Camulos Posted January 4, 2009 Share Posted January 4, 2009 Given that its monomorphic VT I don't know that the magnesium mentioned earlier would have much of an effect. Mind you I don't believe it could cause much harm, providing it is administered appropriately. I do have a couple of theories going but need some more info first. I hazard jumping in too early and giving a stupid answer without gathering all the facts as I normally would. First of all I would love to see the rhythm strip. I am keen to know if it is truly VT or an SVT with abberrant conduction. However I am guessing its not an SVT as the pt loses his pulse and consciousness when it occurs. Does the pt have PVC's present when they revert back to sinus? If so looking at a similarity in the morphology of those may give a clue as to whether it is truly VT or SVT with abberration. Secondly, I would be interested to get this pt's medical history and current medications in case they are an abysmal historian. I am particularly interested whether this pt has a cardiac history. GREAT scenario by the way. One I have certainly not encountered before but this is great food for thought. Looking forward to see how it develops and what the final answer is. Stay safe, Curse :evil: Link to comment Share on other sites More sharing options...
Just Plain Ruff Posted January 4, 2009 Share Posted January 4, 2009 patient has a history of open heart (triple bypass) I cannot remember what medications he was on but I know there is a beta blocker and a blood thinner. There were occasional pvc's but there were more before the lido. Patient keeps pleading for me to help him. The v-tach is getting longer each time, about 8-12 seconds by the time we get him into the ambulance We find out that the bird is now flying and they will meet us at the helipad. 25 minutes out. Patient now in sinus tach and waking up. 12 lead shows when he isn't having the episode a sinus tach with what looks like to me a little bit of elevation in 2 3 and avf but not enough to trigger the MI reading.............yet Link to comment Share on other sites More sharing options...
Camulos Posted January 4, 2009 Share Posted January 4, 2009 As far as diagnosis is concerned I have a few up my sleeve however none entirely fit the picture. The diagnoses that come to mind are Brugada syndrome – possibly made worse by the lignocaine, and R ventricular dysplasia. The inferior ST elevation threw me off track a bit and has led me to include R ventricular infarction. So following the standard 12 lead ECG let’s do a right sided one as well. Heck at least it will look like we are doing something useful for the pt. I’d need much more info to confirm any of these diagnoses though and although they may be going through my head I would never be able to conclusively diagnose this pre hospital in our current system. As an aside to this, is lignocaine, or liDocaine as you spell it, your first line antiarrythmic? Ours used to be however has now changed to amiodarone. In your last post you reported that the pt is “now in sinus tachy and waking up”. In my hopeless ability to not realise exactly what was going on with this pt his condition has luckily improved. Jeez I’m good – he he. As far as my treatment goes before we got to this point. Would I have given my first line antiarrythmic of amiodarone? Well probably not. Only because his rhythm was not sustained and was alternating between VT and sinus rhythm. Hard call to make, especially with the PVC’s, but I’m hoping my high flow O2 makes some in roads there. Would I have given magnesium? In the absence of polymorphic VT I would have to answer no. However as I said before I can’t see it doing much harm. Would I have electively cardioverted him or attempted to over ride pace? I really don’t think I’d have the balls considering his rhythm was so erratic. As such my treatment would have been the basics – O2, monitoring with a big focus on relieving this pts pain and anxiety to stop him pleading with me to help. And of course to provide good pt care – LOL. I would be careful which analgesic I used in this case – particularly with RVI on my list of potential diagnoses (no morphine). I guess I’ve been taught that if I truly don’t know what to do that I should just stick to the basics. So in this case I guess I’m going to have to concede that I’ve been beaten. So I’m gunna stick to the basics and only hope that the helicopter is a lot quicker than the 25 minutes I was told. If the pt deteriorates in that time, and goes into sustained VT, VF etc, his treatment decisions, for me anyway, actually get easier. However if any of my diagnoses above are correct and he does deteriorate we may not need that bird after all. Keen to hear the answer here and boy am I glad we have discussed this scenario here rather than me being unlucky enough to come across it in real life like you did. Maybe you deserve my nickname more than I do. Stay safe, Curse - May be retired and given to RUFFEMS!! :evil: Link to comment Share on other sites More sharing options...
Just Plain Ruff Posted January 4, 2009 Share Posted January 4, 2009 ok the guy had a very feisty ventricle and every little movement caused the runs of v-tach. He indeed lost a pulse when this happened. The ER was able to stabilize him with amiodarone and then fly him on to the city. the cardiologist told me that if we had tried to defib the vtach without the pulse we would have likely put him in v-fib and he more than likely would have died. The unfortunate thing was that every time he went in this rhythm by the time I checked his pulse and LOC and then charged the defibrillator he would convert. Had I have shocked him he more than likely would have converted right before the shock and then we'd have shocked a perfusing rhythm and then we're talking v-fib and then coffin. Link to comment Share on other sites More sharing options...
Camulos Posted January 4, 2009 Share Posted January 4, 2009 Did you ever find out what the final diagnosis was? I suppose the ED, and indeed myself, may have been more comfortable using amiodarone in the setting of the sinus tachycardia they were presented with rather than the earlier combination of sinus rhythm / VT we were originally presented with. I wonder if my choice to not administer an antiarrythmic, as you did, would have made this pt worse? It always would have been a very hard call to defibrillate this pt considering he was in such a fruit salad of rhythms. Out if interest did you administer analgesia to relieve his pain? And if so what did you use? Also keen to find out if lidocaine is your first line antiarrythmic. Great job on that case!!! A difficult one indeed. Goes to show you that not all pts fit into a nice little slot in the cookbook and sometimes we need to think outside the square. Stay safe, Curse :evil: Link to comment Share on other sites More sharing options...
crotchitymedic1986 Posted January 4, 2009 Author Share Posted January 4, 2009 Great post, need someone to step up with a new question. Link to comment Share on other sites More sharing options...
CTXMEDIC Posted January 7, 2009 Share Posted January 7, 2009 Did you ever find out what the final diagnosis was? Also keen to find out if lidocaine is your first line antiarrythmic. Great job on that case!!! A difficult one indeed. Goes to show you that not all pts fit into a nice little slot in the cookbook and sometimes we need to think outside the square. Stay safe, Curse :evil: my first line antiarrythmic is oxygen Link to comment Share on other sites More sharing options...
Camulos Posted January 7, 2009 Share Posted January 7, 2009 my first line antiarrythmic is oxygen Do you revert much VT with that? :roll: Stay safe, Curse :evil: Link to comment Share on other sites More sharing options...
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