56 year old female with a "cardiac disorder"

Here’s an interesting case submitted by Mike from Massachusetts.

Here’s the story in Mike’s own words:

EMS is contacted by a local rehabilitation facility for a female patient with a cardiac disorder. Initial dispatch is an ALS ambulance, ALS squad, and a BLS engine company.

Approximately 20 minutes prior to EMS arrival, patient began experiencing palpitations (“fluttering”) and reported this to staff. Oxygen has been applied by non-rebreather mask @ 15 L/minute. An initial set of vital signs and an ECG tracing were obtained.

Vital signs as follows:

  • HR: 214 (on monitor)
  • Pulse: 40 (manual)
  • BP: 114 / 94
  • RR: 22

The ALS ambulance crew arrives first (my parther and I) and finds a morbidly obese (> 180 kg) 56-year-old female patient resting semi-fowlers in bed. Patient is undergoing inpatient rehabilitation following pneumonia. Patient is pleasant, alert and oriented x4 and does not appear to be in acute distress. Patient is conversing appropriately with staff, continues to complain of palpitations, but denies other symptoms.

EMS’ LifePak 15 is applied, paddles only, showing the following rhythm.

While in the process of obtaining vascular access and applying the 12-Lead, the patient becomes unresponsive and apneic. Her cardiac rhythm is noted to deteriorate to a wide-complex rhythm with an electrical rate at over 300 bpm. The LP15 is charged and the patient is defibrillated at 200 J within 15 seconds of the arrest.

There is near-immediate return of spontaneous circulation and patient quickly regains consciousness. Patient does not recall the event, but otherwise remains alert and oriented.

Vital signs as follows:

  • HR: 90
  • BP: 125 / 74
  • RR: 18
  • SpO2: 100% (100% FiO2)

Intravenous access is obtained. Lidocaine, 180 mg IV bolus is administered and a Lidocaine infusion @ 2 mg / minute is initiated.

A 12-lead ECG is obtained.

Transport time to nearest facility (non-PCI) is less than three minutes.

What do you think of the initial rhythm and arrest rhythm?

Do you see anything to worry about on the 12-lead ECG?

Why or why not?

16 Comments

  • Renee says:

    Looks to me that initially it was asymptomatic VTach with pulses that quickly progressed to arrest monomorphic with quick defibrillation ROSC and the 12 looks like a qwave MI (old or new) w/a Lt bundle…. maybe new onset?? not sure …. I have not got all my scarbossa criteria down yet

  • Troy says:

    Sgarbossa Criteria if I remember right is:

    1mm of concordant elevation
    1mm of depression in anterior leads
    5mm or Dr. Smith formula (>.2 x S-wave depth) of discordant elevation

    As far as the rhythm, I’d be highly suspicious of a developing inferior MI with the inverted T-waves, Q-wave possibly developing, STE (if stretched out) and reciprical change in aVL.

  • Dave B says:

    technically, QRS duration not long enough to be LBBB… plus, you don’t have the normal monophasic R wave in lead I..there does seem to be STE inferiorly, with the largest amount in lead III. some subtle STD in I and aVL reciprocal to the inferior leads… also, V1-V3 have that very flat ST segment, that just looks like possible evolving posterior involvement imho.

    now, if someone thinks that 114 ms is splitting hairs, and it is a LBBB, you would have concordant STE in the inferior leads, and borderline concordant STD in V1-V3, so whether no LBBB or LBBB with Sgarbossa met, it doesn’t really matter because the result is the same: cath lab.

  • Rm says:

    12 lead Looks like incomplete lbbb to me based on morphology…. Expect the t waves to be deflected opposite the qrs but not the the concordant ste in inf leads. Here I see value in right sided leads en route to the cath lab. STD in v1 v2 is extremely subtle and more flattening then depression and Id bet is reciprocal to inferior leads. However if you were super cautious, posterior leads wouldn’t hurt.

    Looks like a well managed call! Anyone have thoughts about holding off on post arrest lido?

  • Medic768 says:

    Amio seems appropriate especially considering the BP at the time… Cath really appears to be the most appropriate tx. I wish we still had lido as an option sometimes sometimes!

  • paramedic1052 says:

    Methinks something sinister is afoot. I don’t like the look of the ST segments in the inferior leads at all, and whether it is a developing MI or a developing LBBB, it’s all bad. As for post-arrest Lidocaine, I would have held off, at least on the bolus. Without a 12-lead of the initial wide complex rhythm, or at least a strip in MCL1, we can’t be sure if the patient was in ventricular tachycardia or another rhythm, such as rapid a-fib with a rate-dependant bundle branch block. Amiodarone drip, high-flow O2, a second line (if possible), medical command contact, serial 12-leads, rapid transport to the closest PCI center.

  • Christopher says:

    Initial rhythm VT, next V-flutter, then sinus rhythm, near IVCD, inf elevation and t wave changes, some depression laterally. Very atypical LBBB if it were one. I don’t have enough for a STEMI criteria, and those could be ischemic changes due to the arrhythmia. I’m going to the PCI friendly hospital and trending the 12-leads for a more definitive one.

    Oh, and can I swap out a LP12 for that 15?

  • Troy says:

    I agree Chris! Didn’t even see that it was an LP 15. Must be the rich area. Lol. I wouldn’t call it a LBBB, just was stating the criteria! Definite conduction delay though

  • Dann EMT-I says:

    The inital rhythm is V-tach with no symptoms. i would have pushed amiodarone 300 mg immediatly to try and get rid of that (of course after placing the pads just in case). The pt goes into a more rapid v-tach then nothing. the 12 leads show a new LBBB so the pt is having some sort of CAD, the pt needs the Cath Lab immediatly!

  • Darrin Moore says:

    Would not rule out LBBB. Recheck lead placement/rule out conduction issue. Hold off on lidocane, unless V-tach can be verified.

  • Patrick F. says:

    Looks to be wide complex tach. if iv access was established prior to pt going into arrest I would give 150 amio over 10 minutes. But since the pt when into pulseless v-tach then i would give 300 IVP. If cath lab was 10 minutes i would go there otherwise nearest ER. I don’t like to have post arrest PT in the ambulance for a long period of time. 12 lead looks to be elevation in the inferior leads.

  • haven’t seen ventricular flutter in a while…

  • medic says:

    The pt was in a sinus rhythm after the defib, I would hold off on the lido, i would have it out and ready and watch my rhythm, but with the hospital three minutes away i wouldn’t waste any more time on scene and head to the hospital.
    p.s. hopefully they have a cath lab there.

  • David says:

    Dann,
    Amiodarone is a good drug, but I wouldn’t jump to 300mg push. It has a lot of side effects that increase with rapid administration and the dose for people with a pulse is 150 mg over 10 minutes. In the new ACLS, 300 mg is only for “VF/VT Cardiac Arrest Unresponsive to CPR, Defibrillation, and a Vasopressor.

  • Renee T says:

    12 lead shows inferior ST elevation with reciprical changes in high lateral leads.  Given pt's symptoms, would have run this in as a STEMI to be safe. (AVF is borderline). Would not have given lidocaine after defibrillating.  Definitely not a bolus, and unless there were many PVCs, probably not the drip.

  • Sean says:

    Being that the patient arrested, that should be enough for a PCI visit.

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