Here's an interesting and somewhat unusual case submitted by a faithful reader who wishes to remain anonymous.
EMS is called to the residence of a 82 year old male complaining of shortness of breath and weakness.
On arrival the patient is found slumped sideways in a chair.
He is weak and in significant distress, repeating, "Oh Lord…. Oh Lord…"
Past medical history: HTN, NIDDM
Medications: Unknown
The patient is African American.
Skin is diaphoretic. Nail beds are bluish. Capillary refill is delayed.
Breath sounds: Basilar rales
Vital signs are assessed.
RR: ~30 (estimated)
Pulse: 36 Irregular
NIBP: 142/122
SpO2: 88 on RA
The cardiac monitor is attached.
A 12-lead ECG is captured.
And another.
An IV is established and labs drawn.
BGL: 450
How would you describe this patient's condition?
What is your treatment plan?
See also:
Keep it simple. He’s sick! If I’ve got a line sedate, fluid bolus and
Keep it simple. He’s sick! If I’ve got a line sedate, a careful 200ml fluid bolus (bc of lung sounds) and pace. Assess/Maintain BP, see how pacing is doing our gentleman
My guess is Junctional Bradycardia. Looking at what little PMHX provided I suspect the possibility of this Man’s Potassium being off the charts. I had a simular Patient.
This is interesting I will follow the case.
Bradycardiac a-fib. with a LBBB.
High flow O2. IV and 0.5 mg Atropine followed by some NTG for those rales. Not worried about fluid for the high blood sugar, he’s got bigger problems.
I’m not sure why the computer is calling it a sinus brady. I don’t see p waves and the rhythm strip does not look regular.
By my protocols he’d have to be hypotensive or have decreased LOC for me to go straight to pacing.
Hyperkalemia. High Flow O2, Calcium Chloride, 0.5g – 1g per online medical direction, Sodium Bicarbonate 1mEq/kg per online medical direction. 20mg Albuterol Nebulized per online medical direction. Pads placed for pacing, our protocols dictate that the basilar rales would be enough of an indication, plus consider the narrowing pressures indicating the poor ejection fraction. Had an almost identical case with similar presentation.
Slow, bizarre, and wide usually point to Hyper-K. For completeness I’ll add: AMI with cardiogenic shock, cardiac tamponade (given low voltage and narrow pulse pressures) with cardiogenic shock, and pulmonary embolism with cardiogenic shock. Hmm, ok I guess those all have cardiogenic shock with them.
Regardless, pacing, lines, calcium (if it is Hyper-K, pacing may not help without it; if it is not Hyper-K, it isn’t going to hurt), CPAP can be considered as well.
Crazy strips.
ECG
Well, our vitals come back with an IRREGULAR pulse. Right there is a red flag, especially with a slow rate.
Right then and there, I believe the rhythm to be either a block or just an occasional dropped beat/pause. It can be seen in the 4 lead. I only have limited tracings to go off of, so for the sake of online review, I’ll call this junctional with a 2nd degree type 2 block. Dropped complex can be seen in the 4 lead and 12 lead. Axis is normal off the 4 lead. No ectopy.
A-fib
The 4 lead totally looks like artifact. As far as a slow a-fib, that would look more like a 3rd degree block, due to the seperate atrial and ventricular rates, if you count a-fib as haivng an atrial rate. Look at the last 12 lead…totally clean in respect to the possibility of a-fib. I have never heard of nor seen transient a-fib.
HyperK
As far as hyperK, it is suspicious, however, I don’t see any obvious signs of such, as can be seen by lengthened QRS complexes or hyperactue T waves. Do I still suspect hyperkalemia? Yes. CHF, African American, Hypertensive, Hyperglycemic. He probably has kidney issues and I’d bet money on it.
Treatment
Give O2 per protocol. IV/IO access and atropine. Levalbuterol would be my choice for the rales. I don’t want to mess with the heart as albuterol does because as described above, the blood pressure indicates poor EF and a cardiac history.
Give a 250-500cc bolus and let’s see what happens.
I’d push one dose of the bicarb+cacl. 2nd atropine by now becuase that first one probably didn’t do anything. Grab another set of vitals and lets give our last atropine.
Pacing is next on the list. I hope we’re at the hospital now. My friend here needs an ICU bed.
