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57 year old male: Chest Discomfort – Conclusion

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This is the conclusion to 57 year old male: Chest Discomfort. We suggest you read the backstory first!

We're now in the back of the ambulance with our stubborn 57 year old male with a rapid heart rate. He looks unwell, but is otherwise hemodynamically stable. Our partner is working on a line.

Let's review the initial rhythm and 12-Lead ECG:

Round and Round He Goes - Initial Rhythm

The rhythm strip shows a narrow complex tachycardia at approximately 150 bpm. Atrial activity is not visible and may be buried in the T-waves. Our differentials include: sinus tachycardia, supraventricular tachycardia (e.g. AV Nodal Reentry Tachycardia and orthodromic AV Reciprocating Tachycardia), 2:1 atrial flutter, and junctional tachycardia.

Round and Round He Goes - Initial 12-Lead

The 12-Lead also shows a narrow complex tachycardia at approximately 150 bpm. Atrial activity is vaguely appreciable in the T-waves of V1 and III. The list of differentials remains unchanged, however, given the continued regularity sinus tachycardia seems less likely.

The paramedic who sent this case in elected to treat the patient with adenosine to convert or unmask the underlying rhythm.

Round and Round He Goes - 6mg Adenosine Bolus

The post-adenosine rhythm strip shows clear flutter activity in leads II and aVF, however, the paramedic admits they did not initially notice the F-waves. The rhythm then devolved into an irregularly irregular rhythm and a strip was printed.

Round and Round He Goes - After first Adenosine

While there is some baseline wander present, given the previous ECG, it seems very likely that this is atrial flutter with a variable response. However, the rhythm quickly accelerated to its original rate of 150 bpm.

As the treating paramedic did not appreciate atrial flutter, they administered a second dose of adenosine.

Round and Round He Goes - 12mg Adenosine Bolus

Atrial flutter is readily appreciable in Leads II and aVF, and as before the rhythm accelerated to its original rate.

Round and Round He Goes - After second Adenosine

The treating paramedic recognized atrial flutter and contacted medical control asking for orders for Cardizem.

Orders were received for 10 mg Cardizem slow IV push, which resulted in some reduction in rate but without conversion to a sinus rhythm.

Round and Round He Goes - After 10mg Cardizem Bolus

The patient was transported to a local hospital where he was placed on a Cardizem drip, resulting in conversion to a sinus rhythm after a few hours. A follow-up with a cardiologist was scheduled and the patient was discharged home without sequelae.

Any time you are faced with a regular rhythm at around 150 bpm, remember that the most common atrial rate in atrial flutter is 300 bpm and the most common conduction is 2:1.

Posted by on September 21, 2012 • Filed under: ems-topics, patient-management • Tagged: , , , , , , ,

Atrial flutter can cause false-positive ***ACUTE MI SUSPECTED*** interpretive statements

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I first heard about this issue a couple of years ago in a webinar at the D2B Alliance website. Since then I have seen it several times in my own EMS system.

I also mentioned it when I commented on:

Review of Factors Associated With False-Positive Emergency Medical Services Triage for Percutaneous Coronary Intervention

According to that study the most common factors associated with false positives statements were:

  • A specific brand of one of three monitors used in the system
  • Sinus tachycardia
  • Missing lead recording on 12-lead printout
  • Atrial fibrillation
  • Female gender
  • Poor ECG baseline
  • A discussion ensues during

The authors make this important statement:

“Poor ECG baseline and failure to record all 12 leads for machine algorithm interpretation are false-positive associated variables that can be addressed by improved quality in field acquisition of 12-leads.”

It can’t be said often enough! That’s why I’m always harping on achieving excellent data quality!

The authors continue:

“Variables more difficult to address are sinus tachycardia and atrial fibrillation, which had a tendency to be wrongly interpreted by machine algorithm as acute MI.”

In response to that statement I made this comment:

“It would be interesting to know if they are including atrial flutter in with atrial fibrillation. Either way the message is clear. The specificity of the computerized interpretive algorithms is highest when a tachycardia is not present.”

