Wide and fast

[fiznat]

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Caught this patient the other day, wanted to see what the SDN cards guys thought about it:

I have larger sizes if need be.


42 year old guy in good general health (albeit obese) complaining of an acute onset of weakness, diaphoresis, and shortness of breath while sitting at his desk at work. No pain or chest discomforts. BP is 128/82, he's pale and soaking wet. No medical history/meds/etc....

I did a few things for this in the field (I'm a paramedic), and I have a final result from the cardiology consult he got in the ED, but I'd like to see what your impression is of this first if I can...

 

[nstemi]

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[fiznat]

I did start with adenosine. I didn't get much result (even after 12), although the space between the QRSs did widen briefly. During that time I *thought* I saw flutter waves, but couldn't be totally sure with such a short window. There was definitely what I would call "atrial activity" though.

 

[DrMom]

The OP asked me if they could have the EM opinions.

 

[WilcoWorld]

Given the age, the rate, and the possible p's peaking through my money is on SVT with abberancy/Antidromic WPW. If I call the patient "stable" then I'd load with procainamide. If I'm calling him unstable then I'd shock him. I would be surprised if the patient didn't just go right back into the initial rhythm after adenosine but it could illuminate the situation by running a strip during the infusion. Sure, it's relatively contraindicated here, but in my opinion it's safe.

Whatever you do, don't "rate control" this guy!

 

[WilcoWorld]

PS: When in doubt, a reasonable approach is to treat all "fast & wide" like v tach until proven otherwise. It pans out to go pretty much the same as antidromic WPW SVT treatment anyway: Stable--> procainamide, unstable --> shock.

 

[emrox]

from a long time lurker who finally got their act together and has a username:

my diff dx would be vtach vs svt with aberrancy-likely not vtach based on age and history of patient, plus i think there are regular conducted p waves (probably retrograde?) in V5. i'd be concerned about wpw.

would probably shock here or start procainamide. sounds like the patient can tell you when he went into it. if it is within 48 hrs, i'd start with electricity.

would stay away from any AV nodal blocking agents, including adenosine-start with electricity or procainamide for wide complex rhythm.

 

[fiznat]

I'm surprised to hear so much about procanimide. Around here, that drug has largely been phased out in adult use in favor of amiodorone. I know that opinion on these things tends to change fairly often though, and I've read that the research AHA cited in their support of amio was not great. Does that mean everyone is going back to procanimide now?

I would be surprised if the patient didn't just go right back into the initial rhythm after adenosine but it could illuminate the situation by running a strip during the infusion. Sure, it's relatively contraindicated here, but in my opinion it's safe.

This patient actually did go right back into the initial rhythm after the adenosine. I did run a strip while pushing the drug, which is how I got those results detailed above. Why would adenosine be contraindicated here?

 

[joeDO2]

I'm surprised to hear so much about procanimide. Around here, that drug has largely been phased out in adult use in favor of amiodorone. I know that opinion on these things tends to change fairly often though, and I've read that the research AHA cited in their support of amio was not great. Does that mean everyone is going back to procanimide now?



This patient actually did go right back into the initial rhythm after the adenosine. I did run a strip while pushing the drug, which is how I got those results detailed above. Why would adenosine be contraindicated here?

I don't really see any contraindication with giving some adenosine as a diagnostic since any effect it has will be worn off within seconds due to its short half-life. However, given this presentation of acute onset of difficulty breathing and poor general appearance, I would lean more towards cardioversion.

 

[WilcoWorld]

In the 2010 AHA guidelines procainamide is the 1st line antidysrhythmic for both stable, monomorphic v tach and for antidromic WPW tachydysrythmia.

The relative contraindication of adenosine is mostly a hold-over from the older days, due to the fear of AV-blocking an antidromic SVT, and thereby favoring the accessory pathway. However, given the very short action of adenosine this theoretical contraindication doesn't pan out to have clinical significance.

 

[Arcan57]

The main issue with amiodarone is that it's not very efficacious for dealing with ventricular tachycardia. And to stress what's been mentioned before, wide-complex tachycardia above 120 bpm is v-tach for EM purposes. The criteria for determining v-tach vs. SVC w/aberrancy is complicated, has mediocre inter-rater reliability among cardiologists, and is still not 100% sensitive.