Tough one to distinguish between ventricular (or junctional) escape rhythm verses slow a-fib with BBB or hyperkalemia. I am suspicious of an O.D. on a beta blocker or other BP med (get med list and treat appropriately). A dose of Calcium chloride might help if it’s hyperK+.
This guys cardiac output sucks….perhaps some atropine or dopamine? Also, consider pacing, as he is symptomatic.
KISS would work wonders in this case. First and formost a NIBP of 144/122 on a patient with a pulse of 30 with signs on shock means he has no BP or atleast nothing the NIBP can find. Take a NIBP on a chair leg and see what you get, something like 144/122. Don’t get your brain wrapped around ONE vital sign that says the patient is profusing when EVERYTHING else says he’s not. I’d love to of seen a EtC02 on this gentleman not for the waveform but the number. I bet it’s crappy. Remember Capno is the smoke from the fire of profusion. As far as the ECG is concerned. It’s slow it’s ireg. Probably a block, who really cares at this point. His heart is failing and we need to help profuse this patient ASAP. Back to KISS, treat the rate first. Let’s pace and see what it does for him. I’d like to keep a slower rate at maybe 60 due to the possible AMI. only then let’s try some fluid, maybe a pressor (yeah I said it) if we can’t get a MAP to 50-60. He needs a comprehensive ED is a cath lab. I like the Hyper K rational too and good point on pacing issues with Hyper K disturbances. Especially when he codes…and that’s what it looks like what happend at the end of that last 12 lead.
I recall the voice of my salty 30 year Paramedic professor “treat the patient not %#!*^ the monitor”. – Priceless
Hi My friend
first he have bradycardia that we shore about that , what I do , I give O2 , IV/IQ ,check Glucose , it’s can be low , if is not low , try Atropine 0.5 mg , and I give 2-10 mcg/min Adrenalin , and take pacemaker SB , check again BP.
For this guy, I think I would jump to pacing pretty quickly, he is not going to like it, but I am going to wait to sedate. Andrew makes a good point on the vitals, I would have liked to see how his radial pulse feels to compare it to the pressure. He is showing classic signs of hypoperfusion. We need to treat symptomatically first then look closer for the cause. Also, lets get an ETCO2 on him and keep in mind that we may have to control the airway
Thus, first I would pace, the differential leads us to believe that he could crump really quickly. Use a HR of 60 and see how it helps with perfusion.
I would not do atropine first, the ecg lends itself to being a varying morphology, thus I question the ability of atropine to help this rhythm.
If his pressure and clinical status improves with the pacing, then I would sedate him. If I was in a remote area, I would work on arranging for a helo to rendezvous with at the local small town hospital.
This is definitely a case that I would want to send the rhythm strip AND 12-lead and discuss with medical control
The top of my differential is hyperkalemia, he is definitely in an electrolyte derangement, the BGL and rhythm morphology lends us to that.
Thus, they may likely have us give some calcium gluconate and bicarb.
Next on my differential would be to look at the possibility of a medication overdose, we dont know what his medications are or his compliance, could be an OD of HTN meds. Also look for any steroids in his medication list, he could have been sick recently and the high BGL could be due to that and could have caused a cushing’s syndrome with a sudden cessation. Then, I would look for a diuretic in the med list, that could be a contributor to the electrolyte derangement.
And, as always, an MI would be on my list of differentials
Yeah, I know I am a little scattered, but I think that should be close to what Id like to do on this guy.
First and foremost I'd like to mention that I'm a fairly fresh paramedic student and still quite lost in the world of ECG's. I see some people are recommending Atropine and to wait for pacing, others are mentioning pacing first. Personally, I feel that I would probably jump to pacing pretty quickly. I don't care what the monitor says, this mans general appearance alone leads me to believe that he might be getting ready to crash. Per our protocols this man does not appear to be hemodynamically stable which would indicate the pacing rather than Atropine especially due to the irregular pulse. Other than that I feel that the general consensus of keeping it simple would be the best plan for this man. As I said I'm new and still learning so I may be wrong, any comments/advice would be great.
01Ranger,
You're right on track. Atropine is very low on my list due to the somewhat wide escape rhythm and the bizarre irregular appearance. What many folks have keyed in on is that pacing is certainly indicated, but if this is due to Hyperkalemic causes, pacing may not be effective without concurrent treatment of the electrolyte disturbance (which may or may not be the cause).
