12 year old male CC: Palpitations

Here’s a case submitted by Bob Sullivan, NREMT-P from New Castle County EMS in Wilmington, DE.

The case occurred six years ago so certain details are missing. However, there is more than enough here to discuss the most relevant points about the case.

The patient was a 12 year old male whose only complaint was palpitations.

The patient’s pulse was extremely rapid. However, he appeared to be perfusing adequately and the blood pressure was stable.

A 12-lead ECG was captured.

And another.

Online Medical Control was contacted and the treating paramedic was advised to watch the patient’s blood pressure and cardiovert if the patient became unstable.

The patient converted after the ambulance went over a bump. Unfortunately, a post-conversion 12-lead ECG was not recorded.

At the time, Mr. Sullivan was a new paramedic. He states that his co-workers felt that he should have given adenosine, since a 12 year old “could not be in VT.” He also mentions that he’s gotten different interpretations from each doctor he’s shown it to.

The case has been bothering him ever since.

What do you think is the best field treatment for a patient like this?

What do you think of Online Medical Control’s advice?

What do you think is wrong with this patient?

42 Comments

  • Brian T says:

    I think this is most likely PSVT with preexcitation (WPW), or a ventricular tachycardia related to a prolonged QT interval. I would try vagal maneuvers first. If I felt chemical cardioversion was neccesary, I would probably lean towards adenosine first because I think the clinical picture is more consistent with PSVT with WPW (delta waves in the right precordials?). Very interesting case….

  • Max says:

    Long time lurker, first time poster.A medical director of mine once told me that if you had a VTach with a rate greater than 200, then it was WPW. While I do typically shy away from such absolutes, it will be very high on my differential before I can knock it off.In this case, I think it makes sense. At 12 years old, it's within the realm of reason to consider aberrations of a pathophysiological cause. This could well be the first episode that he's had. So odd things to me, would be "all in" for consideration.There's definitely no shortage of delta-waves, he's in ERAD, wide-bizzare QRS consistant with alternate electrical pathways, ridiculously fast rate, and he's 12. So I'd feel confident in calling it WPW.For treatment, I'd start with O2, vagal maneuvers, and get a line. If (when?) that doesn't work, I'm going to contact medical control and make a pitch for overdrive pacing. Being that he's still in that age group that has the remarkable compensatory mechanisms, I'm going to want to be as aggressive as my medical control feels comfortable with.Add a side of safe, rapid transport to one of our pediatric ED's, and I'm comfortable on this one.

  • 12 year olds can't be in V-tach someone says…wow. They can't go into V-fib either I guess.I agree with medical control on this one. As anxious as the trace makes some, the description here is of a stable, alert, compensating young man who just happens to have a rapid pulse rate.Cardioverting or treating this now is treating the machine.That doesn't mean I don't have the adenosine out and my calc set in my mind, but I'm trying the basic efforts, vagal tricks, maybe even skipping along to the ambulance (Oh dear Gods! Happy walks AND skips patients to the rig?)A calm ride to a pediatric receiving center is indeed warranted, but intervention with the current presentation could lead to more complicated problems.I'd also advise the mother to ask for copies of everything she gets at the hospital pertaining to the impressions of the MDs and treatments given in case we ever come back.HM

  • WPW. Hemodynamically stable.Treatment: Rapid diesel bolus, and Tincture of Time. If decompensation occurs or symptoms worsen, sedation and synchronized cardioversion.Adenosine would have been bad juju.

  • Tony Debelow says:

    I would have asked OLMC for amioderone drip. and if pt becomes unstable then would cardiovert.The old question is: how do you know if any wide regular wide complex tachycardia is v tach or a supra rhythm with aberrant conduction

  • #1 Never is an adjective that should "never" be used when diffrentiating any event. My feelings are if he was unstable he was in VT. The 12 lead reflects poasitve concordance in all V leads and an axis of 262 a Northwest, No mna's land extreme right axis deviation all which suggest to me a ventricular origin. And the Med Control advise of cardioversion with unstable would and is still appproiate for either unstable VT or SVT. Too bad this was a number of years ago amiodarone would have been a good choice short of "lighting him up"

  • Christopher says:

    I see delta-waves, so WPW, and the rate already had me considering an accessory pathway. No to AV-nodal agents. A chux pad for me and cardioversion if little buddy starts to decomp.

