EMS is called to the residence of a 77 year old male complaining of palpitations.
Upon arrival, paramedics find the patient lying in bed. He is awake but lethargic. He is oriented to person, place, and time.
The patient’s skin is cool, pale, and diaphoretic.
He admits to chest discomfort and mild shortness of breath. Breath sounds are clear bilaterally.
Past medical history is significant for HTN and CABGx3 (a year and a half ago).
Medications: unavailable
Vital signs are assessed.
RR: 22 and shallow
Pulse: Too rapid to count
BP: 88/68
SpO2: Does not register
The cardiac monitor is attached.
A 12-lead ECG is captured.
What is your assessment of this ECG?
How would you treat this patient?
*** UPDATE ***
The patient was transported to the emergency department where he immediately received synchronized cardioversion.
Here is the post-cardioversion 12-lead ECG.
V-tach w/ RBBB morphology. CABG PMHx, ERAD, and V1 has a monomorphic R makes it more likely V-tach than an SVT. O2, immediate synchronized cardioversion, IV, fluid challenge, post cardioversion 12L. 77yo, so 0.75mg/kg Lidocaine bolus provided we don't have any problems post conversion. Hang a lidocaine drip if time permits, safe and expeditious transport to the hospital.
C. Watford -Sometimes I have difficulty beleiving that you're a first-year paramedic!Outstanding analysis.Tom
Thanks, I had great instructors. Interesting post-cardio 12L. PRi is slightly prolonged. The baseline wanders a bit in the limb leads, but I think it has STE inferiorly. Perhaps an IWMI precipitated the V-tach episode?
I think It's A tach, rate is 300bpm way too fast for vtach. I also see ST depression.Let me know what you think.Thx Tammy
I thought he was having A Tach? Isn't 300 bpm way to fast to be ventricular?Tammy
Tammy – The rate approaches 250, so it's close to the "suspect the possibility of an accessory pathway" range but at 230 we can't discount the obvious "wide and fast" equals VT.Christopher also pointed out some morphological clues that strongly suggest VT (I'm not a big advocate of diagnosing wide complex tachycardias based on morphology but ruling in VT is fine, it's ruling out VT I have a problem with).I use the large block method myself for "fast and dirty" estimates of heart rate, but remember that while 5 small blocks is 300, 6 small blocks is 250! At rates this fast, fractions of small blocks matter, so I'm more inclined to believe the monitor.Also, when I scrutinize the 12-lead ECG the R-R interval appears to be about 6.5 small blocks (1500 / 6.5 = 231).Good thought though! Tom
Tom, In my mind, wide without P Wave is Ventricular until proven otherwise. Based on his skins, blood pressure (unless that is close to his norm), lethargic mentation, he is going to get oxygen by non-rebreather, IV for starters, probably two if time permits, and electrical energy by cardioversion. The Base may order us to hang something. We have in our protocols that we can give MS and Versed prior to the Energy, but that would greatly depend on his pressure and how it relates to his baseline, my guess, he is not close and I would end up holding off.Post 12 Lead looks like an Inferior Wall MI. It may or may not be induced by the tachycardia and cardioversion, then again, it could have caused it. With that said, he needs to be in a Cardiac Care Center regardless.Chris
SoCal Medic – Sounds logical to me! I was wondering the same thing (if the inferior injury pattern could have been caused by the cardioversion).I agree! Either way, the patient should be in a cardiac center (or at least a PCI hospital).Is this a possible argument in favor of performing synchronized cardioversion for wide complex tachycardias in the field?It would be a shame to find out it's a STEMI after reaching a non-PCI hospital.Tom
I agree with the previous treatment, O2, IV, Possibly sedation, synchronized cardioversion (we don't carry Lidocaine here anymore and Amiodarone is only for cardiac arrests), try to get a repeat 12 lead & transport. As for why I'm thinking VTach, please tell me if I'm looking at this the wrong way.Wide & Fast, VT until proven otherwise. Also I'm thinking VT due to age, past history. Axis 200 in the extreme right quadrant (northwest, undetermined, negative in I & aVF), V1 positive w/ RBBB L "Rabbit Ear" bigger than right? & RS ratio in V6 <1 = VT? Are these good examples of that? I got that from the Western Journal of Emergency Medicine WCT, Part 1, Epidemiology and Electrophysiology. This is my first crack at a tricky one, so please go easy on me.Here is a link to the article I was talking about if anybody is interested.http://escholarship.org/uc/item/9651n6v3?query=WCT