 

[RustedFox]

Finkle and Einhorn, Finkle and Einhorn...


- I had the same thought as the poster above with 'who uses Procainamide in real-life?' It is taught heavily in academia, but just last week during conference we had a WPW rhythm on the big-screen, and three of us residents shot our hands up and screamed 'Procainamide!' Meanwhile, our attendings all chuckled and said - "Yeah, you'll have that in an hour or so when pharmacy dusts it off and sends it up via the tube; use amiodarone, jokes."

What gives? We don't use fomepizole or methylene blue a whole lot, but we sure as hell had better have it around, y'know?

*Note: This is not to cast a negative light on our attendings at Midwest U. They're great. They just also have a killer sense of humor when it comes to 'jobbing' us like that.

 

[EMRAGE]

If I deemed the patient unstable Versed, shock and hang some Mag. If stable, 150 mg of Amiodarone over 20 minutes and hang some Mag.

Some thoughts:

Procainamide is a great alternative but, at least in my experience, usually not obtained and delivered as quickly in our ED. Amio is in the box and ready to go.

Anytime I say procainamide, the nurses look at me like I have a penis on my forehead. When I say Amio, things happen quickly.

Procainamide has wt based bolus dosing, which adds a level of confusion to an already stressful situation. K.I.S.S. Amio is in the tachycardia algorithm and the dose is easy to remember and applies to anyone with the exception of kids (5 mg/kg).

RAGE

 

[WilcoWorld]

I know this might make me sound like a jerk, but I'm going to say it anyway. We have stocked procainamide in our pyxis since the 2010 guidelines came out. You should too.

 

[LotaPower]

why is there even much convo about this? this is a regular wide regular complex tachycardia. this person needs amio or shock. thats it. kapeesh.

I really think that trying to figure out if this is svt with abberency or not is a bad idea, is somthing that the cardiologists can sit around and talk about . plus giving adenosine (just to see) is bad b/c this can also be aberrant wpw.

 

[Dwindlin]

When looking at an ECG's in general I understand it is not generally good to trust the computer diagnosis (without first making your own interp anyways), but how much do you trust the other data (PRI, QT/QTc, QRS, Axis, etc.)?

 

[emrox]

Here's a link to the AHA tachycardia with pulses discussion, where they talk about both procainamide, amiodarone, and sotalol. There are no firm recommendations that I can find? It looks like they recommend amiodarone for "preventing recurrent monomorphic VT or treating refractory ventricular arrhythmias in patients with coronary artery disease and poor ventricular function." They also recommend not using procainamide and sotalol in patients with known prolonged QT. Obviously, in our patients, we likely will not know what medical history they have.

<http://circ.ahajournals.org/cgi/content/full/122/18_suppl_3/S729?maxtoshow=&hits=10&RESULTFORMAT=&fulltext=tachycardia+with+pulse&searchid=1&FIRSTINDEX=0&volume=122&issue=18_suppl_3&resourcetype=HWCIT>

Also, when reviewing it, I take back my earlier statement about not using adnosine in this case- it is a monomorphic and regular rhythm so adenosine would be ok to use in this case- would NOT use for polymorphic or irregular rhythm.

For THIS case, I would do electricity first, then procainamide as it is a drug that can be used and is recommended for both V-tach and WPW, and both of these diagnoses are on my diff dx for this case.

I have seen procainamide for a wide complex tachycardia used as recently as a few months ago by my colleague, when a patient with known WPW came in and did not respond to shock-it came up from pharmacy quickly. I usually use amiodarone if I think a patient has a V-tach from ischemic HD, which is the etiology of the majority of V-tach in this country.

 

[fiznat]

...but how much do you trust the other data (PRI, QT/QTc, QRS, Axis, etc.)?

I have been told and in my experience, the measurement data is usually quite accurate. The interpretation bit not so much, although it is pretty decent at identifying certain things (STEMI being one of them).

I really think that trying to figure out if this is svt with abberency or not is a bad idea, is somthing that the cardiologists can sit around and talk about .

