78 year old male CC: Dizziness – Conclusion

Many apologies for the delay, your author worked a 48 over the weekend and was unable to get time to type up this article!

This is the conclusion to 78 year old male CC: Dizziness.

There were so many great comments on this case, including some great discussion on classifying wide complex tachycardias!

All Hallows' Eve - Initial Strip

The first rhythm strip clearly shows a wide complex tachycardia. An important point to note is the rate is well above the predictive maximal sinus rate for our patient’s age. This rules out sinus tachycardia with a bundle branch block. At this point, providers may ask themselves if this is Ventricular Tachycardia or SVT with aberrancy.

If we take a look at the 12-Lead ECG, we can look for signs which rule-in Ventricular Tachycardia.

All Hallows' Eve - Initial 12-Lead ECG

We have a QRS duration of ≥140 ms, amplitude of R > R’ in V1, a non-specific IVCD, and an R wave in aVR; all of these point to Ventricular Tachycardia. Additionally, the patient has a significant cardiac history. Some readers noted the normal axis and what potentially are P- or F-waves. I would offer that these points are moot: from this ECG alone we cannot rule-out Ventricular Tachycardia.

Wide and fast is Ventricular Tachycardia until proven otherwise.

Besides, our patient is unstable and needs immediate synchronized cardioversion.

Which is just what the crew did! Given the potential for atrial flutter, the initial cardioversion setting was 50 J. With no conversion they increased the energy to 100 J.

All Hallows' Eve - Synchronized Cardioversion at 100 J

No change was noted. A supervisor on scene mixed up 150 mg of amiodarone and began a 10 minute infusion. After no change with two cardioversions, the decision was made to move the patient to the unit.

In the back of the truck a sudden change of responsiveness was noted. The energy setting was increased to 150 J.

All Hallows' Eve - Synchronized Cardioversion at 150 J

At 150 J the cardioversion was successful!

All Hallows' Eve - Post-cardioversionA ghost made off with the final 12-Lead; true story.

The post-cardioversion 12-Lead showed diffuse ischemia and the patient ended up receiving an Automatic Implantable Cardioverter-Defibrillator. Great job by the responding crew!

UPDATED 12 APRIL 2011

Jeremy asked how the QRSd was measured in this case. Usually I try and find the earliest onset and match that with the latest end in a grouping of leads, then use the largest value to map each grouping. The following image may help illustrate this point.

All Hallows' Eve - QRSd Marked Up

I first saw this visualization on Dr. Smith’s ECG Blog, where he uses it for more than just determining the QRS duration in “Cardiac Arrest, Wide Complex, Is it STEMI?” and “Wide Complex Tachycardia; It’s really sinus, RBBB + LAFB, and massive ST elevation”.

See Also:
Differential diagnosis of wide complex tachycardias – Part I
Differential diagnosis of wide complex tachycardias – Part II
Differential diagnosis of wide complex tachycardias – Part III
Differential diagnosis of wide complex tachycardias – Part IV
Differential diagnosis of wide complex tachycardias – Part V
Differential diagnosis of wide complex tachycardias – Part VI

17 Comments

  • RM says:

    Very interesting case.. I also would definitely have hung amio for a shock refractory wide complex tach. A couple discussion points… Personally I would have started with 100 joules for sync cardioversion as we are treating this as vtach and not mess around at lower energies unless you knew you had an svt. In addition, I’m not sure if this was clarified but I would escalate successive shocks and for wide complex with a biphasic lifepak I would likely go 100 200 300 360. 50 j increments probably wouldn’t be wrong but I’d rather give less total shocks and I think you get a little more bang for your buck going up by 100.

    Any word on sedation or analgesia and what was used for the shocks?

  • Rm says:

    Oops my apologies I see that each cardioversion did have a increase in energy. I would have run it the exact same except perhaps started at 100 and escalated to 200. I think it was a good call to move the patient after a few unsuccessful shocks and allow the amio time to work…. I don’t think it would’ve been wrong to escalate on scene either. If the patient was any more unstable I’d probably opt for the latter…

  • thank goodness no one was having a svt-vt discussion on scene.

  • Chris T says:

    This is the place for the discussion and it is perfectly safe to explore options and provoke conversation by stating controversial points. No one in all the responses disagreed with treating as VT and cardiovert. Thankyou everyone who took the time to discuss different points.

  • RM,

    It is always a tough call if you decide to treat on scene as to when you move to the truck if your course of treatment is not working. Especially if the reality of “patient movement” is taken into account. In this case, with the patient in the basement, the crew did what I’d likely do and run through a few steps in my treatment plan and reevaluate the situation.

  • burned-out medic,

    I liken it to arguing “asystole” versus “fine v-fib”. Save it for the hot wash, you treat it the same!

  • Chris T says:

    ok maybe causing discussion is a waste of time then ? Sorry if thats the way everyone feels. I do not treat asytole and fine v fib the same. interesting, oh well.

  • Chris T,

    What we were referring to is how providers should operate in the field.

    In the field wide and fast is treated as ventricular tachycardia. On this website, we have the luxury of expanding our diagnoses to include SVT w/ aberrancy, and other zebra.

    In the field fine v-fib should receive another 2 minutes of CPR rather than a defibrillation attempt (just as asystole would). Recently, certain monitors will advise against a defibrillation in cases of fine v-fib if it believes it will not be successful!

    We weren’t saying the discussion is not relevant or a waste of time, merely the discussion isn’t worthwhile to have in the field.

  • Chris T says:

    ok few ! that is more reassuring. everytime i say something that is wrong and someone tells me why i find myself doing research and expanding my knowledge 10 fold for each case. Everyones time is so much apreciated.

  • Chris T says:

    Just curious why/how would one monitor find a fine v fiv to be refractory to defib?
    Arent I the one who decides to shock not the monitor?

  • Chris T says:

    or so you dont have to explain If you have covered these points already can i have the link. I am trying hard to catch up with other cases and teachings. Picking though axes right now! good stuff Tom

  • Chris T,

    I know the Philips FR2+ AEDs will analyze the amplitude and frequency of the v-fib present and creates a value from these data to determine if it would be better to have a round of CPR prior to defibrillation.

  • Jeremy says:

    Could some post how the width of the qrs was measured?

  • Brandon O says:

    I admit this is a new one to me as well; is this practice (delaying defib for additional CPR) supported in ACLS, Christopher?

  • Christopher says:

    Two things, on the topic of waveform analysis guiding defibrillation: “The value of VF waveform analysis to guide defibrillation management is uncertain (Class IIb, LOE C).”

    And on asystole versus fine v-fib, if it ends up being asystole: “In certain cases of cardiac arrest, it is difficult to be certain whether the rhythm is fine VF or asystole…There was a worse outcome of ROSC and survival for those who received shocks.”

  • Rose says:

    Sir, I can not tell you how helpful (and addicting) these case studies are. All I can say is, Can I have another?

    Thank you for the time you dedicate to this site and to help improve the care on the streets.

  • Rose,

    I’m glad you found this case helpful!

    Jeremy,

    I have updated the case to include my demarcation of the QRSd. Someone may be able to create a more accurate representation, but I feel mine will be within 0.02 (half a small block) of the correct QRSd. I calculate it out at just about 200 ms.

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