Synchronized Cardioversion - What happened?

[Christopher]

Here is an interesting case which came across my desk that I'd like to share, the full details of which will be in a post on my blog shortly:

EMS was dispatched for a 62 year old male with an altered mental status. Upon their arrival they found the patient to be non-communicative, responsive to verbal stimuli, in moderate respiratory distress, with pale, diaphoretic skin, and weakly palpable radial pulses.

A 12-Lead ECG was obtained, showing a wide complex tachycardia with left axis deviation. It was interpreted by the paramedic as Ventricular Tachycardia.

A blood pressure was unobtainable, however a pulse of 150 was palpable at the carotid. Labored respirations were present, with clear breath sounds bilaterally. The patient had an extensive cardiac history, renal failure, and insulin dependent diabetes mellitus. The patient's blood sugar was 300 mg/dL.

Given the presence of hemodynamic instability the patient was prepped for synchronized cardioversion. Combo-pads were placed anterio-laterally, the Sync button was pressed, and sync markers were noted with each QRS complex.

Printed summary of synchronized cardioversion (click for mega-res):


So what do you think happened next?

 

[nocoderob]

He sync'd that??

 

[DrankTheKoolaid]

Please, Please, Please say he didnt cardiovert that

 

[Christopher]

Had multiple bouts of VT prehospital and inhospital. This is only the strip from the cardioversion. Only going off what I've got

 

[fast65]

 

[DrankTheKoolaid]

re

I so just jacked that image for my collection Fast

 

[NYMedic828]

I'm nowhere near the ECG reading level most of you are, is this issue here that it is terribly synced?

 

[DrankTheKoolaid]

Looks like ST with a LBBB to me.

I would be more inclined to give rapid fluid challenges to increase his preload and to correct the suspected right heart failure by presentation.

But hey im no expert

 

[NYMedic828]

Looks like ST with a LBBB to me.

I would be more inclined to give rapid fluid challenges to increase his preload and to correct the suspected right heart failure by presentation.

But hey im no expert

How do we distinguish VT from LBBB? It's still a wide complex tachycardia?

Are we assuming left anterior fasicular blockage to rule in LBBB?

(not asking to criticize, asking because I don't know)

 

[DrankTheKoolaid]

While it is a wide complex tach by definition. Sometimes you have to dig deeper and try to figure out what came first the chicken or the egg. Is this patient symptomatic because of the " wide complex tach " or is he compensating by becoming tachycardic in response to the insult, which is my suspision based on the into given and the presentation of leads II, III and aVf.

Im not skilled enough to use just II, III, aVf to differentiate them.

History of cardiac coupled with his age and diabetes points towards and exisiting LBBB and not a VT

 

[Christopher]

While it is a wide complex tach by definition. Sometimes you have to dig deeper and try to figure out what came first the chicken or the egg. Is this patient symptomatic because of the " wide complex tach " or is he compensating by becoming tachycardic in response to the insult, which is my suspision based on the into given and the presentation of leads II, III and aVf.

Im not skilled enough to use just II, III, aVf to differentiate them.

History of cardiac coupled with his age and diabetes points towards and exisiting LBBB and not a VT

I've intentionally left this ECG vague as the rhythm itself is not quite the important message. For those interested, the 12-Lead I would say is either 2:1 atrial flutter or ST w/ a really long 1AVB. My retrospectoscope would have done adenosine first, but I don't know anything really about the patient.

 

[Handsome Robb]

I've intentionally left this ECG vague as the rhythm itself is not quite the important message. For those interested, the 12-Lead I would say is either 2:1 atrial flutter or ST w/ a really long 1AVB. My retrospectoscope would have done adenosine first, but I don't know anything really about the patient.

Wondering why on the adenosine? Not saying your wrong just wondering. Doesn't seem fast enough to be SVT. I agree with ST with a LBBB. Fluids and a quick ride seem like the way to go here plus that does not look like it's synced properly. Was he complaining of anything prior to this episode?

 

[DrankTheKoolaid]

Because adenosine is an acceptable treatment per latest AHA guidelines for undifferentiated wide complex tachycardia, would be my guess

 

[Christopher]

Wondering why on the adenosine? Not saying your wrong just wondering. Doesn't seem fast enough to be SVT. I agree with ST with a LBBB. Fluids and a quick ride seem like the way to go here plus that does not look like it's synced properly. Was he complaining of anything prior to this episode?

