36 replies to this topic

[akroeze]

I posted this 12-lead a while back in a scenario and asked for input on the interpretation but there was surprisingly little discussion. I'm wondering what people feel this is:

[Trauma612]

I'm going with vtach

[chbare]

Actually, a couple of things lead me to question the diagnosis of ventricular tachycardia. First, a down and dirty 3 lead axis determination does not indicated right shoulder deviation. It actually looks like pathologic LAD. Second, pathologic LAD is commonly associated with a left anterior fascicular hemiblock. If we look at this as something other that VT, then we can also appreciate a RBB as well. LAFHB + RBB leads us down the path of a bifascicular block.

What is the patient's past and present medical history?

Take care,
chbare.

[akroeze]

Here are some snippets from the scenario I presented:

As you eneter the room you see the patient supine in bed, she seems to be breathing slightly fast and on a scale of looking not sick to sick she would rate a sick.




You quickly assess her responsivenes and get a GCS of 13 (3-4-6). Airway is patent and there is no JVD or edema. While you take a pulse and SpO2 reading your partner gets a BP and resps.

HR: 40 weak/regular
BP: 98/68
SpO2 RA: 88%
R: 24
T: 38.1C tympanic
A/E clear = bilat

The nurse hands you a history sheet which states increased cholesterol, NIDDM, Heart bypass in 2000, dementia.

You throw the limb leads on her and get a sinus brad, no ectopy noted. Same on the 12-lead. You grab your glucometer and find it to be 26.1(469.8 ).

There is no known history of trauma and she is in a private room, no room mate.



NKA

Nitro prn
Lipitor
Glyburide
Metformin
Allopurinol



The patient has received all of her meds. The patient has very severe dementia and unfortunately can't tell you much about her symptoms.

You put the NRB on the patient and transfer her to your stretcher. As soon as she hits your mattress you hear the QRS beeps on your monitor jump in rate. You turn to look at it and find the following rhythm:



(This is the actual strip from the call)




The patient still has a pulse, you look at her and she doesn't appear to have changed physically. She is still looking at you.

HR: 128
SpO2 is now 98% on NRB
BP unchanged




It's a bit everywhere, but that's all the info I have.

[fiznat]

What was the complaint/why were you called?

The progression in the chest leads makes me think that this is VT, although other posters are right that the mean QRS axis seems to be downward and to the far left (LAD), which I don't believe is common in VT. Still, the width and negative complex in V6 really makes me lean towards a ventricular origin. The history and age (which I assume is older since you mentioned dementia) might also contribute to this suspicion.

I don't know, to be honest. I don't even know how to tell for sure. Surely someone on here does!

[p3medic]

There are NO absolutes unfortunately....There are different criteria people use to differentiate the two, I was a product of Marriot's, however Brugada's criteria seems to be more specific, and easier to remember, at least for me. I'm also leaning towards v-tach on this one.

[zzyzx]

I commented on your scenario. The rate (just under 150) was a little slow for VT, and the patient was totally stable, so I said that I would go with a very conservative Tx (no drugs, no shock). Things just didn't quite add up, so I didn't want to treat the rhythm like it was VT.

Now the question is, what would I have done if the patient had been presented as being unstable? To be honest, in that case I would have shocked her. The patient, as you presented, went from a narrow-complex bradycardia to a wide-complex super-tachycardia. If it looks like a duck, walks like a duck....

[firefighter523]

This strip is very hard to read in this post, maybe I need stronger glasses. It is very hard to differentiate which way the qrs is pointing, definately down in AVF. Both negative qrs's in lead 1 and AVF and with the caviot of neg qrs's in 2 and 3 points to VT. If you cant tell, you must treat the VT if it is wide. If you have amiodarone that is better, (treats narrow and wide).

[firefighter523]

Now that I have figured out how to zoom in, I am calling this SVT with a RBBB with pathologic left axis dev. This one would get a call to the Doc, no doubt.

[Dustdevil]

firefighter523 said:

...I am calling this SVT with a RBBB with pathologic left axis dev.

As much as I hate to agree with a fireman, I agree with this interpretation. :wink:

Although, I can think of no reason to call a doctor about it. We want to treat the patient, not the monitor.