Geoff – I'm looking forward to reading that article. Thanks for the URL! In the meantime, the only comment I have is that this ECG shows a monomorphic R-wave in lead V1 (as C.Watford mentioned). So there's only one bunny ear! It's a cyclops bunny. That finding "strongly supports VT" depending on what you read, but I should mentioned that I've seen it on several occasions with bifascicular block, and on rare occasions with simple RBBB. That's why I take morphology with a grain of salt. What I really like about what you said is that "wide and fast" is VT until proven otherwise! But what constitutes proof that "wide and fast" is something other-than-VT? That's the real trick, and so far I've not seen anything that convinces me morphology of the QRS complex can do the trick by itself (but as I said before, "ruling in" VT is fine with me! Tom
Hi Tom,I see some irregularity here, which tells me that it probably is not V tach, however since it is a very tachy rhythm & patient is unstable (BP & mental status) I would cardiovert right away, regardless the rhythm patient should be cardioverted.Why didnt the medics cardiovert in the field?As usual it is a great case.
T.D. – I'm not 100% sure why the paramedics didn't cardiovert in the field, but probably because they had never done it before and were nervous.Conscious patient with a pulse = good.Cardioversion = unknown change.I myself often preach that if you're not sure you're doing the right thing, you can always "prepare the patient for ALS" by placing the patient on oxygen, starting an IV, and capturing a 12-lead ECG with excellent data quality (which helps with definitive treatment in the EP lab after the fact).I can't complain with the data quality of the 12-lead ECG for this case, although if you look at the times, it wasn't captured until late in the call.I (personally) don't see the irregularity, but on the other hand, I haven't marched it out with calipers either.Regardless, I'm confident that I wouldn't use a CCB on this patient (and I'm sure you wouldn't either).Thanks for the comment!Tom
I volunteer for a small town squad in upstate NY and was credentialed at the Critical Care level about a year ago. The one and only time I've cardioverted a pt was about a month after I went online. Online doc told me to cardiovert an AFib pt that was circling the drain and 80 J later he had NSR, was pink, AAO and talking with us. He arrested three times after we handed him off, but was converted each time and, after treatment, has been home since discharge (10 days after we brought him to the ER). Come to find out after-the-fact that the doc is a retired OB-GYN that delivered me about 31 years ago. In fact, he delivered about half of our squad… I wouldn't be surprised if the crew didn't cardiovert the pt due to inexperience with the procedure. I was told that before I hit the shock button I muttered "here goes nothing". Having an hour transport to the nearest PCI center lets us play a little more than some squads and if we had a short transport I'd have preferred not to syncronized cardiovert for the first time (not just for me…but in the history of the squad) without a safety net.
Anonymous – That is an awesome story! Top 10 things you don't want to hear your paramedic say:"Here goes nothing!"Hahaha!
Tom
Geoff, thank you for the article. Part 1 had some pretty neat ECGs! If you click Similar Items you can read Part 2 which covers management of patients with WCTs, which was a very enlightening read. The article basically states what we all learned in paramedic school, and what Tom preaches here:"In patients presenting with WCTs, correct interpretation of the ECG should not be the primary concern of [providers]".
Glad you guys liked the article, looking closer, I see what you mean about it being monomorphic, I guess I was looking at the complex too much and thought I saw a notch. Yes, I read Part 2 as well (sorry I didn't put the link on there initially), pretty much sums up treatment. I have a question for you out there regarding these rhythms, we often get asked about the "interpretation of the 12 lead" by the nurses. They want to know what the computer says.Tom, if you don't mind, I'd like to email you a strip one of our crews had from a patient that looked similar to this one (if my memory serves me right), see what people think.Thanks again,Geoff
Sure, Geoff! I'll tell you in advance that the GE-Marquette 12SL interpretive algorithm isn't the greatest at rhythm analysis.Here's my email:ems12lead@gmail.comTom
I don't think that we have any other way to treatment exept to give O2 IV line and cardioversion that what AHA say about all Tachyarrethmia with low BP or Chest pain and after to watch what the patiant have more and cuntinue to treatment
Aharon – I agree with you! Electrical cardioversion was the preferred therapy for this case.Best wishes,Tom
The first ECG shows monomorphic ventricular tachycardia with RBBB..The definitive treatment is the synchronized cardioversion, O2 supplement and infusion theray .. The last ECG shows an elevation of ST segment in the diphragmatic leads II,III,aVF indicating STEMI could be the etiology of VT .
