60 year old female CC: Dizziness

Here’s an interesting case study from the Right Honorable Mark Glencorse of Tyneside. In addition to being a founding member of EMS 2.0 and the Chronicles of EMS, he also hosts the popular ECG Geek series at 999Medic.com.

Here is the situation (and no, I’m not talking about Mike Sorrentino).

Called to a 60 yr old female patient. She had been suffering with dizzy bouts and collapses for a couple of weeks and had been diagnosed with vertigo.

Has a medical history of MI (with cardiac arrest) in 2009, severe heart failure, COPD with home O2 via NC @ 2 LPM 24hrs per day.

She called 999 as she felt her dizzy bouts were getting worse and the medication that had been given to her for the vertigo was not working.

On arrival she was dyspnoiec (although in her normal state), slightly pallid and feeling dizzy. No chest pain.

Observations :

GCS: 15
Resps : 32, use of accessory muscles
SaO2: 95% on 2 litres/min O2 via nasal cannula (all normal for her)
Pulse: 92, irregular and weak radial pulse
BP: 102/55

Skin was warm to touch and dry.

She complained that her dizzyness was worse today and that sometimes she felt as though she was falling even when she was lying in bed.

Whilst completing my assessment, my partner rechecked her blood pressure and mentioned that her pulse had gone very irregular and she seemed bradycardic.

A rhythm strip was taken.

Chest electrodes were applied and a 12 Lead ECG was captured.

Patient was moved to the ambulance via carry chair and once on the stretcher called out to say that she had gone dizzy again. Leads were immediately attached to the monitor again which showed the following rhythm strip.

What do you think of these ECGs?

See also:

60 year old female CC: Dizziness – Discussion

24 Comments

  • Christopher says:

    Very interesting rhythm strip, almost looks like bigeminal PACs or MAT. MAT is common in some respiratory diseases and I wouldn’t be surprised to see it in COPD. P-waves are nuts, P-pulmonale for certain.

    His partner mentioned the pulse felt bradycardic, which I’m wondering if that points the interpretation towards frequent non-perfusing PACs (which sounds odd) or if it means inadequate ventricular filling due to the rate?

    When we pop over to the 12-L we have even more P-waves morphologies! Certainly leading towards MAT. No elevation or depression or other findings pointing me towards STEMI.

    The final rhythm strip shows a regular, narrow complex tachycardia, with QRS morphology identical to the 12L and prior 3L. SVT perhaps initiated by one of the ectopic atrial beats.

    I’m going with MAT progressing to SVT. Going to check her temp, get access, fluid bolus (with a listen to her lungs first), adenosine potentially, and cardioversion potentially.

    Great strips!

  • Steve Pike says:

    Given the Hx of respiratory issues, MAT could certainly be an issue, especially if the pt is on Theophylline.

  • Do I see some inverted Ps in the anterior leads on some of those bigeminal runs?
    The third trace makes me nervous knowing Mark’s inability to treat this rhythm with electricity should it become necessary.
    However, since she has not yet expired, I’m not too worried that will happen this time. Her RR is 32 because she can not get enough O2 carrying blood to her body, we could give her 100% but until we fix the rhythm/pressure issue she’ll be in distress.

    I’m not sure to the cause, whether the tach is causing the bigeminal PAC/PJCs or the other way around.
    Can anyone steer me true?

  • bennett says:

    did these changes in HR/dizziness occur only during movement/position change? was the pt tilted back as the litter was loaded into the truck? and what was the BP doing during these dizzy spells?

  • Jay says:

    I had something like this a few months ago, but, it was with a male in his forties. He had dizzy spells, got better, but when he started again, he went into a really poorly compensated SVT, with pressure drop, color change, etc. He eventually broke on his own, but, he did it again 5 more times till he got to the ER. With her history, her heart is crap to begin with, I would at least put the pads on just in case. Is she compensating for the tachy, or not? What IS her pressure? Lung sounds?

