What would you do?

[tpchristifulli]

Dispatched to an assisted living center for a 70 yr female pt with shortness of breath, diarrhea, and vomiting.Pt has normal mental status.
Upon arrival you find your patient sitting in her recliner in obvious distress. She states she feels very nauseated and sick to her stomach. Onset of this morning upon waking up. Hx of LBBB and implanted pace maker.
You palpate a pulse of 162 and regular. Lung sounds clear bilateral,Glucose 108, Bp 138/76, sp02 94%.
Initial 3 lead is this:

12 lead shows this:

You are 15 minutes from the hospital.
You start a line and administer 700cc of fluid with no change in rate.

How would you treat?

 

[STXmedic]

Hmm... History? Meds? Temp? Pedal edema? Chest pain? Was the onset immediate or progressive?

 

[tpchristifulli]

She woke up with the symptoms.Yes temp 104 with loose stools. She was on amiodarone, metoprolol, aspirin, some vitamins... I forgot a few. No chf meds, no thyroid meds, one psych/sleep med.

 

[captaindepth]

I think I would call into medical control for an order of Amiodarone (150mg over 10 minutes). As a paramedic student Adenosine scares the sh*t out of me and if WCT is VT 80% of the time ill go with that (plus she has a cardiac hx).

Pt is stable (at this moment) but I would apply the pads and be ready for synchronized cardioversion/defibrillation if she deteriorated.

What type of pacer unit does she have? I see no evidence of pacer actiivity on the 12 lead so I guess its functioning by sensing the intrinsic rhythm.

 

[OnceAnEMT]

Sorry to dumb things down, but how do you tell that rythm is sustainable VT versus an abnormally high rate on the ventricular pacer?

 

[tpchristifulli]

Sorry to dumb things down, but how do you tell that rythm is sustainable VT versus an abnormally high rate on the ventricular pacer?

Pacer magnet, pacer spikes will not always be present ( especially on zolls).

 

[captaindepth]

Sorry to dumb things down, but how do you tell that rythm is sustainable VT versus an abnormally high rate on the ventricular pacer?

I did not see any pacer spikes on the 12 lead and I THINK most pacemakers will not increase the rate they fire at and will stop pacing once the pts HR exceeds the pacers setting. I think there are some pacers now that respond to increased/decreased activity and will slightly increase or decrease their paced rates but definetly not to 160bpm.

 

[Rialaigh]

I would love to hear Christopher weigh in on this EKG but I would be sorely tempted (with a 15 minute transport time) to do nothing, well, Zofran and the fluids that OP stated were given, then do nothing...

 

[Brandon O]

Is there an old ECG in their records for comparison? What was the pacemaker placed for?

I would give at least some thought that this may be a sinus rhythm under her baseline LBBB. Impressive rate for her age, but still.

 

[Rialaigh]

Is there an old ECG in their records for comparison? What was the pacemaker placed for?

I would give at least some thought that this may be a sinus rhythm under her baseline LBBB. Impressive rate for her age, but still.

Not that impressive if shes really really septic...temp, nausea, SOB, tachy...diarrhea...

I'm leaning towards sepsis and think this patient is probably really really sick with underlying infection...play the odds and guess urosepsis secondary to pylo...your right like 80% of the time with that in older people

 

[Brandon O]

Not that impressive if shes really really septic

On amio and metoprolol though

 

[Rialaigh]

Not to sound like Dr. House and all my patients lie , but Assisted living center, if shes responsible for her own meds I'm thinking it's a lot more likely shes tachy and septic then that this is full blown Vtach.

Idk, big picture is regardless of what this is do you feel comfortable transporting her with stable vitals, non emergent 15 minutes to a hospital without doing any interventions. Because I think I do.

 

[Christopher]

160 bpm is clearly above the upper rate limit for this patient, given their age. Pacemaker mediated tachycardia seems out of the question as well at that rate.

That being said, if the patient has simply a pacemaker then there is no expectation it will intervene.

If this is a pacemaker/ICD combo, then perhaps: (a) the VT rate is set >160 bpm (odd given age), (b) ATP/defibs occurred without success (doubtful if she didn't complain!), or (c) some sort of atrial arrhythmia is present which the ICD has decided not to respond to (Arate >= Vrate without evidence of AV dissoc).

 

[Rialaigh]

160 bpm is clearly above the upper rate limit for this patient, given their age. Pacemaker mediated tachycardia seems out of the question as well at that rate.

That being said, if the patient has simply a pacemaker then there is no expectation it will intervene.

If this is a pacemaker/ICD combo, then perhaps: (a) the VT rate is set >160 bpm (odd given age), (b) ATP/defibs occurred without success (doubtful if she didn't complain!), or (c) some sort of atrial arrhythmia is present which the ICD has decided not to respond to (Arate >= Vrate without evidence of AV dissoc).

15 Minutes transport time, What do you do, Go!

 

[Christopher]

15 Minutes transport time, What do you do, Go!

Me? Treat the patient not the monitor! (hahaha, just kidding guys.)

IV, adenosine, then lidocaine. Strong consideration for elective cardioversion.

 

[Jason]

How long has the Pt had GI upset? It's possible a series of events has caused this to get further out of hand.
With a GI issue of any length, the Pt may not have absorbed her meds, causing a temporary non-compliance, resulting in cardiac issues.
GI upset + Fever may very well be sepsis, giving to a higher HR. Higher HR and not getting the benefits of her meds resulted in the VT on the monitor.
This is not a pacemaker or ICD issue. I would transport with the preparation of intervening on the HR and possibly future decrease in BP (as VT doesn't hold a good BP for very long). Considerations for Amio, Cardioversion, fluid management - of course not all or all at once. Mental status would be a good vital sign to follow as well during transport.
On a note on the magnet: If the Pt has had a Pacemaker / ICD in the last [about] decade - then all the magnet would maybe do for you is determine if you have a pacemaker only or an ICD, (whether demand pacing kicks in or not).
**Of course, I believe we all have good thoughts and remember, you're asking us to play backseat quarterback on scenarios.

 

[Brandon O]

Any abdominal pain, by the by? Or an abd exam?

 

[tpchristifulli]

Fluids and zofran were administered. Upon arrival at the ED the physician contacted an Electrophysiologist. It was determined by a 12 lead that the pt was in Afib with RVR. Cardizem drip was initiated and symptoms resolved. I just don't see how in the world he was able to tell this was Afib RVR!

 

[chaz90]

Fluids and zofran were administered. Upon arrival at the ED the physician contacted an Electrophysiologist. It was determined by a 12 lead that the pt was in Afib with RVR. Cardizem drip was initiated and symptoms resolved. I just don't see how in the world he was able to tell this was Afib RVR!

**Sweeps hands** Electrophysiologist magic!

 

[Rialaigh]

Are any of you guys using Cardizem in the field to treat Vtach? I have heard and seen several ER physicians using it to convert Vtach (or Unidentified wide complex tachy) in the ER setting. I believe ER cast did a good podcast on this subject that brought the use of Cardizem up as well for Vtach