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 ). 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]

Originally Posted by Trapper John

Which lead on the ECG are we looking at?

Lead II

Don't have a 12-lead. Sorry.

[Trapper John]

Originally Posted by Sdiver

Lead II

Don't have a 12-lead. Sorry.

Ok thanks! Sticking with AF.

[PedOncoDoc]

Originally Posted by 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 ). 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]

Originally Posted by PedOncoDoc

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?

[PedOncoDoc]

Originally Posted by Trapper John

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]

Originally Posted by PedOncoDoc

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

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)?

[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]

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.

[longrange1947]

K OD?

[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.

[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.

[Sdiver]

Originally Posted by PedOncoDoc

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".