Snapshot Discussion: 32 year old Male–Chest Discomfort

Here is the discussion for the Snapshot Case: 32 year old male–Chest Discomfort. Sorry for the delay.

If you recall, we have a young patient, a 32 year old male, with a heart rate too rapid to count. He is alert and oriented, and has a good pressure (126/70). He has been in the following rhythm for at least two hours:

 

So, what do we know about the rhythm? It is wide and fast, with a rate of 262. Since wide + fast = VT until proven otherwise, you couldn't be faulted for running it as VT.

Unfortunately as a "Snapshot Case", we don't know the outcome of this patient. However, our mission was to come up with a differential for this rhythm, so I'll share some thoughts:

  •  A-Flutter with 1:1 conduction: With rates approaching 300, it would be appropriate to consider it. I don't see any evidence of flutter waves though.
     
  •  SVT with LBBB aberration: The QRS is wide, but not that wide at 130 ms. V1 is negative, and there are monomorphic R waves in leads I and V6.   This is typical morphology for LBBB. Also, let's look at a clear QRS, from lead III:

           

           You can see that the initial downstroke of the QRS is sharp, and occurs in less than 20 ms. This as well favors SVT/LBBB over VT. If it is SVT, it could be either AVRT (WPW) or AVNRT.

  • VT: The rhythm is wide and fast, and it is possible that this is VT. The QRS is not that wide but it could still be fascicular VT (but I would have expected RBBB morphology) or RVOT VT (which would not have RBBB, but then I would expect the inferior leads to be positive not negative). It doesn't seem to meet any criteria that rule in VT (no initial R wave in aVR, concordance, etc), but that does not rule out VT. And then there is the sharp initial deflection of the QRS, instead of a slower activation. And of course the patient's age and history do not favor VT.

All in all, I think any of the above are reasonable in this case. We can't know for sure, but I lean towards SVT with LBBB aberration, probably rate related, unless he happens to have LBBB as a baseline.  You may have other thoughts, and I'd love to hear them!

As far as treating the patient, his mental status is good, his pressure is good, and he has been tolerating this rhythm for at least two hours. I think he's a good candidate for a trial of Adenosine, which might reveal the answer. If that fails, there is Amiodarone, cardioversion, or diesel as far as my protocols go. 

With no clear cut answer, I'm sure you all will have some good thoughts to add to this discussion. Sometimes, we just don't know for sure, but we still have to hone our skills of considering our differentials.

Thanks for reading, and I'm looking forward to your comments!

28 Comments

  • Chuck Barrier says:

    AHA saysAdenosine 6mg is indicated for wide regular monomorphic. That might give the underlying pattern for further trx

  • robert says:

    v-tach with a pulse as for treatment start a iv d/5/w kvo,put the patiant on o2 non-rebreather at 100%,while that is going on have partner remove all jewlery,if patiant was swimming or in the shower make sure pt is completley dry,i also would draw bloods,i would also cardiovert starting at 100 joules,patiant is already on a monitor,i would push amiodarone at 150 mg every 10 minns

  • HunterMedic115 says:

    You can’t go wrong with Adenosine to see what’s going on. In my protocols case, if it is indeed a-flutter we do Cardizem .25 mg/kg over 2 minutes, since by all accounts he is a stable patient except for the rate. Other options at my disposal are an Amiodarone drip (150mg/100ml D5W/10 minutes) and even Magnesium Sulfate 2gm/10ml/2min. Some new medics would see this rhythm and say “OMG he needs to be cardioverted.” But I’ve always believed in chemicals over electricity, wouldn’t you agree? 🙂 too bad we can’t see the outcome.

  • dr rajendra Prasad says:

    VT monomorphyic

  • Joseph says:

    Id get airway ready, attach combi pads, 02 titrated to 92%>, obtain 12 lead, start 2 lines minimum 18g atleast one in the ac, draw my adenocard and coach the patient through whats about to happen (givem the opportunity to try vagal stimulation but ultimately ive never seen it work and it didnt work for me when i used to have my svt episodes that bought me a $32,000 ticket to the cath lab). with all the equipment prepaired for the worst id look forward to the best and slam the adenocard with print running. if it doesnt fix it it might slow it down to help read it. worsat case scenario i have to code him and im prepaired for it. if adenocard fails and he doesnt arrest, ill max out the drug and move on to syncronized cardioversion if needed. whats everyones opinion on trying to use cardizem as a last line of defense?