Dr. Hillis – I agree with your analysis. To clarify for my readers, Dr. Hillis is saying that the monomorphic VT shows RBBB morphology in lead V1.VT is often classified as LBBB-type or RBBB-type depending on whether or not the QRS complex is positively or negatively deflected in lead V1.The clarification is important because you need to establish that you're dealing with a supraventricular rhythm before you determine that a wide complex rhythm is a bundle branch block as opposed to a ventricular rhythm.Thanks for the comment!Tom
Thanks alot Tom for responding and for explaination .. You are right the presence of right or left bundle branch block determine that the rythm is supraventricular in origin not ventricular !! So the first ECG shows wide-complex supraventricular tachycardia which is very common misdiagnosed with ventricular tachycardia. But the treatment remains the same becouse of the instability of the patient . Becouse of the difficulty of determining the rythm, therefore it is wisest to assume that all wide complex tachycardia is VT until proven otherwise.
I still have some concern about the rythm in this condition , becouse the patient has a histroy of CABG which rises the suspicion of the wide coplex tachycardia to be VT !!Any way as i said before assume that all wide complex tachycardia is VT until proven otherwise, especially if the patient is not stable becouse the key is saving the patient's life.. Many thanks
Dr. Hillis – I completely agree that all wide complex rhythms, fast or slow, are ventricular until proven otherwise.What constitutes proof? Reasonable people can disagree here, but I'm not a big proponent of using QRS morphology to make the distinction, even when it's a "typical" bundle branch block or bifascicular morphology.In my opinion, for the reasons already stated by C.Watford, the QRS morphology (right superior axis and monomorphic R-wave in lead V1) seems to favor VT.But again, I agree with you 100% that VT should be our default diagnosis!Tom
Dr. Hillis – Thank you so much for that important reminder that we must always consider the history and clinical presentation when considering an ECG! Tom
VT likely, infero-apical exit. DD. atrial flutter with 1:1 – at this rate bets are off as to what constitutes typical and atypical RBBB. Monomorphic VT is an uncommon presentation of a STEMI; favours an old inferior AMI confirmed by Q wave and fragmentation of QRS in inferior leads. The ST elevation in inferior leads, and ST depression in V2, may be old, or an injury pattern, but can’t be certain so off to the cath. lab with you!.
Mark P. -
Awesome analysis! Always delighted to receive a comment from you.
Tom
Doesn’t having concordance across the v-leads suggest Ventricular rhythm?
@DR Concordance does suggest ventricular rhythm but V5 probably, and V6 definitely, are negative.
ventricular tachycardia with AV dissociation induced by acute infero-lateral MI
treat for STEMI right away because the ventricular tachycardia is the hearts way of trying to overcompensate for the lack of 02 and ischemia. if you knock ofF the overcompensation mechanism then you starve the heart.
Vtach-NRB @ 15 L-Prepare to cardiovert due to Vitals-sync and shock-prep amio drip post vtach and get pt to cath lab
Don’t forget Aspirin people!
First thing you know its wide complex tachycardia. Check, Next thing to rule out for V-Tach is check out the axis. This pt has Extreme Right Axis Deviation (ERAD) which is the slam dunk sign for V-tach. Pt is unstable obviously and agree with the treatment above.
I see v-tach. This patient should’ve received immediate cardioversion in the field. Irregardless if VT or not, the rapid rate, coupled with the low BP and mental status calls for cardioversion. I would be more concerned with morphology if it was a stable tachycardia and I was going to treat pharmacologically first.
why was he transported instead cardiovereted on scene hemodynamically unstable. as i remeremember acls says fix it now bump meds give him the juice.