  • RobertB says:

    I agree it looks more like WPW, and also that since the patient is asymptomatic to leave well alone – but be prepared. I'd imagine if he's going to go from this to crapping out, it'd be a rapid decompensation so I'd err more to cardioversion that chemistry…Oh, and more speedbumps !

  • Bren says:

    Hi all,A great strip that would cause differing opinions on no matter who it was presented to..My thoughts are this…You won't see delta waves in WPW antridromic or orthodromic tachycardias, only when there is 'normal' conduction through the AV node. (In the orthodromic setting that is, as the delta wave signifies pre-excitation merging with normal conduction.) This could be an antidromic re-entry tachycardia, it 'could' be VT, and looking at aVF, III, and avL it could also be Atrial Flutter with a 3:1 conduction – Lead aVL in isolation looks like classic Atrial flutter to me, and the QRS is even <0.12 seconds.I don't think this is VT because there are many leads that look like they have associated atrial activity, and there is r wave progression through the pre-cordial leads, but regardless, where I am from, we treat all wide complex tachycardias as VT – we don't use adenosine, and calcium channel blockers have long half lives and nasty side effects (particularly on VT!) so we DO NOT admisister them if there is even a remote chance of it being VT.Also I feel that VT would be unlikely to revert with a speed bump! (and so would atrial flutter for that matter!)Since this patient is asymptomatic, as has already been discussed, vagal manoeuvres and transport are best, (and running a strip whilst doing vagal manoeuvres may help with diagnosis) if they start to show symptoms consider amiodarone 5mg/kg over 10/20 minutes (on consultation with a paediatric hospital) and if they really deteriorate, synchronised cardioversion with sedation should terminate the arrhythmia regardless of what it is!But I would be happy not having given adenosine to this patient.Cheers, and sorry for the long post.Brendan

  • Looks like the differential here is Ventricular tachycardia vs. WPW/pre-excitation. While WPW is likely in this young man, and it was my first thought–it isn't of total concern because the treatment will remain the same in my opinion. If he is stable, rapid transport to a pediatric facility would be suffice. If decompensation occurs, synchronized cardioversion. I would treat with O2 and a fluid bolus as well. It's just my experience that those are the two best dysrhythmics we carry.

  • Andrew says:

    Only need to avoid AV blockers in WPW if afib. I think that this is SVT from WPW because of rate and ST elevation in lead aVr. I would give adenosine.

  • Christopher says:

    Question: at 12yo do we still going with WCT if QRS is >0.08s? At what age do we go with >0.11s?

  • Tom B says:

    Gentlemen – It's nice to know that my blog is in such capable hands! I think I'll change the name to the "Fire and Forget" blog. :)The main points I wanted to make have already been made.1.) The patient is hemodynamically stable and appears to be perfusing. That's a good thing! 2.) When we give antiarrhythmics, they may help, and they may hurt (especially in the setting of WPW)! We don't know what we're going to get, but we do know what we've got (which is a pulse and a blood pressure).3.) Synchronized cardioversion works for VT, SVT with aberrancy (although I dislike the term SVT), and antidromic tachycardias (down the accessory pathway and up the AV node) with WPW.This patient needs supportive care: calm reassurance, position of comfort, some O2, an IV, the combo-pads, and careful observation.First, do no harm!Tom

  • Tom B says:

    Brian T – Remember that you need to consider the QT/QTc of the underlying rhythm when considering prolonged QT as a cause of an arrhythmia (and the arrhythmia is likely to be TDP).It's impossible to say during the tachycardia whether or not the right precordials show delta waves or if this is just a RBBB-type VT.Tom

  • Tom B says:

    Max – I also look carefully at the heart rate with WCT. Extremely fast rates, an accessory pathway needs to be considered.I calculated this heart rate at about 230 (1500/6.5) which approaches 250, but there's certainly an area of overlap between VT and WPW.I also agree that the patient's age points toward the possibility of an accessory pathway.The point is, if WPW is in the calculus, you need to be very careful with antiarrhythmics, including adenosine, CCBs, and amiodarone! Remember, the maximum pacing rate of the LP12 is 180.Tom

