up ole snaggletooth again.

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

[longrange1947]

K OD?

[Sdiver]

Originally Posted by 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.

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.

Originally Posted by longrange1947

K OD?

Oh look, a late entry.

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 .......

[longrange1947]

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