  • turo says:

    i would probably have to go with the mat just because nothing else really makes sense.. also theres retrograde p waves so im gonna say those are PJC’s i wouldn’t doubt there’s also pac’s in there .. also i dont think her oxygenation is the problem with hx of copd 95% isn’t bad at all i do think she needs 100% though …but oxygenation isn’t her problem i would say its the lack of perfusion that making her SOB…definately put the pads on and if your going to try to convert the svt you better be ready for a code because her heart looks really sick im not sure it would do good with neither adenosine or cardioversion …but you have to do aomething because she probably isnt going to maintain the svt for too long …

  • Medic999 says:

    Bennett,
    I only witnessed the single episode in the back of the ambulance and it was in fact just after she had transferred from the chair to the cot.
    The episode for which we were called was not associated with movement though, just whilst sitting on the edge of her bed. As far as the BP goes, the life pak 12 was unable to catch a reading and manually it was very difficult to auscultate, but I put it at about 70 systolic (couldnt get the diastolic) during the SVT.

  • Medic999 says:

    Jay,

    Lung sounds were consistant with severe COPD, i.e. a multitude of whistles, and wheezes. Lungs sounded dry with no evidence of cardiogenic pulomary oedema.

  • Faye says:

    Could someone please explain your acronyms? I don’t use them and so don’t know what some of them stand for.

  • totwtytr says:

    A rule of thumb I was taught many years ago is that when the rhythm is irregular and you have to “explain” the P waves in great detail, it’s Atrial Fibrillation. I’m going to go with that. I had a patient similar to this several years ago. We could slow her rate but it would come right back. The attending physician explained to me that it wasn’t unusual to see this type of thing with COPD patients with advanced disease.

    I’ll stick with A-Fib, but I’m sure Tom will show me the error of my ways! 🙂

  • Medic999 says:

    TOTWTYTR,

    The rule I use for A Fib is that “any irregularly irregular rhythm with no DISCERNABLE P waves” is A-Fib. In this case, I could see lots of definate P waves, but what I didnt know was why they were so tall and why there was so many differet morphologies? I even had trouble judging what was a P and what was in T wave in some cases!

    But just like you said, I bet Tom can give an example where my definition of A-Fib can be incorrect too!

  • nerdymedic says:

    A-fib and MAT are essentially the same, but with different atrial rates. Both cause an irregularly irregular ventricular response, and both have multiple atrial focii trying to pace – but in A-fib there are so many competing focii at such a high rate that the atria fibrillate. In MAT it’s slow enough and there are few enough focii that the atria are able to response, albeit irregularly. The multiple atrial focii are where you get your variety of p-morphologies from.

  • phoenix says:

    Sawtooth in appearance HR 216….Atrial Flutter.I would go with adenosine soon,at her age,a pressure of 70 Palp, R-32, and her extensive HX… she going to decompensate soon and fast, I would have the pads in place

  • PARA-GOD says:

    Nerdymedic hit the ball on the head here for you totwtytr.

    This is MAT with PAC’s. I noticed compensatory pauses after PAC’s which is why it appears grossly irregular. On the 12 lead, I noticed a PJC. Eventually the rhythm changes into SVT, and the treatment modality changes due to a rhythm consistent with decreased cardiac output and the patient showing signs of just that.

    My treatment, Bump up to NRB, let’s roll with lights/siren and call a cardiac alert to the hospital so they’re ready for this. Vagal the patient down, fluid bolus of 250-500cc NS, 6-12-12 of adenosine. Reassess to determine if we are going to cardiovert. If stable, then ditilizem, if unstable cardioversion. Another fluid bolus. We should be at the hospital by now.

    A cardiac alert is called if patient presents with: symptomatic myocardial ischemia in absence of ST-elevation, significant ECG dysrhythmias where patient is symptomatic or cardiac output is compromised, or in the judgement of an EMT or Paramedic, when the patient shows signs and symptoms of a significant cardiac event

  • Randy says:

    I’m curious if she’s thrown an emboli!!

