Just say no to drugs... and this rhythm

[jwraider]

Hey guys, this is one of the last few calls on my internship and the treatment really made me think since it did not fit into the cookie cutter scenarios presented in school. Thanks for playing along and giving me your ideas I'm really interested to see how everyone handles this:

Dispatched to a BART station (above ground public transportation train) about 1 mile from a Hospital with a cath lab. Apon arrival you look around at the crowd and it's hard to find your patient as the local fire ALS engine hasn't arrived yet. You finally settle on a 40 yo male who is sitting alone on a bench and he looks scared or even as if he's seen a ghost.

"Hi sir whats your name?"

"Bob"

You notice his skin is pale warm and dry and that he has labored breathing and is staring into space.

"Whats wrong Bob?"

"It's hard to breath.................... and my chest ..........hurts"

You listen to his lungs and they are clear bilat and he moves adequate amounts of air. You have your EMT start prepping 02 (I used both a NRB and a capnography rigged nasal cannula) and get the BP cuff while you put him on the monitor.

The FD shows up to help.

You get: BP 148/90 HR 84 RR 16 SP02 on RA 96% GCS15 (no allergies no viagra type meds) and below are 2 looks at his ECG:

ECG 1

ECG 2

You notice the rhythm goes back to normal sinus rhythm whenever the patient coughs... This repeats itself without fail on command 4-5 times during the call. Otherwise he stays in the bad rhythm.

So questions? What are your treatments?

[Arizonaffcep]

Interesting strips...Right off the bat, IV, O2, Monitor (sounds like you've done that), NTG, ASA and Morphine. I would really like to see a 12 lead on this guy...I was thinking of possibly using Lido to control the PVC's, but as they are perfusing, you don't want to shut those beats down. Any other HX? Maybe make him inhale some dust on the way in (to stimulate the cough... :shock: ).

[jwraider]

Sorry don't have the 12 lead printout but it confirmed the rhythm and did not show elevation when in NSR although it was tough to get a good picture because coughing doesnt lend to a steady EKG.

All of those interventions are what I did and he does not change or feel better.

Hx: Asthma, Pericarditis, Orthopedic surgeries (long time ago)

Meds: Albuterol, Asthma

Allergies: Torodol, Ibruporfen

[Arizonaffcep]

Sorry don't have the 12 lead printout but it confirmed the rhythm and did not show elevation when in NSR although it was tough to get a good picture because coughing doesnt lend to a steady EKG.

All of those interventions are what I did and he does not change or feel better.

Hx: Asthma, Pericarditis, Orthopedic surgeries (long time ago)

Meds: Albuterol, Asthma

Allergies: Torodol, Ibruporfen

Can you describe his pain? Onset, etc? When was the pericarditis??

[jwraider]

woke up with it 7 hours ago then drove 4 hours before calling 911 (he was driving from texas to california on a big rig)

Substernal, no radiation

dull

9/10

no relief, he was sitting and in semi fowlers I did not try and lay him down.

constant

He forgot to mention the Pericarditis to me when I asked him about his history (why bother?). I found out about it in the ED from soemone else. My guess is it was long enough to go he did not think of it when I asked about it.

[Arizonaffcep]

woke up with it 7 hours ago then drove 4 hours before calling 911 (he was driving from texas to california on a big rig)

Substernal, no radiation

dull

9/10

no relief, he was sitting and in semi fowlers I did not try and lay him down.

constant

He forgot to mention the Pericarditis to me when I asked him about his history (why bother?). I found out about it in the ED from soemone else. My guess is it was long enough to go he did not think of it when I asked about it.

I'll bet this was a PE. How did his legs look?

[jwraider]

No edema anywhere.

SOB relieved with 02. Breath sounds equal bilat. RR 16

But maybe I didn't get the final ED diagnosis.

So my protocol says to treat "tachycardia" with amiodarone. But this HR is 84 bpm and Ventricular tachycardia is defined by the AHA as 100 bpm (my protocl doesn't specify). Would you treat with Lido or Amio and could you call this V-tach?

[ERDoc]

No, you cannot call it V-Tach as it is not tachycardia. What are some things that will give you a wide complex but with a normal rate?

[jwraider]

Doc I came up with the following am I on the right track?

Sinus bradycardia with or without increased automaticity

myocardial ischemia (especially inferior wall)

dig toxicity

electrolyte imbalance

hypoxemia

av dissociation

reperfusion therapy

rheumatic fever leading to valve damage

congenital heart disease

I think the low 02 disorders are very possible here but why? Probably either due to an MI or maybe a combo of something he ingested and an infection?

He looked fairly healthy, I know I said poor IV accss but he wasn't severly overweight (just your typical 40 yo).

So I have to go with some kind ischemia d/t an MI or damage from an infection.

[ERDoc]

Those are potential causes, but what name would you give to the rhythm?