zzyzx Posted March 23, 2008 Share Posted March 23, 2008 Hey guys. I'm stealing this scenario from a recent issue of JEMS because the treatment recommended by the authors (three doctors) goes against what I've been taught. I'd like to hear what other people think about it. You respond to a 52-y/o male who got mildly short of breath after going for a jog. You hook him up to the monitor and he is in a wide-complex tachycardia at a rate of 310. He is no pale and diaphoretic, but he is fully alert and oriented and has a stable BP. No significant history except asthma. Besides basic treatments like O2, positioning, IV, etc., what advanced treatments do you provide? Sorry, don't have a copy of the ECG. Link to comment Share on other sites More sharing options...
SWM_Medic Posted March 24, 2008 Share Posted March 24, 2008 Well since he isn't showing any symptoms you can try and iv push of lidocaine. Although if that dosen't work your gonna have to burn him. Remember to synchronize. Link to comment Share on other sites More sharing options...
Scaramedic Posted March 24, 2008 Share Posted March 24, 2008 Amiodarone 150mg over 10 min., repeat x1. If no change, Versed Cardiovert Link to comment Share on other sites More sharing options...
vs-eh? Posted March 24, 2008 Share Posted March 24, 2008 Hmmm... Honestly prehospital, there aren't going to be many options besides anti-dysrhythmics's and electricity. I would definitely be calling a doctor regardless. With a ventricular rate that high (assuming this isn't atrial flutter that actually has a lower ventricular response) finding the underlying rhythm would be difficult to say the least. Are these doctors thinking a-fib that is compensatory and using an anti-dysrhythmic would knock that out? Electrolyte imbalance and needs potassium? SVT with abarancy vs. V tach? Meh... All things being equal I would agree with Scara, but add ASA. Link to comment Share on other sites More sharing options...
akroeze Posted March 24, 2008 Share Posted March 24, 2008 I'd be more inclined to stare at the monitor in disbelief at such a high rate for a while personally Link to comment Share on other sites More sharing options...
AZCEP Posted March 24, 2008 Share Posted March 24, 2008 Stable tachycardia grants the luxury of time. At that rate, there is only one possibility for what the rhythm can be and it is not ventricular. Avoid all AV nodal blocking agents while moving quickly to the hospital of choice that has the capacity for radio frequency ablation. Link to comment Share on other sites More sharing options...
SWM_Medic Posted March 24, 2008 Share Posted March 24, 2008 Your right that sinus tac gives you time espically if the pt is not showing any symptoms, but I wouldn't wait for a cath lab for treatment. This can turn into a fatal rhythm real quick. Link to comment Share on other sites More sharing options...
AZCEP Posted March 24, 2008 Share Posted March 24, 2008 I did not say "sinus tach". I said stable tachycardia, of which this is. This patient is asymptomatic, save for the diaphoresis. You have time to evaluate the rhythm to find the best treatment for it. Due to the rate, there is only one possibility. This patient does not need cardioversion, nor any of the commonly available prehospital medications. Ca++ channel or beta blockade will make this rhythm worse. Amiodarone is the best choice, but it too will cause a deterioration in the patient's hemodynamics with it's administration. DO NOT take this patient to the standard cath lab. They need radio frequency ablation. Link to comment Share on other sites More sharing options...
DwayneEMTP Posted March 24, 2008 Share Posted March 24, 2008 Have you all actually seen an asymptomatic ventricular rate of 300+? (I'm not being sarcastic.) I can't really invision the physiology that would allow sufficient filling at that rate. I've had several patients with SOB, ALOC, C/P with v-fib/rvr in the 180s-200s so I'm having a hard time imagining the patient mentioned above... I don't mean to derail the thread...was just curious. Dwayne Link to comment Share on other sites More sharing options...
AZCEP Posted March 24, 2008 Share Posted March 24, 2008 This patient is "symptomatic", they are not unstable to this point anyway. Stable/unstable vs. symptomatic/asymptomatic is of importance when deciding how aggressively to treat the patient in front of you. With this patient's symptoms, I'd elect to place the hands free pads, and monitor closely for changes. Link to comment Share on other sites More sharing options...
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