44 year old male CC: Palpitations

Here is an absolutely fascinating case submitted by G.W. Lyster (who credits the case to J.C. Neetz).

It's a patient who presented with a wide complex tachycardia who ended up receiving the kitchen sink!

Here are the basics.

44 YOM C/O "palpitations". Denies CP, SOB, N/V, dizziness, weakness. Pt in NAD.

Meds include Coreg, et al. (poor historian on meds) No allergies. Hx MI 8 days ago with stent, MI 5 years ago with "rapid heart rate".

P228, R20, SaO2 98, BP 160/102, BS 116, Skin WPD

Here is the initial rhythm:

Here are the 12 lead ECGs:

During the course of treatment, the patient was shocked at 100, 200, 300, and 360 Joules.

Here's an example:

After the unsuccessful shocks, the patient received lidocaine, adenosine, and procainamide! This particular service does not carry amiodarone.

Here is the code summary.

At the emergency department, the patient converted post-amiodarone.

Here is the patient's disposition:

Supervisor was able to obtain the following:

ICU Dx with recurrent arrythmia. No further episodes. They decided he had a non-acute MI (unknown age). He will get a consult to determine if there is a conduction issue (re-entry rythym). The Cardiologist thought he may have a WPW, but he will need the follow up with a specialist in regards to further exploration of the conduction pathways.

31 Comments

  • I just want to say…it's always very impressive to me when medics remember to push the "MARK EVENT" button, even in the heat of the moment.

  • Tom B says:

    MIFL – Agreed! I was impressed that this feature was utilized to great effect on this call. I'm going to have to give that a second look.Tom

  • akroeze says:

    I'm going to go out on a limb and risk proving myself a fool but to me it looks like it isn't syncing on the right spot.

  • medic1488 says:

    I would have to agree with akroeze; its looks like the QRS has a small rR' pattern and the sync is hitting the first r. Also after the area of shock it seems as though that the rhythm picks up where it would have been in the cycle had no energy been delivered. This would probably indicate the cardioversion was ineffective because your not getting the mass depolarization you need. Just my thoughts, giving an answer a try before Tom educates me 🙂

  • Anonymous says:

    Hey Tom. I just found your blogg and i must say im impressed by your skills in the art of EKG interpretation. =)I will definitely follow the blogg in the future. Best regards from Sweden. /Ambulance-Anesthesia nurse.

  • SoCal Medic says:

    I agree with MIFL, the ability to use the event markers was very impressive. I am having a hard enough time trying to get those I work with just to hit print a few times during the course of a call to document the cardiac rhythm. Props should also be given for obtaining the two 12-Leads prior to treating the patient. I do think it is amusing that the computer calls it a wide complex tachycardia in one, and atrial flutter in the other (but with a wider qts duration).

  • akroeze says:

    I agree with SoCal. Once again we see a demonstration of why it is so dangerous to just look at the itnerpretation at the top by the machine and no further. Yet so many do it!

  • SoCal Medic says:

    Reviewing this this morning, I want to ask this question. It appears that the LifePak was not finding the proper point for the cardio version. On it's printout, it marks those points (of course that comes after the shock is delivered), so I pose this, can you print a strip with the sync button on to ensure it is marking the proper point prior to delivering the energy? I am away from my office at work and dont have a generator to test that theory.

  • Tom B says:

    akroeze – I had the same perception! I can't help but wonder if this is (one of) the reasons you don't synchronize the shock for pulseless VT.Perhaps pulseless VT is more likely to be so-called "ventricular flutter" where the computer has a difficult time differentiating between R waves and T waves.Tom

  • Tom B says:

    medic1488 – I'm not sure I'd call this an rR' QRS complex (which would imply an upright QRS).If you look at the 12 lead ECG, it's clear that the QRS complex is negative in lead II, making this a QS complex.Now, it's hard to say exactly where the QRS leaves off and the ST/T complex begins with a heart rate this fast.I'm also not sure why it matters, except that a shock in the "vulnerable" part of the cardiac cycle might precipitate VF.On the other hand, none of the shocks were effective, so I'm just looking for possible explanations.Tom

