Chest pain, HR 190

[rhan101277]

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.

 

[Handsome Robb]

That's a puzzler. I would have tried the adenosine then if that didn't work sedated and cardioverted him. I'm thinking with him taking amiodarone PO daily and it isn't working there's no reason for me to give him more while risking the possibility of dropping his BP.

He's AAO however symptomatic, that's why I say sedate and cardiovert after trialing the adenosine. My instructor has always told me not to be afraid of electricity.

Just my .02, remember, I'm young, dumb and not very experienced

 

[Dwindlin]

That's a puzzler. I would have tried the adenosine then if that didn't work sedated and cardioverted him. I'm thinking with him taking amiodarone PO daily and it isn't working there's no reason for me to give him more while risking the possibility of dropping his BP.

He's AAO however symptomatic, that's why I say sedate and cardiovert after trialing the adenosine. My instructor has always told me not to be afraid of electricity.

Just my .02, remember, I'm young, dumb and not very experienced

Agree with NV. As long as he is compliant with his meds I think I would skip the Amio.

 

[Handsome Robb]

I would love to see the 12 lead as well if you have a copy of it to post up.

 

[rhan101277]

Yeah I have a copy, I am not afraid to use electricity but I would not have been able to sedate him with his pressure. We carry versed for that and he was hypotensive but not by much. I will try to post up the 12 lead tomorrow.

 

[Handsome Robb]

Yeah I have a copy, I am not afraid to use electricity but I would not have been able to sedate him with his pressure. We carry versed for that and he was hypotensive but not by much. I will try to post up the 12 lead tomorrow.

What about a 500cc bolus then see how his pressure is?

Theoretically you could cardiovert him then push the versed for the retrograde amnestic effects but that is also banking on the rhythm converting on the first try. I'd personally try the bolus first though since I'm not a very lucky human being.

I'm waiting for someone way smarter than me to come in here and tell me I'm way off base h34r:

 

[Nervegas]

What about a 500cc bolus then see how his pressure is?

Theoretically you could cardiovert him then push the versed for the retrograde amnestic effects but that is also banking on the rhythm converting on the first try. I'd personally try the bolus first though since I'm not a very lucky human being.

I'm waiting for someone way smarter than me to come in here and tell me I'm way off base h34r:

I wouldn't call it way off base, but I would trial the fluid challenge first, and then see where I was at before sedation.

As far as this scenario, I would have checked lung sounds before going ahead with a fluid challenge, then trial Adenosine. Rapid Tx to the appropriate facility. I would avoid additional Amiodarone, he is already hypotensive, even with a fluid challenge, no reason to risk it. I would also consider some fentanyl for pt comfort depending on our ETA.

If the pt continues to deteriorate enroute, then I would have moved towards cardioversion. But I think you handled this one the right way.

 

[firetender]

I'm waiting for someone way smarter than me to come in here and tell me I'm way off base h34r:

I'd like to but my world is still defined by phones at home!

What I'd be looking for are signs of decreasing perfusion. Does the elevated heart rate continue to increase? The BP doesn't appear to be getting affected.

For me, this was a major tip-off (from the OP):

Pt was admitted two weeks ago for this and they waited 3 days before electrical cardioversion.

This alone tells me there may have been good reason NOT to be concerned about the aberrancy of an increased pulse that's not getting worse. Or even more reason to suspect other things need to be in better balance first that are not related to emergency interventions.

So as far as urgency goes, electrical intervention would not be appropriate unless it was treating something moving toward life-threatening. This doesn't sound like a situation getting worse; There is stability here.

And that's what you're working with. It's a matter of supporting what is working rather than interposing a treatment that has the potential to upset the applecart. The hospital is only 15 minutes away. Don't kid yourself, cardioversion at any level holds the potential to make a working heart stop.

An important point I would have liked to have been made more clear is How was the patient (subjectively) doing on fiirst presentation compared to once in the back of the ambulance? How was he feeling? Any change?