  • Joseph says:

    ** forgot to state lines would be tko, 500ml one side, 1000ml other, both NS

  • aboubaker el-agnaf says:

    I totally agree with you the only thing to add to your discussion is that if you see carefully at V5 you will see a P wave and the RP interval< PR interval and this indicate this patient is infact AVNRT as supposed to AVRT and the LBBB pattern is just rate related and the age of the patient infact in favor of SVT as you alredy said

  • Jon says:

    So Robert, you would shock this pt???? Negative. Drug therapy for it. Adenosine to see if it works and an underlying rhythm is noted…..amiodarone after……oxygen and diesel…..NEVER MESS WITH A STABLE PT!!!!!!NEVER!!!! set everything up but never mess with it. If one thing is out of norm and everything else is fine and pt is talking and feels fine….DON’T MESS WITH IT. GET TO THE HOSPITAL AS FAST AS POSSIBLE. Remember our job is to stabilize until we get to the hospital, not Tx and Dx in field. If they are stable, well my job is done. Granted if this 32 y/o is in fact in V-Tach get everything set up because we all know they won’t be stable for long.

  • Josh says:

    I’ve been impatiently awaiting an outcome on this case since it was first posted, it’s unfortunate that no follow up could be made. However, as a new medic, I am happy to see that my differentials and subsequent route of treatment fell in line with what you have mentioned above… Maybe I do know what I’m doing after all!

  • jean says:

    the pt is a 32 year old male who has been in this rhythm for 2 hours and tolerated it with stable v/s. i would of course start iv access, place pt. on 15 liters via nrb. be prepared to cardiovert if v/s become unstable first try a round of adenosine and use high flow diesel to pass him on to someone else. you treat the pt not the rhythm.

  • James says:

    my initial treatment would have been for SVT, 6 mg adenosine followed by 12 mg and 12 mg if no conversion on initial dose. If no change here I would have bolused 100 mg of lidocaine up to max dose if needed. If lidocaine converts I would have hung a lidocaine drip at 2 mg/min and tritrate to effect. If all else fails I recommend DIESAL THERAPY. Going by information provided here, it appears the pt is asymptomatic and I would rule against any cardioversion at this point, but don’t get me wrong because combipads would be in place.

  • Wtfchuck says:

    ALS established. Continue to monitor patient for he is stable. Consult cardiologist.

  • Melissa says:

    does he have a pacemaker? It looks paced. It sure as shit isn’t VTAC since he’s been in it for 2 hours. Have him vegal if you can. Try the adenosine last

  • Paul Bishop says:

    I’m sure this will sound crazy, but my drug of choice for this patient would be procainamide. 17mg/kg over 30 minutes, or 100mg over 5-10 minutes. Procainamide can safely be used to treat a-fib, a-flutter, SVT’s, AND VT. Failing that, I would sedate and cardiovert in a controlled fashion.

  • Smurfe says:

    As of last Moday when our protocols changed I would now give a trial af Adenosine then move to Amioderone. I would never cardiovert unless the patient became symptomatic such as dyspnea, chest pain, altered mental status.

  • Melissa,

    I have a case report of a patient being in stable VT for multiple days because they were inappropriately diagnosed as SVT with Aberrancy:

    We report a patient who, despite significant cardiac disease and inappropriate therapy, endured continuous undiagnosed ventricular tachycardia (VT) for 5 days without hemodynamic deterioration. The two main reasons for the frequently missed diagnosis of VT are (1) the mistaken belief that VT cannot be well tolerated, and (2) ignorance of the many helpful electrocardiographic clues. Six precepts for avoiding misdiagnosis are enunciated. (Symanski BJ, Marriott HJ. Ventricular tachyardia, diagnosis and misdiagnosis: A case report. Heart Lung. 1995 (24):121-3.)

  • VegasMedic says:

    SVT with wolff-Parkinson-White
    Delta waves?

  • aboubaker el-agnaf says:

    this patient beyond any dought is AVRT with atrial rate 250b/m  and the treatment   as you said
    1- carotid massage
    2- adenosine
    3- i/v  rate limiting CCB
    4- if no reponse  try ammiodarone infusion
    5- if no reponse   overdrive pacing
    6- if no reponse  cardioversion
     electrophysiological studies later
     

  • Mary says:

    I know a lot of people have already said it, but it warrants saying again: if this guy is stable and normal LOC why would we even give medications? Get ready for the S*** to hit the fan, but don’t mess with someone who is stable if you don’t have to. No way I would cardiovert this guy until he started developed signs of inadequate perfusion. O2, monitor, patches out, IV fluid bolus, get to cardiologist quickly.

