60 year old male CC: "I don't feel well"

Here's an interesting case from an faithful reader who wishes to remain anonymous. Some changes have been made to help preserve patient confidentiality.

This is a 60 year old male, who activated EMS for not feeling well.

The call came in from a home way out in the county, and although it was dispatched as a low acuity sick call, the responding unit ran emergency traffic to the home.

On arrival, a BLS fire unit was on scene, triaging the patient green.

Report from the firefighter EMT was as follows: Patient contacted EMS for slight shortness of breath, we have him on 15 liters O2 NRB mask, he just had a pacemaker put in three days ago.

Patient is alert and oriented x4,

VS as follows:

  • BP-180/90
  • RR-28
  • O2 sat- 98% on non rebreather (RA sat was 92%)
  • Pulse- around 100

Patient contact reveals the patient sitting upright in his recliner, speaking in full sentences.

He states that she is absolutely not going to the hospital no matter what!

On further questioning, patient says he has been feeling a “funny feeling” in addition to a little shortness of breath for the past hour.

  • Onset of one hour
  • Exertion makes it worse  
  • Severity is a 2/10 
  • Was walking to the restroom when the funny feeling started 

It feels like its getting better as long as he stays still. He hasn’t taken any of his meds today.

Questioning of family members reveals that he received multiple prescriptions but hasn’t had them filled yet. He has been off all of his meds since he left the hospital two days ago.

They are unsure of all of the medications but know that they included:

  • Coumadin
  • Amiodarone
  • Lasix 

Patient has no drug allergies.

Hx of:

  • Diabetes
  • HTN
  • CAD
  • A-fib
  • Pacemaker/ICD placed three days ago

Ate a big meal last night

Bilateral breath sounds are clear and slightly diminished.

EMS crew convinces patient to go to the local hospital 20 minutes away just to get checked out.

Patient finally agrees but is adamant about walking to the truck or else he is not going.

During the trip to the truck, patient begins to experience severe dyspnea and says that he needs to sit down.

The patient sits down on the cot for transport to the unit. Audible rales are heard when the patient begins complaining of the severe dyspnea.

In the truck, patient is attached to the cardiac monitor and a 12 lead is performed.

What is the differential diagnosis for this heart rhythm?

What do you think is going on?

How would you treat this patient?

See also:

Discussion to 60 year old male CC: "I don't feel well"

54 Comments

  • Troy says:

    Interesting Case!!

    I’m gonna take a stab and call it pre-exitatory A-fib (A-fib w/ abberancy) with a run of V-tach. I could only see a few beats with pacemaker spikes so the pacemaker is failing.

    CPAP, IV, 12 leads, ASA, trial of nitro, and procainamide. Fast patches on and drive fast!

  • Troy says:

    If we know his history and know he has no history of WPW or LGL and does have a BBB then diltiazem would be the drug of choice.

  • Jenny says:

    Does his palpable pulse meet the hr on the monitor? Looks kinda idioventricular to me, and he should get a refund on the pacer! CPAP, ntg if bp supports it, a couple IV's w/ ns tko and labs, pain meds and cardioversion per protocol and transmit the 12 lead.

  • Robert says:

    12 looks like a normal axis, and judging by V1, a LBBB. Sgarbossa’s criteria isn’t specific for an MI but the tracing isn’t that great. Looks like either the patient was mistaken and he only has an ICD, or the pacer has failed. This guy has potential to go south fast. Can’t rule out MI quite yet.

    O2, ASA, Nitro, CPAP if needed, repeat the nitro q5 (my protocol allows for up to 3 nitro if SBP is >180 mmHg). Fluids, both NSS and diesel.

  • Robert says:

    @Jenny: Transmit the 12 lead? Your system sure does value your training when it comes to 12 lead interpretation.

    @Troy: Amio is also a possibility, and would prevent a slowed a-fib with runs of vtach from becoming vtach with runs of vtach.