  • Tom B says:

    THM -That's a good point! There are no absolutes. VT may be "less likely" in a child, but it's still within the realm of possibility! I agree with the conservative approach. Do you really skip patients to the rig? LOL! :)Great idea about having the mother keep copies of everything in case you come back! I'm going to steal that.Tom

  • Tom B says:

    AD – Well said! It's risk/benefit.Tom

  • Tom B says:

    Tony Debelow – The VT vs. SVT with aberrancy question has been kicked around a lot on my blog lately.In my opinion? There is no safe way to classify WCT as SVT with aberrancy in the field.On the other hand, I don't think amiodarone works particularly well.What's the rush?Tom

  • Tom B says:

    Bostonmedic109 – A couple of nitpicky points.The literature states that hemodynamic stability is not particularly useful when differentiating between VT and SVT with aberrancy.Having said that, I don't fault anyone for having a default diagnosis of VT for WCT! In fact, I encourage it.I'm not sure I agree that all 6 precordials show positive concordance of QRS complexes since lead V6 appears to show a negative deflection.I'm also not sure I agree with the computerized calculation of the frontal plane axis, although I have no problem with using axis and morphology to "rule-in" VT as long as the failure to "rule-in" is not used to "rule-out" VT.Again, I'm not a huge fan of antiarrhythmics, especially when WPW is a possibility.Tom

  • Tom B says:

    Christopher – As already mentioned, you really need an ECG in sinus rhythm to identify delta waves! Good plan, though! :)Tom

  • Tom B says:

    RobertB -I'd lean more toward cardioversion than chemistry myself, but only if 100% necessary.If you skip the patient to the rig you might not need the speed bumps! This is called the "Happy Maneuver"! You heard it here first.Tom

  • Tom B says:

    Brendan – Awesome comments! May I please know where you're from?Tom

  • Tom B says:

    Adam – I like the way you think! You're thinking in terms of a differential diagnosis (clinician mentality)."I think it's A, but it could be B; I don't think it's C, but it's definitely not D."When we hedge our bets we act responsibly.That's the problem I have with people who classify WCT as SVT with aberrancy (with techniques proven to be error-prone) and give drugs (like CCBs) that can harm the patient if they're wrong!Tom

  • Tom B says:

    Andrew – What if this turns out to be a patient with WPW who is going in and out of atrial flutter and atrial fibrillation?When you see it, it's atrial flutter (regular and very fast). You say, "it's not AF/WPW so I can use drugs that act on the AV node". Do you see the problem? We're gambling with the patient's life when we give antiarrhythmics.Tom

  • Tom B says:

    Christopher – I know the PALS manual give a different QRS duration. I personally look at QRS morphology. If it looks like it might be a WCT, then I treat it like it is!Tom

  • Strong work responding to everyone. I am really glad to see how popular your blog is. You have done a really good job providing a another great resource for all of us EMS types.

  • RobertB says:

    I'm thinking a little more work needs to be done here on establishing a clinical basis for the 'Happy Method' and or the 'Bump Maneuver'. We are trying to promote Evidence Based Medicine, after all. What do you think the likelihood is of getting grant funding for a randomized double blind study on the efficacy of the bump in treatment of WCT, SVT, VT and VF ? There would need to some type of agreed dosing criteria regarding the size of bump, speed duration and repeat dose. I'd like to recommend that a pilot study be done here in Vermont, where we have absolutely no shortage of bumps in all sizes and durations – especially at this time of year with all of our frost heaves. Maybe I'll start working on a research paper for 4/1 publication. JEMS here I come….

  • Tom B says:

    Adam -Thanks for the kind words!I think you've done a tremendous service for the EMS profession by starting the Paramedicine 101 blog! paramedicine101.blogspot.comTom

  • Tom B says:

    RobertB -Sounds like a fun reason for Chronicles of EMS to visit Vermont! Maybe the guys from MythBusters could help out, too! :)Tom

  • RobertB – I detect sarcasm, but you bring up a good point. Most of what we do has no evidence based research to back it up. We base our judgments on experience and education.Waiting for the evidenced based model to prove a blanket is what made my patient better will not help anyone indeed.And skipping my patient to the rig, he'll grunt as we go. Any different than "traditional" vagal maneuvers? No, except now he's smiling, less stressed and just might fix himself without all the cardiotoxins we all seem so quick to give, including myself.But if that article makes JEMS, make sure they spell my name right: HAPPY. heheHM