 

[Chief Complaint]

I think you handled it well. With the hospital so close i wouldn't have cardioverted either. As mentioned above, its possible that it might make things worse. Sometimes less is more if you arent exactly sure what's going on with your patient.

 

[systemet]

A couple of quick opinions:

* Deciding a WCT is supraventricular in origin with aberrancy is a very hazardous thing to do. You may be right, and certainly if the axis isn't extreme right, and there's a classic RBBB pattern in V1, you may be right a lot of the time. But you'll also be wrong, and giving metoprolol or diltiazem to a VT is going to disastrous.

* Have you considered the possibility for WPW? The patient has had a previous tachycardia requiring cardioversion. I know many of these patients don't have a clue as to what happened, what meds they're taking, what they did last time they were in hospital, etc. But it would be nice to know if this has been considered.

* You can still see ST elevation in RBBB. It doesn't prevent you from diagnosing a STEMI. Even with LBBB, the Sgarbossa criteria allow the identification of STEMIs, although the sensitivity is poor.

* I'm not saying you did the wrong thing here. But, be aware that it's not usually a sin to bring in a stable patient with an untreated tachycardia. A lot of these patients develop an arrhythmia, spend a couple of hours feeling funny, drive themselves to the ER, sit around in the waiting room for a while, and then lie in a bed for an hour while the doctors decide the best course of action.

 

[rhan101277]

The patient did not have any change in the back of the ambulance. He did not get worse but he also did not get better. Through the whole trip he was AAOx3 and his mentation was great, this was a key factor in my decision making. If he is talking to me his brain is perfusing well despite him being borderline hypotensive (our protocols use 90mmHg as hypotension). It is normal for the body to shunt flow to the core and just because you are seeing a blood pressure of 84/56 or what not when taking from an extremity does not mean you would see that same number if you had an arterial line in.

I have seen people with manual pressures like this only to have a femoral artery pressure of around 100 systolic, not to say it always works like this but still. I am still going to post up the 12 lead, I got it in the car but it is to cold to walk outside right now.

 

[rhan101277]

Here is the strip

 

[46Young]

The patient did not have any change in the back of the ambulance. He did not get worse but he also did not get better. Through the whole trip he was AAOx3 and his mentation was great, this was a key factor in my decision making. If he is talking to me his brain is perfusing well despite him being borderline hypotensive (our protocols use 90mmHg as hypotension). It is normal for the body to shunt flow to the core and just because you are seeing a blood pressure of 84/56 or what not when taking from an extremity does not mean you would see that same number if you had an arterial line in.

I have seen people with manual pressures like this only to have a femoral artery pressure of around 100 systolic, not to say it always works like this but still. I am still going to post up the 12 lead, I got it in the car but it is to cold to walk outside right now.

Did you consider using quantitative capnography on this pt (assuming that you have it)? You can get real time feedback as to their hemodynamic status. For example, in a low flow state you can expect the ETCO2 to be below the norm, for example. A downward trend in ETCO2 capnometry values could suggest the progression of cardiogenic shock in this case. Less blood flow to the lungs will result in less CO2 being delivered for exhalation. Also realize that in the presence of rales, which could develop w/ heart failure secondary to this tachydysrhythmia, CO2 is 20 times more soluble than O2 (IIRC), so it will move through fluid the same speed as through air. Peripheral SPO2 readings have a delay in representing the pt's true status, but quantitative ETCO2 gives immediate feedback.

This would be another vital assessment tool to determine if your pt is stable or unstable to help determine treatment.

 

[rhan101277]

Did you consider using quantitative capnography on this pt (assuming that you have it)? You can get real time feedback as to their hemodynamic status. For example, in a low flow state you can expect the ETCO2 to be below the norm, for example. A downward trend in ETCO2 capnometry values could suggest the progression of cardiogenic shock in this case. Less blood flow to the lungs will result in less CO2 being delivered for exhalation. Also realize that in the presence of rales, which could develop w/ heart failure secondary to this tachydysrhythmia, CO2 is 20 times more soluble than O2 (IIRC), so it will move through fluid the same speed as through air. Peripheral SPO2 readings have a delay in representing the pt's true status, but quantitative ETCO2 gives immediate feedback.

