another interesting ECG

[viostorm]

After that great discussion prompted by Fiznat I thought I'd post this ECG that has been giving me trouble for a while.

19 year old male, CP, no meds, no hx

http://www.viostorm.com/ecg/19yo_male_CP_small.jpg

Anyone have any insight?


Outcome:

Converted at ED w/ a calcium channel blocker to a narrow complex rhythm, no strip was available.

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[fiznat]

Wowzers! Alright, to start with a systematic approach:

Rate: 247 per the printout
Rhythm: Regular
Axis: Normal
QRS: Hard to tell but about .20-.24? Wide
P: None visible

Jeez I donno. The strip says A-Flutter but its so rapid you cant really tell. Looks almost like VT but you say his only complaint was CP and the morphology of the QRS is a little too straight I think. The BBB is obvious, so I suppose we can attribute some (or all?) of the widened QRS to that. With a strip this quick how can you decide between a SVT or an accelerated junctional/ventricular rhythm?

Possible treatment: O2, IV Adenosine (6mg, 12mg, 12mg), hopefully slow it down and see what that underlying rhythm is? If his presentation is bad enough then light him up!

I defer to the experts, lol, or at least those who have finished cardiology.

 

[12R34Y]

Wowzers! Alright, to start with a systematic approach:

Rate: 247 per the printout
Rhythm: Regular
Axis: Normal
QRS: Hard to tell but about .20-.24? Wide
P: None visible

Jeez I donno. The strip says A-Flutter but its so rapid you cant really tell. Looks almost like VT but you say his only complaint was CP and the morphology of the QRS is a little too straight I think. The BBB is obvious, so I suppose we can attribute some (or all?) of the widened QRS to that. With a strip this quick how can you decide between a SVT or an accelerated junctional/ventricular rhythm?

Possible treatment: O2, IV Adenosine (6mg, 12mg, 12mg), hopefully slow it down and see what that underlying rhythm is? If his presentation is bad enough then light him up!

I defer to the experts, lol, or at least those who have finished cardiology.

I'd call this v-tach (wide complex tachycardia) and if symptomatic....cardiovert. Rate is fast for typical V-tach so I'm guessing some sort of AVNRT (av nodal re-entrant tachycardia), consider WPW etc....

Look for other reasons why he's in this. urine drug screen, chemistry. blah blah.

later

 

[fiznat]

I donno, the axis is normal which is a count against a possible VT diagnosis. Also, leads I and V6 show the typical LBBB characteristics (hard to see in V1) which suggests a supraventricular focus.

Urine screens and chem panels are great for the ED, but this the EMS forum and for some reason my medcon isnt exactly eager to have me run labs in the back of the ambulance

 

[12R34Y]

I donno, the axis is normal which is a count against a possible VT diagnosis. Also, leads I and V6 show the typical LBBB characteristics (hard to see in V1) which suggests a supraventricular focus.

Urine screens and chem panels are great for the ED, but this the EMS forum and for some reason my medcon isnt exactly eager to have me run labs in the back of the ambulance

Axis isn't something I'd worry about when looking at this rhythm strip. This patient would be called wide-complex tachy and if CP (equals symptomatic would get zapped) no questions asked.

Cardiologists disagree wholeheartedly all the time on these type of rhythms (unless you are in an EP lab you won't know definitively what it is/was every possibly).

The more I think about it this looks like ventricular flutter (fast V-tach usually around 300) very commonly associated with WPW (I still think this is WPW with a bypass tract b/c the rate is waaay too fast for normal AVNRT).

I also would buy A-flutter with 1:1 conduction through a LBBB. Again.......WPW.

This rate is too fast for non-WPW in my opinion.

It's all a moot point. This guy gets cardioverted after our friend propofol is given and adios to the bad rhythm.

later

 

[greytmedic]

I go by one simple rule when it comes to EKG's. If you don't the rhythm, shock it until you do. Makes it simple, all you need to know is asystole.

 

[viostorm]

Axis isn't something I'd worry about when looking at this rhythm strip. This patient would be called wide-complex tachy and if CP (equals symptomatic would get zapped) no questions asked.

Cardiologists disagree wholeheartedly all the time on these type of rhythms (unless you are in an EP lab you won't know definitively what it is/was every possibly).

The more I think about it this looks like ventricular flutter (fast V-tach usually around 300) very commonly associated with WPW (I still think this is WPW with a bypass tract b/c the rate is waaay too fast for normal AVNRT).