  • Tom B says:

    Christopher (SoCal Medic) -I'm not sure if you can print it out while it's marking the QRS or not.However, if you check lead II in the 12 lead ECG prior to cardioversion, you should have some idea of where the QRS complex is and where the T wave is.In this case, it appears that the "points" of the QRS complex point down (which tells me the T wave points up).If you look at this you can see an example of the computer having difficulty marking the QRS complex in the right spot.Tom

  • Tom B says:

    I almost forgot! To the Ambulance-Anesthesia nurse from Sweden…Thank you for your kind words! :)Tom

  • medic1488 says:

    Just wondering if the spot it marks the wave at would have effect on shock success. From a treatment standpoint, I might be trying a new set of pads, making sure they have good aherence, and possibly trying anterior/posterior in hopes of delivering a stronger current to succesfully cardiovert. Seems odd not to break this with a 360J shock.

  • Tom B says:

    It seems odd, indeed! I can't imagine why, in theory, you couldn't depolarize the remaining myocardium and interrupt the reentrant pathways, even shocking at a less-than-optimal moment in the cardiac cycle.This warrants further study! Tom

  • Tom B says:

    Here's an update you might find interesting.I checked with a well known electrophysiologist and he told me the computer synched just fine.He stated that the shock perterbed the VT but did not stop it, probably due to the high catecholemine state of the patient.He states that often these kinds of VTs just immediate reinitiate, even if you stop them, for this reason.Beta blockers, procainamide, and amiodarone are his favorite drugs in this situation, and he feels that "some people did a fine job in a scary situation." I would agree.Tom

  • Yes, I got this one before reading the comments. So this would be due to absolute refractory period?

  • Tom B says:

    Adam – It seems to me that synchronized cardioversion anywhere in the absolute refractory period should increase the odds of successful cardioversion, but I'm researching the topic.The danger, it seems to me, would be shocking the relative refractory period, and in fact that's how they induce VF in the lab (with low energy shocks in the vulnerable phase of the cardiac cycle).It just seemed strange to me that the computer wasn't tracking a point on or near the nadir of the QS complex. With a rate that fast, I'd try to stay away from the T wave.But, I have it on good authority that the tracking was appropriate. So, I'm doing some reading.Tom

  • Royce says:

    Maybe I am too conservative, but I would not have used electricity on this patient (initially)…he is not “symptomatic enough”. Meds…sure…and if they did not work AND the patient became symptomatic…yes on electricity. This patient seems much too stable to be this aggressive. Please educate me on why you believe going to electricity first on this patient was warranted…THANKS!!

  • Bill Miller says:

    Like Royce, I think I would have held off of the electricity. It looks drastic but pt is not in distress. Our service does not carry amiodarone; I think I would have called Med Control about Lidocaine… Also, I was taught to only give one anti-arrthythmic — here we’re seeing Procainamide, Lidocaine, and then Amiodarone given. What’s this about?

    Thanks for this service!

  • nopatientcontact says:

    just a random fact: in my system, this patient doesn’t meet criteria for a 12 lead. in fact, it was go to county EMS as an “unusual occurrence.” heres why: “44 YOM C/O “palpitations”. Denies CP, SOB, N/V, dizziness, weakness.”

    per EMS, this doesn’t indicate a STEMI, and the false positives are causing strife between the providers and the cath lab team. ugh.

    • Medic Lane says:

      12 leads are not just for identifying STEMI. How about differentiating V-tac from SVT with aberrancy, or WPW delta wave presence, malignant PVC’s or any other countless markers that are not related to STEMI.

  • MediMike says:

    Agreed with those above, electricity wouldn’t be utilized around here. I can understand a little pucker factor looking at it, but we’d go straight to an amiodarone infusion. Vitals are too stable to just start throwing lightning around for my taste haha

  • CBEMT says:

    Agreed- he's "Stable" in my protocols.  Our sole treatment option for "stable" is Amio drip (after a Mother May-I call to Med Control). 

