Need some advice on this scenario

[rhan101277]

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I treated this patient, although i realized I could have consulted with a doctor for further treatment options, I think I did good. I consult a good bit on the phone for unusual calls or calls where I just want to run something by the doc. Just wanted to see what some doctors thought.

Chest pain, HR 190
Here are the details, this happened a couple days ago.

Age: 56 y/o male
Pmhx: COPD, CHF, previous Dysrhythmia requiring non-emergency DC cardioversion.
Meds: Amiodarone, Furosemide, Albuterol, Crestor, Lipitor, ASA


Scenario:

I get a call about chest pain around 4am, pt is mildly SOB, has substernal chest pain 9/10 - non radiating, that started while sitting still. He has previously taken 350mg ASA today and our protocols state to not administer any ASA if they have had some. He has wheezing but it is not acute, says he has had it for "years.:

The patient is alert and oriented x 3, GCS 15. His diaphoretic, pulse is 190 wide complex tach with QRS 138ms, but he has RBBB also and takes amiodarone (200mg x 3 daily) so I think it could be widened due to that. Pt was admitted two weeks ago for this and they waited 3 days before electrical cardioversion. I initially think this is SVT w/ aberrancy due to the rate is regular and I think QRS is wide due to reasons stated above. The reason I think this is that the axis deviation is not extreme right axis and also V1-V6 are not in concordance.

Vitals:

BP: 84/54
HR: 190
Pulse ox: 99 on 4L oxygen
12 Lead: No st elevation or depression ( can't really detect ST elevation with a BBB in place).

I try vagal maneuvers and rate doesn't slow, I try using adenosine as a diagnostic tool to slow rate 6mg, 12mg then 12mg and no slowing. We arrive at ER before I have time to mix amiodarone 150mg over 10 min. He remains AAOx3 and systolic BP never drops below 80. Transport time was 15 minutes.

ER doc opts to cardiovert, but contacts cardiology for a consult. He gives etomidate, starts up amiodarone drip and before he can cardiovert the pt goes into a flutter with 3:1 conduction and he doesn't cardiovert. I didn't find out any more behind what went on but I was definitely more stressed on this call than usual. Dr first thinks this is vtach but then says it is afib with RVR but it is regular, he said sometimes rate can be so fast it always looks regular.

Would you have cardioverted this patient? I elected not to.

http://www.emtlife.com/attachment.php?attachmentid=928&d=1323364263

 

[BADMD]

Would you have cardioverted this patient?

Yes.

 

[Tiger26]

I would absolutely cardiovert--dude's extremely tachycardic, hypotensive, and symptomatic. Even the most astute emergency physicians and electrical physiologists will disagree on whether it's VT or SVT w/aberancy

 

[Arcan57]

Wide-complex tachycardia = V-tach until proven otherwise in the EP lab. Honestly though, I don't care what the actual rhythm ends up being called. The final common pathway for every tachyarrhythmia with signs of hemodynamic instability is electricity. You may hang magnesium if you think it's torsades or give procainamide if you think it's WPW w/ A. fib, but he's getting shocked.

 

[alphaholic06]

An unstable patient (hypotensive, tachycardic, and symptomatic) with a wide complex tachycardia gets to ride the lightning. It doesn't matter if it's VT or SVT with aberrancy, electricity corrects both. And as Arcan said wide complex tachycardia equals Vtach until proven otherwise.

 

[rhan101277]

I was 15 minutes out from the ER, I was thinking it would be better to do in a controlled environment. In the field hypotension in my area is considered SBP <90 and while 84SBP would be considered hypotensive it is borderline. Also while he is symptomatic our protocols say that shock if the patient has altered mental status, hypoxia and/or hypotension.

I would have had to shock him with no sedatives since we only carry versed and it causes hypotension. I will make sure to learn from this call though, first VT i've seen in the field.

It would have been tough to explain to the family what happened if he was talking to me and then I was doing CPR when we arrived due to asystole or vfib. Which granted could occur from me not doing anything but can also occur from cardioversion.

 

[Tiger26]

Again, don't want to second guess you, but the right thing would have been to shock him at the outset. Do you have any pain meds on board your rig?

 

[rhan101277]

Again, don't want to second guess you, but the right thing would have been to shock him at the outset. Do you have any pain meds on board your rig?

Yeah I have morphine and fentanyl, I would have to call for orders for both to use as an adjunct to cardioversion but thats a good idea. I know people make mistakes and no one is perfect, I will learn from this and no bad outcome happened.

Same scenario, I will probably call doc and consult, that way if it goes bad no one can say well the paramedic thought it was unstable and cardioverted.

 

[goodoldalky]

I would start with the idea that I had been taught which is, it's never wrong to shock in this situation. In fact, if there is any doubt, it's VT unless proven otherwise. Unstable, cardiovert. VT, cardiovert. Not sure, wide complex tachycardia, cardiovert. 80+% of wide complex tach is VT, all comers. Couple of thoughts based on my limited experience:

Age: 56 y/o male
Pmhx: CHF

These are two huge risk factors for VT over SVT with aberrancy. Age > 35 has something like 80+% PPV for VT as opposed to SVT. Plus, he has structural heart disease.

His diaphoretic, pulse is 190 wide complex tach with QRS 138ms, but he has RBBB also and takes amiodarone (200mg x 3 daily) so I think it could be widened due to that.

The morphology helps you here. If it is widened, but doesn't look entirely like RBBB, it's not widened due to his BBB, it's VT. I am assuming it looked like a RBBB to you which doesn't help much. I would also say the QRS width doesn't say much here, but if it were a bit longer, 150, 160, that would be another indicator for VT being much more likely than SVT. Tough to say anything with a QRS of 138, though.

Obviously P-waves are huge. If you can find any P-waves, noting if there is any evidence of AV dissociation will also indicate VT.

I try vagal maneuvers and rate doesn't slow, I try using adenosine as a diagnostic tool to slow rate 6mg, 12mg then 12mg and no slowing.

This is another sign that this is VT and not SVT with aberrancy.

There are some other things, like Brugada's sign, where you are measuring portions of the QRS and determining what the intervals are, etc.,to determine SVT vs VT, which would theoretically require calipers and time etc... frankly I just looked it up as I type this to read the criteria. I certainly don't have them memorized, although I wish I did. Maybe the experienced EP's have that memorized and go right to it. I would classify that as less important, because If you are in this situation in the field, you should go ahead and cardiovert rather than wasting time with calipers, because if you're not sure, it's VT. And if it's not VT, it doesn't matter, because cardioversion works either way, and is actually indicated whether it's VT or SVT with aberrancy if the patient is unstable.

And finally I would commend you for following up on this... that's how I learn most of what I learn anyway. Good job.

 

[rhan101277]

Shocking someone in the back of the rig without sedation feels like middle age medicine but if it has to be done it has to be. I can explain procedure to patient and say it will cause pain but this needs to be done and also explain there is a small chance he would get worse, like him going into VF, etc.

Thanks again to all the responses.