  • Chris T says:

    The pacer taint workin just right, I see a few spikes in rhythm strip. Im having a little trouble picking out QRS from T or if i can identify a p wave in the rhythm strip.  Hx strongly suggest SVT w abbarency but thats not good enough for me, wide and fast its v tach. Pt differentials jump at me I think. Torsades and nasty HYPERkalemia.
    start with calcum chloride protect the ticker, consider 2g mag sulfate, consider sync cardioversion or defib if pt loses pulse. Be slightly patient as new pacmaker might do some of the electrical work for us though it seems to be an issue currently. I would also like to give 150mg amioderone over 10 min for now, if he goes pusless id consider the 300mg bolus ami. if everything calms down and patient is still having chest discomfort evaluate if ASA or Nitro would be tolorated or benifit and not contraindicated. Fluids keep ear to lungs. This might be too agressive. LONG transport let me know if any thoughts so I can learn.

  • Robert says:

    Chris, I think you’re way off with the SVT or V-Tach. It’s not fast enough, and it’s irregular. Upright in I, II and III means a normal axis.

    Torsades and hyper K are zebras. The amio I agree with.

  • Rich says:

    Fairly new medic but I'm gonna take a shot:
    Afib with rapid ventricular response, as troy stated: CPAP, IV, 12lead, NTG, sedate and cardiovert. Our protocols here in MA have moved lidocaine to med control option and Amiodorone is standing order but because it has to be given over ten minutes and the patient is becoming unstable per dyspnea I wouldn't want to wait for the infusion. Also the Pt. has Hx of pacemaker so if the pacemaker has failed and the Pt. converts into a bradycardic rhythm I'm not sure I'd want amiodorone running through his system. please feel free to criticize .

  • Robert says:

    Ok, I'm looking for a serious answer from Rich and Chris… why are you guys so aggressively looking to cardiovert a guy with heart rate less than 150, HYPERtensive, and CAOx4?  Even with sedation, that looks unnecessary.

  • VinceD says:

    Rhythm Strip – Underlying rhythm is a-fib w. aberrancy. Beats 2 and 4 of slightly different morphology; leaving me thinking Ashman's phenomenon vs. PVC's. Later in the strip there is a 7-beat run of the same morphology, which gives the appearance of V-Tach but has a slight irregularity to it, so while I wouldn't rule-out V-Tach, it's fairly likely that it's a run of rapid a-fib with "extra" abberancy due to the rate and that the earlier beats were of the same mechanism. There are also 3 pacer spikes noted, none of which appear to capture.
     
    12-Lead – A-fib w. LBBB, normal axis, no pacer activity noted. The anterior leads meet the Sgarbossa criteria for STEMI with excessive discordance with a j-point too high to be measured in V2-V3, but since we cannot see the entire QRS comples, there's no way to know if the more specific Smith modification would still find a STEMI. As things are now, I'm not convinced enough to call an alert, but I would try to control the patient's rate with diltiazem. If the patient's signs of failure don't improve with rate control, I'd start nitro therapy after checking a BP (since we'd now have two vasodilators on-board) and maybe even consider 40mg of Lasix. I don't usually agree with it being a prehospital drug, but in this case the patient has a prescription but is way behind on taking it.

  • Chris T says:

    because tje computer is reading 115 isnt accurate. The run of V tach in rhythm stip is around 200
     

  • Chris T says:

    and the 12 lead in the spetal leads are about 1 box or a little more, so 200-300 ?

  • Chris T says:

    there is irrgulariy now that I march out R to R to answer this. So im at SVT with abbarency also at this point. The irregular rate, find closest r to r and i was told to go off that for a rate. I dunno im just learning.

  • Chris T says:

    i put down the most agressive treatments cause this is a blog not a patient. this is where i get to learn all these neat things from people who have been doing it and may have an interest in teaching the correct ways to better us all. Thank you for your time.
     

  • Chris T says:

    Oh and of course I have two more differentials, so obvious forgot to tye earlier STEMI, and infection
     

  • VinceD says:

    Chris T – When determining rate make sure you're reading from the beginning of one QRS to the beginning of the next and not the space in-between complexes; most of them are indeed about 2 large boxes or 400ms apart for a rate in the 150 bpm range.