This would be another vital assessment tool to determine if your pt is stable or unstable to help determine treatment.

No I didn't, I thought about it. I was interested in focusing on terminating the Dysrhythmia. I get better at this job everyday though.

 

[triemal04]

That isn't vtach. Hopefully TomB will chime in on this and correct me if I'm wrong, but I'm fairly confident in my assessment.

There are several things that would point to vtach; negative QRS in V6 and initial R-wave in avr are both indicative, as well as the right axis deviation (not as good as extreme right access deviation though). If there was no responce whatsoever to adenosine, that would point to it as well.

But, the QRS really isn't that wide; for a RBBB that's pretty decent looking. AVR can look like that without a ventricular origin, though it's rare. It's hard to say for sure (may be some in 2 or that's just movement) but there aren't any fusion beats, and if you look at V2 and AVL you can see atrial activity; specifically what looks to be flutter waves. That part is backed up by the patient's history; a 3 day wait for cardioversion would make sense if he needed to be placed on anticoagulants. (that also does not mean that he had a rapid arrhythmia for 3 days, just that he had an aberrant rhythm). And amiodarone is sometimes prescribed for afib/aflutter.

That being said, this patient still get's the sedative of your choice and then cardioversion. While I'm confident about it being aflutter, and there aren't any delta waves and the QRS's within each lead are the same, I still wouldn't try to give cardizem or amiodarone (or procainamide if you carry that).

The best choice for this is to call it a wide complex tachycardia of unknown origin, and treat it as such...which means treating for vtach.

Sedate and cardiovert.

 

[rhan101277]

That isn't vtach. Hopefully TomB will chime in on this and correct me if I'm wrong, but I'm fairly confident in my assessment.

There are several things that would point to vtach; negative QRS in V6 and initial R-wave in avr are both indicative, as well as the right axis deviation (not as good as extreme right access deviation though). If there was no responce whatsoever to adenosine, that would point to it as well.

But, the QRS really isn't that wide; for a RBBB that's pretty decent looking. AVR can look like that without a ventricular origin, though it's rare. It's hard to say for sure (may be some in 2 or that's just movement) but there aren't any fusion beats, and if you look at V2 and AVL you can see atrial activity; specifically what looks to be flutter waves. That part is backed up by the patient's history; a 3 day wait for cardioversion would make sense if he needed to be placed on anticoagulants. (that also does not mean that he had a rapid arrhythmia for 3 days, just that he had an aberrant rhythm). And amiodarone is sometimes prescribed for afib/aflutter.

That being said, this patient still get's the sedative of your choice and then cardioversion. While I'm confident about it being aflutter, and there aren't any delta waves and the QRS's within each lead are the same, I still wouldn't try to give cardizem or amiodarone (or procainamide if you carry that).

The best choice for this is to call it a wide complex tachycardia of unknown origin, and treat it as such...which means treating for vtach.

Sedate and cardiovert.

I didn't cardiovert him, if I did I would have to have done so without sedation. Because of his BP. Do you think it was wrong for me not to cardiovert? Another thing I took into consideration in not doing so was his stay just two weeks ago where they waited three days to cardiovert, true his BP may have been better. I just know that anytime you use electricity there comes a chance of causing asystole that will not recover. It would be tough me having to tell the family how did he die in route, he was talking when you left.

 

[lightsandsirens5]

I could be way off, having just been introduced to 12 leads, but isn't her getting pretty close to being ERAD based off of that 12 lead?

Like I said, I could be way off.

 

[triemal04]

I didn't cardiovert him, if I did I would have to have done so without sedation. Because of his BP. Do you think it was wrong for me not to cardiovert? Another thing I took into consideration in not doing so was his stay just two weeks ago where they waited three days to cardiovert, true his BP may have been better. I just know that anytime you use electricity there comes a chance of causing asystole that will not recover. It would be tough me having to tell the family how did he die in route, he was talking when you left.