The reason I questioned whether or not atrial flutter was included with atrial fibrillation is simple. Many times I have seen atrial flutter trigger a false-positive ***ACUTE MI SUSPECTED*** message on the LP12 but I can’t think of a time atrial fibrillation cause a false-positive statement (when poor data quality was not present).

Consider these cases that occurred in the past week.

Case #1

In this case the paramedic immediately realized the ***ACUTE MI SUSPECTED*** message was being caused by underlying atrial flutter. A “STEMI Alert” was not called from the field and the patient was not sent to the cath lab.

Case #2

This case was a little more difficult because 2:1 atrial flutter more difficult to recognize than 4:1 atrial flutter. It also must be said that this patient was “sicker” and presented very much like ACS. A “STEMI Alert” was called from the field and the patient ended up in the cath lab. No significant lesions were noted with angiography.

The point isn’t to blame the paramedic from the second case. A board certified emergency physician and a cardiologist both had to agree that this patient needed emergent angiography.

It’s easy to criticize individual paramedics especially when they’re from other EMS systems. What’s hard is to create quality improvement feedback mechanisms so that every call can be a learning opportunity.

There are two kinds of EMS systems in this world: those that make mistakes and those that have no idea whether or not they make mistakes (unless they receive a complaint).

Strive to be the former because anyone can be the latter.

Posted by on February 24, 2011 • Filed under: ems-topics, patient-management • Tagged: , , , , , , , , ,

Differential diagnosis of wide complex tachycardias – Part IV

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Let’s look at a more typical case of wide complex tachycardia.

This case comes from Lt. Jason Kinley of Xenia Fire Division. If you’re not familiar with Xenia Fire Division in Xenia, OH, they have an outstanding prehospital 12 lead ECG program. Jason is also one of the co-moderators at the EMS-to-Balloon (E2B) Challenge! listserv at Yahoo!

Here’s the story.

EMS is called for a 89 year old male with chest pain. Onset 30 minutes ago. Non-radiating. Patient is A+OX4. Skin is moist. Skin color is good. No increase in respiratory effort. Meds for diabetes, hypertension, and unspecified heart problem (patient is a poor historian). The patient is reluctant to go to the hospital. He states he was seen 4 days ago for a possible TIA.



Yes, I know the computerized interpretive statement has been removed. That’s my fault!

Here are the computer measurements:

HR: 150
PR: *
QRS: 126
QT/QTc: 304/475
P-R-T: * -51 110

The treating paramedics correctly identified this as a regular wide complex tachycardia. Because the patient was hemodynamically stable, they initiated a 150 mg bolus of Amiodarone over 10 minutes, with no change to the heart rhythm.

Why Amiodarone?

Because according to the 2005 AHA ECC guidelines, that’s the drug you give for undifferentiated regular wide complex tachycardia. It’s supposed to be therapeutic for both ventricular and supraventricular tachycardias.

You will remember the patient stated that he was seen 4 days prior for a possible TIA. Well, it turns out that the same EMS system brought him to the hospital. As luck would have it, they performed a prehospital 12 lead ECG at that time.

Here it is.


Computer measurements:

HR: 100
PR: 232
QRS: 134
QT/QTc: 350/451
P-R-T: 50 -56 91

Now compare the QRS morphology in the first PH12ECG to the PH12ECG taken 4 days prior, when the patient was in borderline sinus tachycardia with 1°AVB.*

Is it a match? You bet! This patient has a pre-existing intraventricular conduction defect (or atypical LBBB). Note the S wave in lead V6.

Was this patient in ventricular tachycardia? No.

Considering the heart rate of exactly 150, the pseudo-R wave in lead V1 during the tachycardia, and the recently history of possible TIA, 2:1 atrial flutter is the most likely explanation.

However, the first rule applies! In the absence of an “old” ECG for comparison, it’s VT until proven otherwise.

The patient didn’t covert to sinus rhythm, but it was a well-executed call, and no harm came to the patient.

* 3:1 atrial flutter is also a possibility. Note the heart rate of exactly 100.

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

Posted by on January 9, 2009 • Filed under: ems-topics, patient-management • Tagged: , , , , , , , , , , , , , , ,