  • Chris T says:

    ah, i was looking at r to r interval my bad
     

  • adge says:

    Im gonna call it A-fib, with runs of V-Tach, Packmaker is not working well. We are gonna treat the Acute Pulm. Edema from the CHF, with some NTG, ASA, o2 Consider Cpap. I also want to focus on the fact hes supposed to be on amioderone and isnt been taking it.. Bet a try of that might help 150 over 10mins … also want to consider hyperkalemia too, because of the wide weird conduction . Is he taking his old medications?? put some pads on that chest, just in case.. but I think he might come around with standard chf treament, some calcium choloride for poss. hyperkalemia and if not ammioderone, since well hes supposed to be on it and isnt taking it.. 

  • Christopher says:

    Be careful: axis is only helpful in ruling in VT, it cannot rule out VT. The first run is pretty spot on regular. The second run is a bit irregular. Even if the first run is AF w/ RVR it is still fast/wide enough to get my attention. Shortest R-R is 300ms, longest is 620ms (rate of 100-200; usually 150-200).
    The rales seal it for me, I'm treating this guy. CCB's are not anywhere near my first line, but I'd call a doc anywho. Nitro for the rales, NRB, CPAP if they worsen. Amiodarone or procainamide for the dysrhythmia. Going to wait for the tachyarrhythmia to subside prior to making any MI judgement.
    He's Big Sick, expeditious transport to the appropriate facility.

  • Troy says:

    @Robert,

    Based on the underlying rhythm I would want to make sure the runs of V-tach are not a ischemic reaction from the rate. Also I like procainamide more than amio for V-Tach

  • DR says:

    I'd like to see a pre-exacerbation 12-lead and capnography waveform both pre and post exacerbation. My first step would be to CPAP to both help the CHF and the BP if it's still elevated. Nitrates again if BP supports them. Then see if Pt will respond to return to previous baseline of only minor SN/SX. My take is that Pt is in failure due to being off meds and probably will respond favorably to CPAP. I'd guess that the rate is a response to the condition as opposed to the condition being a response to the rate. Unless it's a long transport, I'm a fan of gettings labs prior to Lasix, but as was previously mentioned, he's missed several doses of his Lasix so it would probably help in the long run. Getting the fluid back to the right place should reduce the load and help de-escalate the irritated heart.
    Dan

  • FB says:

    I think you can also consider the possibility that the patient's QRS is normally pretty wide. If he had his pacemaker/AICD placed because of a cardiomyopathy, I've seen patients with a normal QRS of .20 and greater (though rare but patient does have a known history of a-fib, htn, diabetes, cad). At the same time, if his AICD was placed because of a cardiomyopathy is there a possibility that some of the runs of V-tach are being terminated by overdrive pacing (a situation where it can sometimes be hard to see pacer spikes due to the already wide and irregular QRS complexes due to pacing and his intrinsic QRS). I would still most likely be afraid of his acute pulmonary edema and treat with CPAP and a liberal rate of tridal to take the strain off the already sick heart. I guess, in my opinion, I would focus on the pulmonary edema/heart failure and hope once that is fixed the heart will be a lot less irritable.

  • Troy says:

    Also with the width of the QRS one could consider hyper k+, although at that rate it would be a very rare presentation. 1g of CaCl is relatively benign and can be used diagnostically if you’d like.

  • Rich says:

    Robert,
    My choice to go with cardioversion is based on the patient quickly deteriorating from the house to the truck. The crew didnt even have to strap him to the stretcher so it must have been a very short time from the couch to the point at which he had to stop and catch his breath. lung sounds were clear and equal prior to that and now he already has audible rhales. If he deteriorated that quickly, whats gonna happen by the time you get him on the stretcher, get him in the truck, start a line, mix up your amio and run it over ten minutes? my decision to cardio vert was based on the NTG treatment being unsuccessfull, which you still can't start until you have a line in. I understand that the pt's bp is "stable" but a heart that cant move fluid efficiently out of pulmonary circulation to me doesn't seem stable. I hope you dont take this as offensive and I am more than open to criticism.

