Just say no to drugs... and this rhythm

[crotchitymedic1986]

Fair enough, but if you can follow up that would be helpful (someone in the ER should be able to pull up the patient in the computer and give you a diagnosis -- even with HIPPA). Although this has some Vtach looking characteristics, it is a junctional rhythm. We can argue about this all day, but I did holter monitor scans for over a year as a part-time job, and had to argue with cardiologist all of the time. This patient most likely has a conduction delay, which has widened the QRS. You would be amazed how many people have multiple runs of true Vtach every day, and are walking the earth without any symptoms. I am not minimizing treating vtach, but realize that the patient is stable, and that the rhythm is intermittent. An IV should be started, but in my opinion, using Lidocaine or Amiodarone may be more harmful than good.

[defib_wizard]

crotchitymedic1986 said

Although this has some Vtach looking characteristics, it is a junctional rhythm.

A junctional rhythm has a narrow QRS. While a ventricular rhythm is wide. Any rhythm that is faster than its " normal" intrinsic rate is considered accelerated. Until the rate is 100 or more then it is considered tachycardia.

Junctional rhythm normal rate 40-60, >60 accelerated, >100 junctional tachycardia.

Ventricular rhythm normal rate 15-40, >40 accelerated, >100 junctional tachycardia.

Hope this helps.

[ERDoc]

Defib, thanks for posting that. I was going to do the same as I was reading through some of the posts and someone mentioned that their instructor said that it was VTach. This is an accelerated idioventricular rhythm. The QRS seems to have a duration of 0.28 sec (using calipers on the screen). As usual, I have an emedcine article on AIVR for your enjoyment.

http://www.emedicine.com/med/topic12.htm

[AZCEP]

Boy, those doctors know everything don't they?

I seem to recall that AIVR is (was) very common during the time that tPA was the treatment of choice for MI. Reperfusion dysrythmia was the terminology that was floating around at the time. For this situation, I'd be inclined to treat the discomfort with some oxygen and consider some fentanyl/morphine. Using NTG is a good thought, but since it hasn't been very effective moving past it might be warranted.

The lidocaine/amiodarone debate is pretty interesting as well. Without a beta blocker available, amiodarone is the closest you have. That doesn't make it right, just limits the choices you have to make. Remember the ventricles are assuming control of the rate because the SA isn't going fast enough to provide them with what they need. Lidocaine might do the job of reducing the irritable foci just fine, and allow the SA to maintain control. Amiodarone will probably allow for the same mechanism, but tends to take quite a bit longer to take effect.

[crotchitymedic1986]

Sorry, it is not AIVR, although you could find some cardiologist to call it that ---- It is a Junctional Rhythm (if you want to call it accelerated, so be it) with a CONDUCTION DELAY. Take the strips to your local cardiologist and ask an opinion. And yes, I am familiar with the text book definitions, but like almost everything in EMS, there is an exception. The QRS is widened by the conduction delay. This is a common occurence, but rarely captured in the field --- seen commonly on 24-48 hour holter tests.

PS: You usually see ventricular ectopy preceeding and succeeding AIVR --- it can be unifocal or multifical PVCs, couplings, or salvos, but because the pacemaker is ventricular, you see lots of ventricular ectopy. In this rhythm, the patient easily converts back and forth between Sinus and "Questionable Rhythm" without any ectopy or pauses (in the few seconds of strip shown --- longer strips may show something different, but i do not recall the poster discussing any PVCs).

[Arizonaffcep]

Sorry, it is not AIVR, although you could find some cardiologist to call it that ---- It is a Junctional Rhythm (if you want to call it accelerated, so be it) with a CONDUCTION DELAY.

http://www.emedicine.com/Med/topic1212.htm

This link has some great pics of 12 lead of a junctional rhythm, including accelerated junctional. The one thing I don't think you are keeping in mind is, with a conduction delay, you will get widening as you say, but no real change in amplitude with the QRS. If you look at the QRS's in question...there is a HUGE amplitude difference, indicative of ventricular origin.

[crotchitymedic1986]

Like I said, if you asked 10 cardiologists to diagnose this rhythm, you would get 4 that would say AIVR, 4 that would say Junctional with conduction delay, and 2 that would call it something totally different (probably IVCD, which i dont agree with, but have seen it called that).

And you can have amplitude changes with a conduction delay, it is quite common, especially among pre-pacemaker recipients.

The bigger question is whether or not to treat the rhythm with a normal B/P, and which treatment you would employ if you decided to treat the rhythm ? I would treat the chest pain, but not the rhythm, as long as B/P remained stable.

[ERDoc]

Crotch, no offense bro, but WTF are you talking about? Conduction delay refers to delay through the AV node. Since the junctional rhythm is originating in the AV node or just below there is no conduction delay. Sure, you can get delay through the ventricles, but then you get bundle branch blocks. I think you might want to review your physiology. Feel free to provide a reference if you can prove me wrong. Here, I'll provide one to start. Check out the part about "Descriptors of impulse conduction."

http://library.med.utah.edu/kw/ecg/ecg_out...son5/intro.html

[crotchitymedic1986]

Let me do some digging ERDoc, i will have to get back with you --- i think what you guys are missing is that this is an aberrant rhythm. But i will see what i can find for you.

[akroeze]

I think crotchity is calling this a junctional rhythm with abberancy.

Doc: How do you differentiate? Or is this a case (similar to V-tach vs. SVT with abberancy) where you assume the worse one until proven otherwise?