"Altered mental status". Had runs of "VT" in the ED.

Otherwise no idea, not my patient, just a rate ~150 in a patient with prior cardiac (could be AFib, could be CABG/stent, I don't know which) usually dings my atrial flutter bell. Fluid, adenosine...but hell I'd have to see the patient to determine if I'd shock (likely just ride it in).

 

[NYMedic828]

"Altered mental status". Had runs of "VT" in the ED.

Otherwise no idea, not my patient, just a rate ~150 in a patient with prior cardiac (could be AFib, could be CABG/stent, I don't know which) usually dings my atrial flutter bell. Fluid, adenosine...but hell I'd have to see the patient to determine if I'd shock (likely just ride it in).

What was the outcome of their shock?

 

[Smash]

What was his potassium?

 

[fma08]

It's not syncing the same for each complex, thus the sync function is not reading/working properly, thus you cannot perform a synchronized cardioversion. Treat as best you can w/o the electricity, heavy on the diesel bolus.

As stated, not my patient, wasn't there, just basing off of history given and one EKG strip.

Curious to know what happened/outcome of the patient.

 

[firetender]

Please forgive the nosey FOG!

I'm not quite sure what's up here -- what's the main question? -- so please bear with my ignorance.

First, I'm not clear on WHY the cardioversion. Is it because his heart is galloping and showing a slow but steady drop in BP? Is it because the heart is going SO fast (for the patient) that it is suspected that it will give out or be further compromised?

Why the choice to cardiovert? Changes in vitals/status?

Second is where the hell did those "markers" come from? Is that the machine telling you when it's planning to discharge?

To me, this is showing a few markers precisely at the vulnerable stage of the Lead III complex (comparing above with below).

And if you're going to do a synchronized cardioversion, why wasn't the valsalva maneuver performed first (vagal stimulation) or carotid massage for that matter (less likely, but still). Whatever happened to starting with the basics and leading up to the big guns?

Maybe I just need more details.

At any rate, from what I saw, this patient seems to have been put at risk. Am I right? I'm particularly interested in this one because...

Somewhere in my scrapbook is my documentation of an UNsychronized cardioversion I did of an 160+ tachycardia lasting 1/2 hour (60 y.o. male).

YES, UNsychronized because my unit had a Lifepak 4 on it that day without a "synchronize" button on it! The Lifepak 5's had just come out. When the Doc on-duty told me to get ready to cardiovert, I looked for the button, realized we had the old model and tried to bow out (all this after valsalva, etc.). He wouldn't let me, had me tune the beeper for the complex to tone right at the top of the R segment (I hope I'm getting details right!) and said "Hit him just before you hear the beep!"


You can imagine the brown on the floor!

Anyhow, the guy converted (DON'T DO THIS AT HOME!!!) , but back on topic, I really want to know what happened with yours!

 

[Handsome Robb]

"Altered mental status". Had runs of "VT" in the ED.

Otherwise no idea, not my patient, just a rate ~150 in a patient with prior cardiac (could be AFib, could be CABG/stent, I don't know which) usually dings my atrial flutter bell. Fluid, adenosine...but hell I'd have to see the patient to determine if I'd shock (likely just ride it in).

Wide and fast would push me towards amio rather than adenosine. I don't see cardioversion working here since the monitor isn't syncing properly. I don't really see atrial flutter in this strip but i'd like to see more of the 3/4 lead as well as a 12 lead before I ruled it out or ruled in VT and treated as such. I never really thought of your thought process but I like it, it does make sense.

Smash brings up a good point with the question about potassium. That would definitely make sense, although I'd expect bradycardia rather than tachycardia but I'm definitely still very new at this.

 

[Christopher]

I'm nowhere near the ECG reading level most of you are, is this issue here that it is terribly synced?

It's not syncing the same for each complex, thus the sync function is not reading/working properly

Second is where the hell did those "markers" come from? Is that the machine telling you when it's planning to discharge?

To me, this is showing a few markers precisely at the vulnerable stage of the Lead III complex (comparing above with below).

That was my biggest concern when reviewing this case. Apparently, from the cardiac monitor's screen it was not evident it was double and triple sensing the QRS complexes.

Subsequent rhythm change:


Full summary here.