I also would buy A-flutter with 1:1 conduction through a LBBB. Again.......WPW.

This rate is too fast for non-WPW in my opinion.

It's all a moot point. This guy gets cardioverted after our friend propofol is given and adios to the bad rhythm.

later

I like your diagnosis, that is kind of where I have gotten after a while.

I wish I could have gotten a strip after the conversion at the ED to see if there were any WPW characteristics when he was in his *normal* rhythm.

I also think the age suggests more of a conduction abnormality versus VT.

 

[docB]

You've gotta treat this as Vtach until proven otherwise. If they're symptomatic zap them. If you want to medicate them give them amio. Don't give these patients anything that will block the AV node like a Ca channel blocker or Adenosine. If it's a reentrant tach like antidromic WPW then you make it worse. I've seen a few of these and in young patients that EKG would make me highly suspicious for antidromic WPW.

 

[12R34Y]

You've gotta treat this as Vtach until proven otherwise. If they're symptomatic zap them. If you want to medicate them give them amio. Don't give these patients anything that will block the AV node like a Ca channel blocker or Adenosine. If it's a reentrant tach like antidromic WPW then you make it worse. I've seen a few of these and in young patients that EKG would make me highly suspicious for antidromic WPW.

What do you think about stable (rock solid) monomorphic VT treated with procainamide?

Did you read the last Annals of EM about how dismal amio and lido (even worse) are at terminating monomorphic Vtach. Amio converts in like less than 40% of the time. Procainamide takes about an hour to work but if they are stable it works very well.

they came to the conclusion that sotalol is BY FAR AND AWAY the best treatment for monomorphic Vtach, but its only oral in the US and thus not useful.

Procainamide works it just takes a little while.

Amio and lido both are terrible.

these were the conclusions reached .

what do you think?

later

 

[12R34Y]

What do you think about stable (rock solid) monomorphic VT treated with procainamide?

Did you read the last Annals of EM about how dismal amio and lido (even worse) are at terminating monomorphic Vtach. Amio converts in like less than 40% of the time. Procainamide takes about an hour to work but if they are stable it works very well.

they came to the conclusion that sotalol is BY FAR AND AWAY the best treatment for monomorphic Vtach, but its only oral in the US and thus not useful.

Procainamide works it just takes a little while.

Amio and lido both are terrible.

these were the conclusions reached .

what do you think?

later

Again.......I agree with my original reply....Vtach (wide complex tachycardia) and would treat it as so.

 

[emtcsmith]

My first thought was VTach.


If those drugs don't work what else can they give EMS/ER/etc providers to use?

 

[DropkickMurphy]

If those drugs don't work what else can they give EMS/ER/etc providers to use?

It's called a defibrillator with cardioversion capabilities, as pointed out before. And the ER docs have the things to treat them (i.e. procainamide in stable cases as 12R34Y noted). If the patient isn't unstable (asymptomatic), why be in a big rush to correct the rhythm? All you would be doing is putting the patient at risk for little, if any, immediate benefit (or long term benefit for that matter).


To address something else that was brought up: Why in the heck hasn't some drug company introduced a parenteral form of sotalol in the US?

 

[spo0kman]

Adenosine won't work if its a-flutter, and obviously not if its V-tach. I disagree with "treating as v-tach until proven otherwise", your only course of treatment avail would be cardioversion (unless you have cardizem and are treating it as a-flutter).

I believe whole heartedly in diagnosing the rhythm yourself, however the computer may be smarter than all of us this time, so if it says a-flutter, I might be inclined to agree. Additionally, while it *could* be artifact, you shouldn't see an rvr in v-tach.

Your patient description is incomplete, complaint of chest pain doesn't tell us much. Is it cardiac or non cardiac chest pain, how bad is it, how is the patient tolerating it. Were all the beats perfusing (doubtful) but what was the actual pulse rate. What was the patients blood pressure/skin condition. All of these things are important to know before deciding on cardioversion vs channel blockers vs transport to the ER with no treatment and allow conversion under a controlled atmosphere with tPA/rPA available. Lets not forget the potential for microclots with a-fib/flutter.

Another option would be vagal maneuvers to see if you can slow the ventricular rate down enough to identify a flutter waveform or p wave. I'm personally inclined to not be agressive with ventricular anti-arrythmics, as the machine is calling that supraventricular in origin, I'd sure hate to stop ventricular activity..