Nicely put. This was the end lesson for me as well. This is what happened:

I was convinced, incorrectly it seems, that this was 1:1 a-flutter with an abbarency. I came to that conclusion based on the flutter waves that I thought I saw with the trial of adenosine. In addition, I did not believe I was looking at VT as the axis is leftward, there is no precordial concordance, the morphology looks asymmetrical and abbarant, the rate is awful high for VT, and the patient was somewhat young.

I gave 15 mg Cardizem to this patient, which did nothing. Next I transmitted the 12 lead to the ED and consulted with a physician. I was ordered to follow up with another 10 mg of Cardizem (??). That didn't do anything either. In the ED they gave mag and amiodorone with no effect. Cardiology consult eventually decided to cardiovert, which worked immediately. The post cardioversion rhythm had delta waves, and a pattern (not an expert on this part at all) that the cardiologist identified as an orthodromic reentry mechanism/WPW.

Turns out I was right that there was an atrial origin, but dangerously wrong about the rest. I consider this a bullet dodged and a big lesson for me, which is what LotaPower so succinctly summarized above. No reason I should have been messing around trying to identify an atrial origin/abbarency. Wide + fast should have just been amiodorone (or procanimide, which we also carry in our bags).

I'm working on getting the post-cardioversion tracings from the hospital, but it is a bit of a process. I'm trying, though.

 

[EMRAGE]

I know this might make me sound like a jerk, but I'm going to say it anyway. We have stocked procainamide in our pyxis since the 2010 guidelines came out. You should too.

Read my post a little more carefully. It's stocked in our pyxis as well.

RAGE

 

[WilcoWorld]

First -Procainamide works better than amiodarone for SVT.

Second - Some studies have shown trends towards better efficacy of procainamide for v tach, but the numbers have been small, and the effects have not reached significance.

Third - Amiodarone is a dirty drug. With a half life over 100 days it causes pulmonary fibrosis, tremors, ataxia, and smurf skin to name a few.

I understand the appeals to practicality and familiarity, but to me the down sides of amiodarone warrant the trouble of using procainamide.

 

[Tiger26]

First -Procainamide works better than amiodarone for SVT.

Second - Some studies have shown trends towards better efficacy of procainamide for v tach, but the numbers have been small, and the effects have not reached significance.

Third - Amiodarone is a dirty drug. With a half life over 100 days it causes pulmonary fibrosis, tremors, ataxia, and smurf skin to name a few.

I understand the appeals to practicality and familiarity, but to me the down sides of amiodarone warrant the trouble of using procainamide.

Agree with Wilco--the side effects of amio suck

Also, the history screams WPW--otherwise healthy young-ish guy on no meds. Although he doesn't have CP, you describe SOB, weakness and profound diaphoresis.

Just sedate and shock--in the cases of WPW w/rapid a-fib I've seen, they're diaphoretic and stable appearing but then their pressures and mental status start to tank in the time you're putting pads on them.

Also, I see nowhere where diltiazem was ever indicated in this case . . .

 

[EMRAGE]

I can't disagree with either of you, and although I would still spontaneously say Amio. Procainamide would likely be a better drug in this situation. However, I wouldn't feel to badly about Amio as most of the side effects are from prolonged use. Not one single exposure.

RAGE

 

[BKN]

Essentially all antidysrhythmics are conducting system and myocardial depressants. Procainamide isn't much better than the rest for stable V Tach. But is has the advantage of requiring a slow infusion to load (about 20 minutes in an adult). During that time I can watch the QRS and other intervals increase by 50% and the BP drop. Then I can feel good about cardioverting, which is what I should have done in the first place. ;-)

 

[J-Rad]

When looking at an ECG's in general I understand it is not generally good to trust the computer diagnosis (without first making your own interp anyways), but how much do you trust the other data (PRI, QT/QTc, QRS, Axis, etc.)?

Heart rate, QRS duration, and axis are usually pretty accurate. Unless there is P wave wonkiness, PRI is usually pretty accurate, in my experience. QT/QTc is notoriously unreliable and should not be trusted.

 

[MedicFL]

I think factors such as transport distant would play into my choices, however I do not think I would have wasted my time with adenosine, I think in the given situation I would have probably Cardioverted or if I thought he was stable I may have gone with amiodarone. He is a 42 y/o overweight male who isnt going to sustain that heart rate for very long.