  • Robert (Las Vegas) says:

    Rhythm Interpretation: AFibb with RVR, IVCD possible dysfunctional pacemaker
    This is an irregular rhythm, there are no apparent p waves, qrs complexes are wide, and it is fast. LBBB may be ruled out do to not meeting full criteria, No LAD, but none the less its some type of IVCD. 
    This patient appears to be having a CHF exacerbation w/ expected increased RR, BP, Pulse w/ non compliance w/ medications.
    Treat for CHF: High dose ntg, etco2, Cpap.
    If the heart rate begins to decline w/ treatment, then i'll be happy. If not, then i'll consider antidysrythmics such as amiodarone.
    Cheers!

  • VinceD says:

    Rushing earlier I missed the part about the rales being audible without auscultation, so I'd probably instead begin with the CPAP and nitro before rate control (assuming the patient is still hypertensive with a BP check). Hopefully his SOB would resolve and his HR would drop on its own with successful treatment, but if his rate is still up or his is still SOB with maximal nitro therapy, I would also change my preferred rate-controll drug from diltazem to amiodarone since I don't want the more prominent negative inotropic effects of the CCB's worsening his failure. I'm still pretty well convinced it's pure a-fib, but I may have the pads on him anyway since I've been wrong before and in this field we have to play things safe.

  • Jenny says:

    @Robert – 12 lead transmission is more for trending, not an indication of my system's confidence, or lack thereof, in skills.
     

  • Chris T says:

    where are we seeing that they assesed railed in LS. I read above that ls WERE CLEAR AND DIMINISHED BILATERALLY? Id treat that agressively with cpap and nitro if present. 

  • this guy sure is stubborn…

  • Mark says:

    I also agree that what we are seeing may also be anti-tachycardia pacing (ATP), which is very common on today’s new ICDs.

  • Dian says:

    So, I believe I see runs of Vtach. With the rales and non med compliance, diff breathing, I would try the cpap, o2, iv's in place, nitro, asa, and reassess. Am just an intermediate in Maine, in a new medic class, quite interested in learning, a bit hesitant to weigh in.
    Thank you, this is going to be helpful!

  • Dian says:

    Oh, and the pacemaker is not working!

  • Troy says:

    Your right Dian!

    There’s a couple runs of V-Tach. CPAP is the best treatment for this guy for his rales and is an under utilized tool in my opinion. You can tell the pacemakers not working just due to the irregularity of the rhythm. If the pacemaker was working and was trying to overdrive pace the fast rhythm, you would see a fast paced rate for a minute or two but its not the case here.

    Don’t be hesitant to weigh in. That’s how you learn afterall. 🙂

  • Erik S. says:

    Start dumping nitrates into this patient.  I don't think he's having the MI, but the tracing is too poor quality to tell for sure.  With the rales, and history of CAD, I like the failure diagnosis for this patient, so nitro, morphine, O2, and CPAP although I get the feeling he's going to move from distress to failure soon.
    As for the pacemaker failing….what?  It's a pacer, not a AID, so why would it be firing on an intrinsic rate of about 150?
    His rhythm is definitely a-fib with a BBB, and I'm not sure I see the V-tach runs that others have pointed out.   For that reason, I would hold off on amiodarone, and his rate isn't fast enough for me to be considering the cardizem/verapemil.
    Yeah, start dumping in nitrates, and a diesel injection is probably indicated.

  • Steve says:

    @Robert, I agree with Jenny, Transmission of 12 leads can then be compared with old ones, if readily avilabil, and I wil always welcome 2, 3 sets of eyes on a  12 lead like that. Let's try to be possitive and not negitive in our posts.

  • Matt says:

    Robert, transmitting the 12 lead when you have the capabilities is always the best option.
    I'd give 150 of amio over 10 minutes to prevent another run of vtach.  Tackle the rales with positioning first see if they improve while we move him to the ambulance and then CPAP if they don't.  Transport code 3, and because of the call being "way out in the county" I would launch a helicopter if available and fly them.

  • Aharon says:

    I think that the rythem is A.fib with AC and short run of VT 
    Monitor , 12 leads ECG and pules
    I give O2 , Vein line ,  Amio 150 mg  and trnspot him to the Hospital that make the Pace Maker

  • Lance says:

    Did anyone else catch the "the patient ate a big meal last night"?
    I'd like to know what time of day this call occured and any signs of CHF in this patient (pedal edema, JVD, etc).  I've seen quite a few CHF patients who because of a salty pickle or a can of sodium laden soup have a really horrific case of APE.
    Take the fact that he hasn't been taking his diuretics as perscribed for the past few days and you have a serious case on your hands.

