defib_wizard Posted December 7, 2008 Share Posted December 7, 2008 I would call it accelerated idioventricular rhythm with periods of sinus rhythm after coughing. How about transcutaneous pacing and some versed. Or at least have the pads on him. Link to comment Share on other sites More sharing options...
EMT Foose Posted December 7, 2008 Share Posted December 7, 2008 Any more history? Drug use, ETOH, recent illness, unusual activities, etc.. Definitely get the pads and IV TKO on that guy. I would call it a recurrent accelerated IVR, so Lidocaine is contraindicated. I'm going out on a limb and considering an Amiodarone infusion, but would of course be looking for medical consult. I would follow the standard chest pain protocols and see if that provided enough relief of the s/s prior to initiating any antidysrhythmics. I don't know which cardiac drug would be most appropriate, if it's even carried in the field that is.. My differentials include MI, pericarditis, acute metabolic condition leading to acidosis, and keep an eye on his sats for possible PE. Beyond that, I dunno.. Get him in for blood tests and get as much history as possible. Link to comment Share on other sites More sharing options...
Arizonaffcep Posted December 7, 2008 Share Posted December 7, 2008 I would call it accelerated idioventricular rhythm with periods of sinus rhythm after coughing. How about transcutaneous pacing and some versed. Or at least have the pads on him. Good call. Link to comment Share on other sites More sharing options...
jwraider Posted December 7, 2008 Author Share Posted December 7, 2008 OK I'm going to speculate alot here please don't laugh if I'm way off.... =) I called it accelerated ideo ventricular on call and my preceptor sqaushed that and said I need to consider it a V-tach (he says because it was faster than a normal ventricular rhythm or 20-40). I brought up the implications of knocking out an escape pacemaker if the Sinus wouldnt be there to back it up and we really didn't come to a good conclusion on what to do. I ended up using diesel because he was GCS 15, stable BP and had a radial (and the best cardiac hospital in the area was very close by). So anyway I call it "accelerated ideo ventricular rhythm with runs of normal sinus rhythm" and I'm really interested to find out where you're going with this doc because I didn't feel comfortable labeling V-tach or treating it that way and I want to know what was actually going on (imagine if I had a long transport) I guess if I'm calling it ventricular I need to focus on what would cause the ventricles to do that. Since he does go in and out of NSR it seems like the ventricles are irritable or there is increased automaticity in them. Looking closer at the rhythm strip the ventricular rhythm is barely faster than the sinus rhythm but it is faster. So maybe the increase in intrathoracic pressure when the PT coughs provides a momentary vagal effects and the SA takes back over. Or if that is totally wrong and the increase in intrathoracic pressure increases flow of blood back to the heart. So maybe the cough is increasing blood flow to the heart meaning the heart does not have enough blood (02) to begin with. So I'm back to something mechanical like an MI / blockage of a coronary artery. Or maybe disease in the chest wall or pericardfial sac is compressing an artery. I don't think this is an acute issue in his lungs because the lung sounds were too good but maybe something chronic from asthma has led to pulmonary HTN? Link to comment Share on other sites More sharing options...
jwraider Posted December 7, 2008 Author Share Posted December 7, 2008 He denies any recent illness and goes into detail about how he drives a truck and he just finished a trip from Texas to California. He woke up with the pain this morning and you get the sense he might be somewhat stressed overall. He denies alcohol "I'm working" or substance abuse. 02, ASA, Nitro don't offer relief (I was at the ED fairly quick and didn't get an IV so I don't know what morphine would have done). He does move around like he is in extreme pain all over. When you eventually have him scoot from the gurney to the ED bed he acts like he can barely do it and grimaces. He did mention an extensive orthopedic history (either due to sports or work injuries I'm guessing) but I still think this behavior is due to his current infliction. Remember the PT is perfusing so I'm not sure if pacing is the right idea. Pads should still go on (just like they did in the ED) Link to comment Share on other sites More sharing options...
Arizonaffcep Posted December 7, 2008 Share Posted December 7, 2008 So I'm back to something mechanical like an MI / blockage of a coronary artery. Or maybe disease in the chest wall or pericardial sac is compressing an artery. With pericarditis, you'd expect global ST segment elevation. Link to comment Share on other sites More sharing options...
Mateo_1387 Posted December 7, 2008 Share Posted December 7, 2008 Me thinks it could be an accelerated junctional rhythm with the p waves burried towards the end of the QRS complex which make it appear wider than it really is. But I have been wrong before.... Link to comment Share on other sites More sharing options...
jwraider Posted December 7, 2008 Author Share Posted December 7, 2008 Yeah I'm kicking myself for not having the EKG but the one I did get with with some NSR in it did not show elevation and once in the ED they got a good one with elevation in V2 only (2mm). No T wave inversions, no major Q waves, no depression. Link to comment Share on other sites More sharing options...
Mateo_1387 Posted December 7, 2008 Share Posted December 7, 2008 Me thinks it could be an accelerated junctional rhythm with the p waves burried towards the end of the QRS complex which make it appear wider than it really is. But I have been wrong before.... But I do not think it is a junctional rhythm. Link to comment Share on other sites More sharing options...
crotchitymedic1986 Posted December 7, 2008 Share Posted December 7, 2008 Treat the patient, not the monitor. I would call it a junctional rhythm, which we can argue all day (it is not sinus, and it is not wide enough to be Vtach in my opinion). Regardless, he is A&Ox3, with a good b/p. There is no reason to treat the rhythm. Which isnt to say you shouldnt BE PREPARED to treat the rhythm when indicated. With the history of pericarditis it is not impractical to believe that any vagal stimulus might change his rhythm. Link to comment Share on other sites More sharing options...
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