  • g kliniewski says:

    looks  like  sustained  wide  complex  ,  stable  but  dangerous  , 150  amiodarone  with  flush  followed  by  amio   drip  , if unsuccessfull  and  pt  becomes  sympto then  cardiovert  then  electro  phys, studies 
     

  • Dr.Hillis says:

    I do agree  with Royce and beyond regading the treatment  given in this case and don't understand what was the indication of electrocardioversion in such stable condition !!. Looking forward to hear the answer from Tom . 

  • Woody says:

    @ noptcontact I don't bash people and I don't know what service you work for but it's my opinion anyone with palpatations 8 days out from an MI should have a 12-lead ran. Had a guy in his middle 40's couple months ago just felt sick denied cp was warm dry and c/o pain in left arm pit ran 12-lead dude was having inferior MI went into torsades 1 min after arriving at er. Just saying 12-leads are free with the exception of a piece of paper

  • TJ says:

    To me it’s hard because symptomatic is so subjective. One provider may think palpitations is symptomatic while another may not, based upon experience, education, etc. V-tach is a fatal rhythm and I would have welded him. A couple weeks ago I had a lady in vtach and she converted on her own with an IV stick into a Afib with rvr.

  • Knuckles73 says:

    For me this would not be a cardioversion pt either. Amio push then a drip. Then cardioversion if no change.
    But, this is a 12 lead pt all the way…8 days post MI w/stent, HR of 228, skin WPD…he may be talking, joking or whatever, leading a lot of folks to brush it off, but this guy is critical, at very least emergent. Wait until you’ve had this type of “asymptomatic” and they croak on ya.

  • Kevin says:

    Why on earth would you risk VF, by giving Adenosine to rule out rhythms.. This is dangerous, and foolish. There might be a slight chance that this is WPW.. You might as well just give him Cardizem, they are both AV nodal blockers… I don’t know why the AHA even added this stupid idea..

    • Medic50 says:

      Why is it so dangerous? I’m curious here. If you can back it with studies and facts I’m more than willing to listen here. It’s part of our rule-out causation built into our protocols. I’ve seen adenosine work on SVT, and seen it do nothing on non-SVT… (Incl Afib with 1:1RVR rates >220bpm). Just curious, not trying to start a fight.

  • Medic50 says:

    In my jurisdiction and my opinion:
    12 lead would be a must on this patient, anyone complaining of palpitations, regardless of history, would prompt me to run at minimum, a 3 lead, and that 3 lead would prompt a 12 lead. Unless its an obvious isolated trauma issue (i.e. sprained ankle) I try to 3 lead everyone. Sure it may be “extra work” and “looking for things you don’t want to find” but it’s in the end better for the patient, that and if I have it, why shouldn’t I use it? It’s non-invasive and can help with reducing differential diagnoses.

    That being said:
    General Patient Care (too long to explain out here)
    Unstable with serious s/s and HR > 150bpm (Serious s/s defined as: CP, SOB, Dec LOC, hypotension, hypoperfusion, pulmonary congestion, CHF and/or AMI) -> Immediate CV
    Under wide complex (unknown type), “stable”
    Lido 1-1.5mg/kg IVP
    Lido 0.5-0.75mg/kg IVP
    Consult for CRT/EMT-I, No Consult for NRP/EMT-P
    Adenosine 6mg IVP
    Adenosine 12mg IVP (repeated after 2 minutes)
    Electricity. (Consider sedation with Versed)

    My jurisdiction carriers Adenosine, Lidocaine and Dilitiazem for tachydysrhytmias

    I’m with several others, I would’ve probably held off the electricity from the get go and tried pharmacological route first, and go to electrical therapy if either he decompensated or my drugs didn’t work.

    Either way, good job on the medics with the markers, I’m still working on using the specific markers on my own LP15, but I do try to at least double tap the event button to create a ‘generic’ event that I can handwrite my interventions at that time. It’s also helpful if you have an extra set of hands that can hit it for you.

    Very interesting case study, and If it’s ok with Tom I want to fwd this out to members of both my career and volunteer departments for their thoughts.

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