zzyzx Posted December 15, 2007 Share Posted December 15, 2007 This call was run by an a helicopter crew and was posted on FlightWeb. Thanks to Mike McKinnon for letting me steal it. You are called out for an “unknown medical.” A fire medic is already there, and the first thing that happens when you walk through the door is that he hands you this EKG: http://img102.imageshack.us/img102/3325/ekg28wm.jpg :shock: :shock: :shock: :shock: The 50 y/o patient is sitting in a chair. He’s pale, cool, diaphoretic. He’s already on an oxygen mask. His chief complaint is feeling dizzy when he stands and mildly short of breath. No chest pain. History: patient only knows that he has heart problems. Meds: digoxin, Lasix, ASA Allergies: none He has clear bilateral lung sounds with a sat of 98% and a RR of 20. His BP is 82/56. So what’s up with this guy’s EKG? What are the appropriate treatments? “Don’t worry, sir. You’ll be just fine. Don’t hesitate to call us back if anything changes.” Link to comment Share on other sites More sharing options...
mobey Posted December 15, 2007 Share Posted December 15, 2007 I am quite sure i am wrong but i will be the first to say V-Tach because I am interested to find out how I can tell it isn't. BLS treatment High flow O2 Call ALS load and go unless ALS will arrive soon in which case i would... Get the best Hx I could Put the Pt. in position of comfort Clear away furniture Have AED handy & set up BVM out of sight Get meds and health card rounded up keep reassessing pulse & BP every 3 min or so Talk about fire trucks with the Firemedic and twiddle my thumbs waiting for ALS! My guess on ALS Tx, Amiodarone (1st choice), or Adenosine (2nd choice)?? Link to comment Share on other sites More sharing options...
Just Plain Ruff Posted December 15, 2007 Share Posted December 15, 2007 Get your epi and the tube ready, he's gonna code if you don't start to fix what's wrong. Link to comment Share on other sites More sharing options...
sagigl Posted December 15, 2007 Share Posted December 15, 2007 hi all! to my opinion we're watching an unstable rapid a.fib. it might sometimes be mistaking with VT but not on this case because of the irregularity. bls treatment should include laying the patient down or at least getting his legs on a chair if he's got trouble to breath lying. off course- oxygen, opening an i.v. and waiting for als with resuscitation gear standing by. als treatment will include anestesia with ketamin 2mg/kg and midazolam 3 mg and synchronized cardioversion with 100J. anamnesa and physical examination should be completed before but apparently this is the direction. "if it's wide, fast and funny looking- shock it!!" Link to comment Share on other sites More sharing options...
gvandellen Posted December 15, 2007 Share Posted December 15, 2007 Unstable Afib, IV, Maybe sedate, Shock 50J BiPhasic, (cross fingers)...He's on Dig, Lasix, and ASA so there is a cardiac history to suggest Afib. Link to comment Share on other sites More sharing options...
Mateo_1387 Posted December 15, 2007 Share Posted December 15, 2007 Get your epi and the tube ready, he's gonna code if you don't start to fix what's wrong. I agree, be prepared for the worst. To fix his rate problem I would start an amio drip, 150 mg of 10 minutes, and also give a fluid bolus. As far as the rythm, the patient appears to go from a sinus tach, to v tach, to possibly a fib, if i saw a twelve lead at a slower rate i'd expect to see a LAFB and probably another block. Link to comment Share on other sites More sharing options...
Dustdevil Posted December 15, 2007 Share Posted December 15, 2007 Irregular rhythm. Rate around 300. Delta waves. Dig among his regular meds. You might want to re-think the V-tach thing. We're definitely headed towards cardioversion, but I am hesitant with pre-existing a-fib without anticoagulants. If his vitals are remaining stable, I would lean towards holding off until we can get to the hospital. Link to comment Share on other sites More sharing options...
akroeze Posted December 15, 2007 Share Posted December 15, 2007 I'm sticking with my usual Dx.... all patients are suffering from Syphilis until proven otherwise. Link to comment Share on other sites More sharing options...
unknown Posted December 15, 2007 Share Posted December 15, 2007 This is what a flight Nurse had to say..... Its an accelerated idioventricular rhythm. IV, O2, amiodarone IV and if that doesn't work cardiovert. Link to comment Share on other sites More sharing options...
Dustdevil Posted December 15, 2007 Share Posted December 15, 2007 This is what a flight Nurse had to say..... Its an accelerated idioventricular rhythm. IV, O2, amiodarone IV and if that doesn't work cardiovert. Please tell me that was an OB nurse. :? Link to comment Share on other sites More sharing options...
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