  • FB says:

    To Troy,
    When using overdrive pacing, the rates are usually around 110 if I'm not mistaken or up to 150. The goal is to produce a QRS with a smaller QT-interval (QT interval is usually inversely proportional to heart rate. I'm also not so certain you would necessarily see pacing spikes in the case of a broad/fast tachycardia (it may be minimal compared to what the QRS looks like). Also, does the overdrive pacing of the AICD have to last for a few minutes or just until the tachycardia stops? In overdrive pacing for torsades you usually don't have to set that high of a rate (about 110) to shorten the QT because in many cases of torsades the QT is already grossly prolonged.

  • CBEMT says:

    1)  Call the BLS crew back to the scene and ask them if this patient still looks like the green tag they told you he was. 
    2) Make him come for the ride.  He might actually learn something and you can use the hands, especially if this gets worse.
    3)  If you live in Massachusetts or any state like it, remove your certification from your wallet and
    3a) Set it on fire, because that's what OEMS will do when they find out that you let the guy walk and then this happened. 

  • CBEMT says:

    @Robert- you make it sound like Jenny's need to transmit the 12-lead is a direct judgement of her indivudual capabilities and not a decision made at the system level considering many factors that you have no clue about.  Get over yourself.  Even if you're running in the most progressive system out there you still had to start somehere and I bet it wasn't with paramedic-activated cath labs. 

  • Bill says:

    Agree with Vince…given the AF hx, Ashmann's was the first thing I thought of.  treat the patient, not the equipment.

  • tsalva says:

    Abbarent A-fib. They guys on amio but hasn’t taken it. Amio is very potent and has to be weaned down like steroids. I would maintain 02, start an IV, consider CPAP, perhaps some lasix, whih he apparently hasn’t taken, then call and talk to a doc about giving some amiodarone. Because of amios many actions it works above and below the junction, so it should do everything we want, slow the rate, narrow the QRS, and clear up the ectopy. As far as the pacer I don’t really care what its doing all I know is its only firing occasionally. As a sodium potassium and calcium channel blocker with beta blocker effects I think it would solve all his problems.

  • Ken says:

    I think the clue here is recent pacer/aicd. The right vent is highly susceptible to ectopic stimulation. As a matter of fact and EP physician once told me that 75% of all vent ectopic originates there (R vent). The pacer lead has become displaced and the phenomena is called cath or lead “whip” Field tx will be confined to pretty much supportive. The definitive will be to remove the lead and replace,.attempting to better anchor.

  • amal says:

    I think the rhythm is AF with LBBB with series wide QRS tachycardia, there is failure of pacemaker/ICD .
    the pacemaker/ICD lead must be investigated to be displaced, if in place reprograme the pacemaker

  • Todd says:

    @CBEMT and you must be a shining jewel at your department. It's para-assholes like you that divide fire and EMS even more. I'm a medic and a firefighter and I can tell you now if you try to come to me and my crew with that attitude you'd be riding a pole out the door after leaving a tooth donation at our firehouse. Yes, the green triaging was wrong (triaging period was sorta silly imo). If the only way we were going to get him to the hospital was him wanting to walk to the ambulance then so be it. Otherwise they would have been coming back with him in far dier circumstances than what he was presenting in this case study. How about you follow your own and advice and get over yourself…
     
    Now that I've vented/gotten that behind me, I agree with a couple people that have said it that this seems to be a severe exaserbation of this patient's CHF secondary to him not taking his meds. A lot of his problems can be identified by the meds he's on. He didn't take his Amiodarone there for his 12 lead is going to be wild. He didn't take his Lasix and had a big meal (great catch Lance) so he's probably going to be experiencing severe CHF. His pacemaker obviously isn't doing shit for him. Treat for CHF. My protocols state CPAP, IV, MONA, and I'd call our med control to see what they think about ami to control his rate based on his history. His rate is too fast to determine as to whether his tachycardia is ventricular or not. But yeah, I agree with the idea of fluid control to hopefully help with most of the problems seen here…

  • David says:

    Any resolution to this case?