  • arnel says:

    Very nice collection. Rhythm strip is multifocal atrial rhythm (MAR) (WAP wandering atrial pacemake (slower)/MAT multifocal atrial tacycardia (more than a hunderd). THe 12 lead MAR, tall P waves/prominent 2nd component of P wave in V1 – indicative of biatrial enlargement, persistent S in V5 – in all this pt could be having cor pulmonale sec to COPD. Third strip is AF in RVR. These pts are prone to AF. When the ventricular filling is reduced by rapid heart rate then shurely your BP would drop. Now what to do – the dizziness and dyspnea could be due to RVR. Follow your algorith for narrow-complex tachycardia in this case unstable tach. In the background of CHF the rapid rate will push the pt to congestion. Even in normal hearts, pts in AF RVR will develop tachycardia-induced cardiomyopahty. These pts are also prone to embolic events. For me I will control the heart rate. In the background of CHF, amiodarone is a good choice and my next would be diltiazem. If you try adenosine, it will just reveal the AF in this case. In unstable cases, the algorithm says shock. If you consider COPD excacerbation I will shy away from b-2 agonist but rather prefer anticholinergic.

  • NYC Medic Student says:

    I like Christopher’s summary. I too see MAT with ectopic beats in the first three lead. The 12 I would interpret the same way with evidence of bi-atrial enlargement (p-mitrale and p-pulmonale and diphasic P’s in V1). The next 3 I also would call SVT with multiple foci, I wouldn’t say afib considering it is regular.

    O2, access, possibly ask the PT to perform a valsalva maneuver. I think I would apply pads to prepare for cardioversion, but have my partner push adenosine while I call telemetry for sedation orders in preparation for electrical cardioversion. By the time I have given a story to the doc I can tell him if the adenosine has worked (given it’s short half-life) and easily get the orders I need.

    My question to the experienced medics is if diltiazem would be a better choice than adenosine given the patients underlying rhythm.

  • Terry says:

    Looks like a WAP–wandering atrial pacemaker to SVT. She is symptomatic so I would start with vagal maneuvers while I am drawing up adenosine 6-12-12 then cardiovert if adenosine doesn’t work. If the rhythm was a-fib cardizem would be a good choice but it is not a-fib. As stated above there are clear discernable p waves. Gotta love the monitors interpretation “normal ECG non specific anomalies” Ain’t nothing normal here.

  • CBEMT says:

    Hand it to a room full of cardiologists and you wouldn’t get the same answer twice, I bet.

  • arnel says:

    Amen to you CBEMT. But to continue the arguement on SVT (supraventricular tachycardia) vs AF RVR (Atrial fib in rapid ventricular response or MAR – multifocal atrial rhythm), AF is a form of SVT in some nomenclature since the impulse is also above the ventricle. The SVT that most people know could either be AVNRT (Atrioventricular nodal re-entry tachycardia) or AVRT (AV re-entry tachycardia). So loosely those saying this an SVT could be correct. Now going back to the strip, some of the RR interval is 240ms (6 small squares) and others are 280 ms (7 small squares). Second the PR intervals in complexes 12,13,15 (counting from the end of the third strip) are variable. This is typical of MAR. For SVT I cannot see the pseudo S in II (also nice if you have V1 to see the see the pseudo-R). So I am for MAR/AF than SVT.

  • Tom B says:

    Erudite commentary, arnel! You know your stuff.

    Tom

  • Troy says:

    Does anyone else see a digitalis scoop or am i just hallucinating?? I call it MAT. I wouldn’t waste time with adenosine though due to the possiblility that she’s on theophylline which makes it harder to cardiovert chemically. I’d synchronize cardiovert. If she didnt convert, diltiazam. Consider a fluid bolus but that would be given very carefully.

  • Ricktcb says:

    The probable rhythm is Aflutter with variable conduction rate. I concur that it would be helpful and most beneficial to monitor the patient in MCL1 or V1, as this lead gives you more information than lead II.  Also of help would be using a Lewis Lead to help more easily identify the p waves. Lewis Lead = neg electrode in the suprasternal notch and the positve electrode 5th IC space rt sternal border.

  • Mike says:

    All this compounded by hyperkalaemia and pulmonary hypertension. My first thought is SVT when looking at number 3, looks regular to the eyeball.

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