 

[12R34Y]

Adenosine won't work if its a-flutter, and obviously not if its V-tach. I disagree with "treating as v-tach until proven otherwise", your only course of treatment avail would be cardioversion (unless you have cardizem and are treating it as a-flutter).

I believe whole heartedly in diagnosing the rhythm yourself, however the computer may be smarter than all of us this time, so if it says a-flutter, I might be inclined to agree. Additionally, while it *could* be artifact, you shouldn't see an rvr in v-tach.

Your patient description is incomplete, complaint of chest pain doesn't tell us much. Is it cardiac or non cardiac chest pain, how bad is it, how is the patient tolerating it. Were all the beats perfusing (doubtful) but what was the actual pulse rate. What was the patients blood pressure/skin condition. All of these things are important to know before deciding on cardioversion vs channel blockers vs transport to the ER with no treatment and allow conversion under a controlled atmosphere with tPA/rPA available. Lets not forget the potential for microclots with a-fib/flutter.

Another option would be vagal maneuvers to see if you can slow the ventricular rate down enough to identify a flutter waveform or p wave. I'm personally inclined to not be agressive with ventricular anti-arrythmics, as the machine is calling that supraventricular in origin, I'd sure hate to stop ventricular activity..

Rule number one ALWAYS: Wide complex tachycardias are V-tach until proven otherwise. there isn't really an argument to this.

you HAVE to treat this like V-tach ESPECIALLY in the prehospital arena.

Cardiologists argue about the nuances of EKG interpretation and often disagree. I don't want a paramedic (ie: me) deciding that this is A-flutter with a block etc...

you MUST treat this like V-tach and you'd be wrong if you didn't.

just my opinion.

 

[spo0kman]

Well, I'm sorry but I must disagree with you for the moment. I am also an EMS instructor and have never heard that, but I will check the ACLS text tomorrow, so I might be wrong.

Upon furthur review, I would like to point this out about the EKG posted

1. There is clearly an RvR in numerous leads
2. aVL clearly shows the flutter waveform

This to me is not unknown origin.

 

[niko327]

Well, I'm sorry but I must disagree with you for the moment. I am also an EMS instructor and have never heard that, but I will check the ACLS text tomorrow, so I might be wrong.

Upon furthur review, I would like to point this out about the EKG posted

1. There is clearly an RvR in numerous leads
2. aVL clearly shows the flutter waveform

This to me is not unknown origin.

I disagree Spookman,
Treating a wide complex tachycardia of uncertain origin as VT is widely taught, and is in most cases appropriate.

In this particular pt I'd be very wary about using a calcium channel blocker first line.

 

[viostorm]

Spookman ... don't have much other info other then age/sex/CC. It was another crew that ran it a day I was working. I guess I posted it more because I was fascinated by the rhythm and made me think VT or a crazy SVT. I was hoping someone on SDN might have a brilliant insight onto what it was.

The MD at the ED gave the Ca channel blocker and it converted to narrow comple. The crew that transported the pateint just did O2/monitor/IV ... my understanding is the patient was very symptomatic, which is understandable at a rate of 250 whether it is ventricular in origin or supraventricular.

Obviously, treatment of choice for EMS is cardioversion because it works for VT or SVT.

I guess I was just hoping for some brilliant ECG insight. To summarize the consesus seems "who knows but shock it!"

 

[12R34Y]

Well, I'm sorry but I must disagree with you for the moment. I am also an EMS instructor and have never heard that, but I will check the ACLS text tomorrow, so I might be wrong.

Upon furthur review, I would like to point this out about the EKG posted

1. There is clearly an RvR in numerous leads
2. aVL clearly shows the flutter waveform

This to me is not unknown origin.

As a fellow EMS instructor as well as (EM resident starting in June) I can say that at least in my neck of the woods that's a common mantra. Wide complex tach is V-tach until proven otherwise and treated as such until proven otherwise.

If he was "very symptomatic" he gets some happy drugs and I'd electrocute him

 

[12R34Y]

As many of us have said previously I'm very suspicious of this being WPW (pre-excitation) tachy.

therefore I'd be very leary of giving a Ca channel blocker to this patient b/c of the general rule that adenosine, verapamil, diltiazem and digoxin are contraindicated in patients with atrial fibrillation or atrial flutter who have concomitant preexcitation. This may result in ventricular fibrillation, because they often accelerate anterograde conduction down accessory pathways by causing vasodilatation and hypotension, with a subsequent rise in endogenous catecholamine levels.

sounds like the ED doc was lucky.

good discussion however.