  • In support of EBM, Last year there was an abstract (poster presentation or article) by I seem to remember a Japenese cardiologist where he merged some of the more popular WCT diffrentiating algorithms ( Brugada,Verecki and aVR). I seem to remember that the sensitivity and specificity associated with this merging of criteria far exceeded the accurracy of the others including the much tauted Brugada's which though better than flipping a coin is somewhere near 75-80% accurate. if I remember the criteria for WCT=VT was:Initial R inaVRAn RS greater than 100mseca q wider than 40msecThese seem, to be easier to interpt than QTs or delta waves or even concordance in fast & wide bizzare complexes .Does anyone actually have the refrence some of the above is from memory and notes I jotted down somewhere

  • Bren says:

    Tom B,I have set you an email answering your question!CheersBren

  • Jesse says:

    Just out of curiosity…As a class 5, adenosine doesnt have the same effects as a CCB. What would be the downside to trying a round of that prior to synchronized cardioversion? If it doesn't work (because its VT or for whatever reason), then it doesn't work. The half life gives it practically zero side effects. No harm, no foul. You might lose a small amount of time if its ineffective, or you might save adding a really painful shock to this 12 year olds already shitty day.Dont get me wrong. I agree that you should leave well enough alone in this case. He's hemodynamically stable. No need to change that. And I also agree with your lack of faith in amiodarone, or the severe drawbacks of misdiagnosis + CCBs.Im just curious what makes you add adenosine to that list.Thanks Tom! You always raise the very best discussions =)Jesse

  • Christopher says:

    I believe you steer clear of adenosine because it does not slow the accessory pathway in all cases, but it does slow the AV node. If your tachyarrhythmia is conducting antegrade through the AP, you could induce 1:1 conduction potentially leading to VF."Misdiagnosis of the tachydysrhythmia as SVT with aberrant intraventricular conduction may lead to the use of AV nodal slowing agents. In the presence of an accessory pathway, these agents will paradoxically increase the heart rate. Digitalis, calcium channel blockers, beta-blockers, and even the short-acting adenosine have this effect, increasing the risk of ventricular fibrillation. Indeed, AV nodal slowing agents are used in electrophysiology laboratories to artificially enhance conduction through the accessory pathway."Nelson JA, et al, Electrocardiographic manifestations: wide complex tachycardia due to accessory pathway. J Emerg Med 24 (2003), pp 295-301.

  • Tom B says:

    Jesse – I apologize for the delay (I've been extremely busy interviewing people and editing video) but it appears as though Christopher has already done a fine job answering your question! :)Thanks for the positive feedback!Tom

  • bostonmedic:if you still are looking for it, it's "A New, Simple Algorithm for Diagnosing Wide QRS Complex Tachycardia: Comparison With Brugada, Vereckei and aVR Algorithms" by kenichi sasaki.the criteria:1. initial R in aVR,2. longest RS ≥100 msec, and3. initial r or q ≥40 msec.

  • T.I. says:

    LBB with Supra Ventricular Tachycardia

  • john says:

    atrial tachycardia

  • john says:

    adenosine would have been appropriate

  • john says:

    the ST elevation and BBB would be secondary to the ischemia created by the extremely fast heart rate. knock off the rate and everything else falls into place. adenosine would have been perfectomundo

  • Brian says:

    IMO: This isn’t antidromic tachycardia utilizing an accessory by-pass tract. The delta wave axis is not appropriate for this tachycardia.

    Again, IMO, 2 options exist:

    Option 1) Utilization of an accessory by-pass tract with orthodromic aberrancy. Rationale behind this: the V-A time is greater than the QRS duration.

    Option 2) VT originating from the Left Ventricular Outflow Tract.

  • meg says:

    Easy.. WPW.. there are clearly delta waves… I would have treated with an infusion of Amio. 150mg in 100mL over 10 minutes.. that way.. if it “happens” to be v-tach.. you’ve already got something diffusing the whole heart.. atria and ventricles. win win.

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