  • Mel The Medic says:

    Im going to say, cardiac magnet (if in your protocol) and sync cardioversion.  There is failure to capture with his latest and not so greatest pacemaker. It appears as though this is an accellerated IVR with runs of vtach.  Still new at all this, but a fib w/ rvr seems a little out there… not sure thats the case here.  However, still at risk of throwing a clot w/ cardioversion…
    This is a good case, I would like to see what the ending dx was, and tx.

  • Todd G. says:

    This is a case of an irregularly irregular rhythm that becomes widened as it speeds.  The a-fib speeds up and there is aberrent conduction present.  If your not absolutely sure it's regular double check. Simple V-tach is always completely regular.  The rate makes it hard to count, but it's irregular.  It's called Ashman's Phenomena and is generally benign.  In this case treat your patient not the monitor.  Only treat with Diltiazem or cardioversion if the blood pressure is unstable.  O2, CPAP, Nitro, MSO4 are indicated here until things change. 

  • Deb says:

    Postitive lead II,III and aVL. V1 is negative which suggest this originates from the RVOT. I'd say RVOT VT, the rate is ireggular which would be unusual for this diagnosis but I think the patient has AF too ie a double tachycardia. IF the patient does indeed have an ICD fitted this may not ATP the tachy depending on how the device is programmed. I see the non captured spikes but this could be something as simple as undersennsing of AF by the atrial lead. Comments welcome!
     
     
     

  • david64 says:

    The arritmia shows streaks of  a TV, so cardiovert the patient (synchro) with a 100-150 J, then we can add 150 mg amiodarone in SG5% administered in 20 min + diuretics (according to the BP after cardioversion)  You can also add CPAP for a faster and better outcome (if you have one available) and keep tha patient on 15 L/min O2 on no-rebreather ventimask . Later on in the Hospital  we can ask for advanced assessment by a expert but meanwhile we have to reverse the acute cardiac failure-
     

  • Jason says:

    Lots of different thought patterns out there on this case!  I'm oinclined to think we are looking at  APE/CHF.  The h'x of a-fib w/ HTN is highly suggestive of undiagnosised, as of yet, CHF.  The recent AICD/pacemaker leads me to think the desease is progressing.  Add that to noncompliant over the past two days and here we are.  The rythm appears.  a-fib RVR w/ abberancy.  I'm thinking it is irregularly irregular and that there is no axis deviation.  But the tachycardia is compensatory and not our primary cause and the rhythm is likely baseline.
    So as far as treatment goes lets get down that CFH/APE algorythm.  ntg and CPAP.
    I like the diff dx of infection.  Whoever threw that one outh there, kudos.  
    I don't believe we have v-tach; yet.
    I don't believe I want to cardiovert this guy.  My thought process is cardioversion is great for primary problems but this arythmia I beleive to be compensatory.  
    Thats my story and I'm sticking to it.  Now put this ambo in gear and lets boogie…. I want this guy on the hospital bed and not my cot!

  • Walt says:

    Well it's definitely wide complex tachycardia until proven otherwise. I don't see any "p" waves. Rhythm is NOT regular, so that eliminates SVT AND VT. Nothing in hx that tells me that AICD fired which lowers probablity of VT. Maybe a paced rhythm but in my expeince paced rhythms are regular not irregular. Axis is normal. No terminal "R" wave in V1 so probably LBBB morphology. I would call this Atrial Fibrillation. Patient has HX of AF, is on lasix and Coumadin. I would rule out CHF vs COPD vs AF with RVR. As far as treatment, CPAP is best here with 0.04 mg of NTG SL. Would probably give albuterol via CPAP as well. 

  • Brian says:

    There are several pacemaker spikes (like 3rd beat in top strip). It's irregular, most likely a fib with LBBB with occasional pacemaker firing. I would call MC for an order for amioderone and lasix (although doctors around my area probably will decline prehospital lasix). CPAP for dyspnea. CHF + a fib and non-compliancy with meds produces a sick pup. 

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