What would you do?

[Jason]

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!

In rapid rhythms it can be very difficult to determine A-Fib in a split moment record of the rhythm or even 12 Lead. Watching the rhythm for a short time would probably give you a better chance. As it was taught to me - the faster the rhythm, the more regular it looks.
However, I still don't think this was just a rhythm issue.

 

[Jason]

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

Cardizem has been removed from our drug boxes here. We use to have it, but not to treat or diagnose VTach vs A-Fib, just for treating symptomatic A-Fib. We now just have Amio and Adenocard. Adenocard for all rapid symptomatic rhythms (mostly A-Fib & SVT). I don't agree with this (not for A-Fib), but its the protocol. Amio is still avail for symptomatic VT. Amio replaced Lidocaine in our drug boxes.

 

[tpchristifulli]

So any ideas on what the electro physiologist saw?

 

[Jason]

Maybe a rapid ventricular response rhythm with no P waves -- that on 12 Lead the machine measured out the intervals and measurements for him. Measurements you couldn't or didn't get. Remember - the faster the rhythm the more regular it looks. Without machine calculations, we are eyeballing a lot. But that's not to say that the machine is always right. There is the possibility that the EP Doc is wrong. Cardizem might have slowed or broken a ventricular cycle, causing symptoms to resolve.

 

[Handsome Robb]

The only trick I know in tachy rhythms like that to help decide regular vs irregular is crank the volume on the QRS.

Definitely not an exact practice nor would I ever use it as my sole justification for treating something but it can definitely help.

Was her rate jumping around at all? It seems like it's about as regular as AF can get.

Id be very watchful but I agree with the observe and monitor in this case.

 

[Brandon O]

So any ideas on what the electro physiologist saw?

If this were real life I would print a long strip (not stare at a screen and turn my head sideways) and march it out with calipers.

More fluid would also be nice, and any other method you can think of to slow the rhythm.

 

[teedubbyaw]

I'd have been likely to try Adenosine with belief that her underlying rhythm was indeed sinus.

Tricky call.

 

[Angel]

Technically nothing because she's considered "stable" and we cant give adenosine (yet) for WCT. Agree about fluids and zofran however. Transport code 2 unless she declines.

 

[jrm818]

So any ideas on what the electro physiologist saw?

Did they see something on the ECG in the ED, or did the patient go to the EP lab? If the latter, they saw many different squiggles that are beyond the rest of us mere mortals.

 

[Handsome Robb]

Did they see something on the ECG in the ED, or did the patient go to the EP lab? If the latter, they saw many different squiggles that are beyond the rest of us mere mortals.

Very good point.

 

[Nova1300]

Patients with branch blocks have very strange looking EKG when they pop into Afib with a rapid rate. However, a patient on chronic amio therapy usually points to a history of a-fib. It can be used in chronic suppression of V-tach as well, though at higher doses.

A lot of things can re-trigger a-fib and it can be a beast to get under control. Though sepsis can trigger a-fib, the sinus tachycardia seen in sepsis without a-fib is very unlikely to get into the 160's. A HR that high is usually an electrical issue.
The list of a-fib triggers in those with a history is extensive. But one of the primary culprits is electrolyte and acid base derangements. This lady with vomiting and diarrhea is losing potassium, hydrogen ions (acid) and bicarb (base).

Fluids were good, and though amio would be reasonable, it wouldn't do much until you got her derangements corrected.

V-tach in a patient with obvious pre-existing cardiac disease (LBBB, pacer, meds, etc) is unlikely to be tolerated with those kind of vitals.