  • alex says:

    I get stuck on ECGs like this an struggle to identify basic things like the PQRST waves (which are which on this ECG?) and the isoelectric line. Does anyone have any advice?!

  • Alex,

    This ECG is tricky in that there is no isoelectric line visible in any lead. We do however, have the peaks and valleys of QRS-complexes.

    In Lead III which David highlighted we have a QRS complex and a T-wave. The QRS complex begins with a tiny R-wave and is followed by a deep S-wave. The T-wave which follows almost runs into the next QRS. This is pretty common with fast heart rates, and this one is about as fast as it gets.

    You can use the stack of leads (I, II, III or V1, V2, V3) to help by drawing a vertical line through a "feature" and seeing what it looks like in other leads. This can help you confirm if what you're seeing is a QRS or a T.

  • Danny says:

    Anyone who is suggesting that this patient does not warrant any treatment with medications is absolutely crazy. If you get all the way to the receiving facility without taking out a drug box for this patient (potentially vt), then you should reconsider being a paramedic.

  • KEVIN BOUNDS says:

    I see the answer here by several people . I also see some who know the answer but are afraid to act. Yes this pt appears stable but at this rate he will deteriorated suddenly when he starts to decompensate. In my limited experience I would of course do all of the basics, O2, IVs, EKG etc. My experience has taught me that one of my IVs should be a large bore to an EJ. And because I would always prefer medication over electrical therapy on an otherwise stable pt due to burn pathways created by cardioversion, I would use Adenosine at the EJ IV site. I have seen this scenario on real patients many times in my 35 plus years of EMS. Also I would be ready for whatever happens but I have full confidence of a good outcome in a young person with this problem. I would also be a cautious of possible drug use by the pt.

  • Aharon Oppenheimer says:

    Hi my friends
    What I do in that case I decide Adenozin , why? it's short time action and ut's can give chamce to see better the rythem and to give me , maybe other way to tretma=ent this patiant if it's not SVT as usual I give him O2 and I think for next step on amiodoron and on the last step cardiovertion
    but the first  choice is Adenozin
    Aharon

  • Michael says:

    An assessment of VT would be correct and a Medical Control Doc might agree. But the Doc would still be hard pressed to give us permission to try any drug or electrical therapy and would rather have us just transport and monitor the patient, unless there is a change in the patients signs and symptoms.

  • Danny says:

    All of these treatments are generally standing orders though. You have a young patient with a wide and fast 12lead, at a rate of over 260. VT or not, if you do not attempt to treat this, it will be brought to someone's attention at some point in the review process.  Based on that mindset, an ALS ambulance should simply stock fluids. You do not know that this patient will remain "stable" during transport. Better to be a little ahead than to have to play catchup. Just my thinking.

  • K.I.S.S. says:

    I think we all tend to overcomplicate these wide complex tachs: Assume VT until we get a baseline EKG proving an aberrancy. Procainimide if stable (warm extremities + SBP nml for that patient). Electricity if unstable (cool extremities or SBP < nml for that patient).
     

  • Austrian Paramedic says:

    Patient has monomorphic VT (QRS wide). Treatment like VT until proven otherwise. Avoid negative inotrope Meds. Only 10 % of these patients are haemodynamic stable. I would go with VT because of the AV-Dissociation, Capture and Fusion Beats. High risk of VF. Differential Diagnoses woud be: VT, SVT+conduction block, SVT+Preexcitation, SVT+pacemaker and (of course) artifact. So i would go with VT. It´s a shame we dont know the patients condition exactly… 
    Treatment
    If patient is stable 
    – central venous access
    – at least 500ml Ringer Solution
    – Overdrive Pacing
    – if that dont work: 300mg Amiodarone i.v.
    Alternatives: 
    – Catecholamine (to rule out reflex tachycardia)?
    – Ajmanlin fractioned 5-10mg i.v.
    – Lidocaine 100mg i.v. (slow)
    – Mg-Sulfate 1-2g i.v.
    – Beta Bocker (only under monitoring and only if patient has no history of cardiomyopathy)
    If patient is not stable (Signs of ischemia, neurological deficit, BP under 90 sys.)
    – anesthesia with Etomidat – 0,2 -0,3 mg/kg
    – Cardioversion with 100, 200, 360 J R-synchronous
    – Amiodarone 300mg i.v.

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