Interpretation of twelve lead… FUNKY! My biggest concern… wide QRS complexes, bradycardia, and prolonged qt interval, electrolyte imbalance / hyperkalemia.
Diabetics that are in DKA are very suseptable to hyperkalemia due to metabolic acidosis. In addition, if this patient has CHF, medications such as pottassium supps, pottass sparing diuretics, beta blockers, digoxin, and ace inhibitors can also influence hyper k
Based on this patient impression, I would immediately treat hyper k.
Treatment: This patient is going downhill, albuterol and rebreather 6lpm, consider cpap w/ albuterol as well, quickly give Sodium Bicarbonate 50 meq, Calcium Chloride 1 gram (as long as not on dig, can substitute mag sulf 2 g if dig tox is suspected) , D50, and Insulin. If patients condition doesn't improve then i'd repeat the bicarb, calcium, d50, insulin, and albuterol.
I wouldn't pace this patient. This is not a conduction problem w/ the heart, it appears to be an electrolyte problem.
Cheers!
electrolytes aside, i would be impressed if there are tracings of this patient being PROPERLY paced transcutaneously.
Burned out Medic would you match rate first to make it a little easier then titrate up after capture? How would you handle being sure you got proper capture? Why would this rhythm be so much more difficult? You seem to
No one brought up any sedation in this one LOL too funny.
Christopher, cardiogenic shock usually presents with a low bp and treated with dopamine? Is the BP so high due to your suspect of cardiac tomponade? Where are you seeing the AMI? What makes you suggest PE and not CHF? Im sorry to ask so much but when i try to understand the way you think i end up having to research tons, and reguardless i learn a lot.
If this BP is accurate I would assume this is why we arent trying eppi or dopamine as first line? What happens with going with atropine, then calcium, possibly sodium bicarb, maybe albuterol with cpap and pacing for suspected hyper K, if were that suspicious why not be agressive and treat it before he codes for good?
Guess I have too many questions sir, youll need to divert to another ambulance hehe i kid of course.
I would say Hyper K+. As for the patient, 142/122 seems unlikely and a manual should be taken. CPAP placed because its amazing for pulmonary edema. 1gm of CaCl. Pacing if still unstable with IN sedation if mentation improves. Also I would consider BiCarb since calcium only effects the toxicity on the cell walls and doesn’t fix the acidosis but does prevent further acidosis from cell lysis. Anyways, a dose of BiCarb might be in order. Lasix can be considered but I am starting to consider that secondary or tertiary care for the edema.
Chris T,
If patient presents with bradycardia AND hypotension, epi infusion is the first line drug according to new AHA standards. Dopamine is for normal rates with hypotension, cardiogenic shock or septic shock at normal temperatures.
If the BP is accurate, I would lean more towards cardiac tamponade due to hypertensive with narrowing pulse pressure, edema due to restrictive flow, and poor perfusion. If he had JVD or muffled heart tones, this would help diagnose more. As for basis off the ECG, although there is low voltage, its not seen in all leads as my experience with tamponade
has shown.
I too am curious to the PE thing…. if so the embolus location would be unusual
Chris T,
My differentials were listed for completeness, and not necessarily because I believed them to be the most probable cause. Basically, for tamponade I took the NIBP at face value. Moreover, cardiogenic shock does not necessarily require a low BP (BP is the last to fall in shock). As for AMI, there were some strange ST changes in multiple leads and elevation is not required for there to be infarction (once again more for completeness). For pulmonary embolism, once again this was more for completeness of differentials.
Basically it boils down to this patient is in decompensated shock and is periarrest. The only treatable cause, and the most likely cause given our findings is Hyper-K. Calcium should be a first line agent with concurrent pacing due to the derangements caused by hyper-K. More importantly, all other ACLS interventions are likely to be futile without calcium administration in severe hyperkalemia. As Dr. Smith has pointed out, calcium administration is safe and benign even if this happens to be one of the other causes!
chris t.: without considering electrolytes here, i am simply referring to the general inability of crews to properly pace symptomatic bradycardias. for instance, out of the last 10 or so pacings calls i've been shown, only 1 was properly paced.
the most common mistakes:
- not using enough current
- mistaking muscle artifact due to the "jolts" for true electrical capture
- inability to properly verify mechanical capture
tom b. at this site has a great post on false capture.
Christopher and Burned out medic. Thank you so much for your replies. Im learning so much. I have been filling my favorites list with pages from this site for ref. Thanks again!