Holding off based on what happened before isn't the best idea without knowing all the facts about what happened then. Just because he was cardioverted before does NOT mean it was for the same type of situation.

Beyond that, you have someone who has a moderately low BP, in this case most likely caused by his rapid heartrate and maybe his meds (IV amiodarone usually causes hypotension due to the chemicals in the solution not neccasarily because of the drug itself), who is sweaty (can't fake that), mildly short of breath and complaining of chest pain (you didn't elaborate but we'll assume cardiac type chest pain) most likely due to his rapid rate.

So, does something need to be done? Yes. In a hugeohmygodhe'sgoingtodiedoitnownownownow rush? Not neccasarily. If you had access to better sedatives than versed (like etomidate) then there wouldn't be any reason to delay to long, but giving a fluid bolus at the same time as a small dose of versed (say 2.5-5mg depending on his size) and waiting a couple minutes for in to take effect, while being ready to immedietly shock if needed would be ok too.

If you think the hypotension is caused by his meds, then you need to be looking at alternative therapies to raise his BP (or leaving it alone, depending), and if you think it's caused by his rate...that should soon be fixed.

I'd still stay away from treating this with medications, other than a sedative.

And actually, in looking at the LP's interpretation of the QRS axis, that is ERAD. The quick method of checking axis deviation doesn't bear that out, so someone else can answer that one.

 

[46Young]

I didn't cardiovert him, if I did I would have to have done so without sedation. Because of his BP. Do you think it was wrong for me not to cardiovert? Another thing I took into consideration in not doing so was his stay just two weeks ago where they waited three days to cardiovert, true his BP may have been better. I just know that anytime you use electricity there comes a chance of causing asystole that will not recover. It would be tough me having to tell the family how did he die in route, he was talking when you left.

I agree with post # 15. Any bradycardia protocol I've come across advises to sedate prior to cardioversion, time permitting, if the pt is unstable. Hypotension is one of the criteria to call the pt unstable. Just have a bag of NS hanging, and monitor L/S after the fluid bolus if needed. Mix some dopa and keep it nearby as well if you want to stay ahead of your pt.

Again, an ETCO2 capnoline would be of good use here. If the pt's ETCO2 values are dropping, the shock is progressing (less flow, lower ETCO2), and you need to cardiovert. If the pt's pressure holds, along with the pt's mentation and a normal ETCO2, you would be more justified in withholding electrical therapy in this case. Otherwise, if you fail to cardiovert, and the pt has an untoward outcome, you can be found negligent for withholding therapies.

BTW, if it's too difficult to tell if the rhythm is regular or irregular, consider turning up the QRS volume. You'll pick up an irregular beat with your hearing well before you will by sight.

 

[rhan101277]

I agree with post # 15. Any bradycardia protocol I've come across advises to sedate prior to cardioversion, time permitting, if the pt is unstable. Hypotension is one of the criteria to call the pt unstable. Just have a bag of NS hanging, and monitor L/S after the fluid bolus if needed. Mix some dopa and keep it nearby as well if you want to stay ahead of your pt.

Again, an ETCO2 capnoline would be of good use here. If the pt's ETCO2 values are dropping, the shock is progressing (less flow, lower ETCO2), and you need to cardiovert. If the pt's pressure holds, along with the pt's mentation and a normal ETCO2, you would be more justified in withholding electrical therapy in this case. Otherwise, if you fail to cardiovert, and the pt has an untoward outcome, you can be found negligent for withholding therapies.

BTW, if it's too difficult to tell if the rhythm is regular or irregular, consider turning up the QRS volume. You'll pick up an irregular beat with your hearing well before you will by sight.

Two separate doctors confirm it isn't vtach. One says it isn't because v1-v6 are not in concordance. The other says it could be afib with RVR and that the rate is so fast you won't be able to see it being irregular. At least I didn't kill anybody, sometimes you have to make tough decisions with few facts.