Rhythm Identification Help

[fiznat]

Its a wide complex tachycardia with probable P waves. You need a 12 lead before you decide for sure, but my money is on SVT with aberrancy.

I probably wouldn't be giving nitro without at least a 12 lead. It takes maybe 20 seconds to get one, so there is no reason you should start giving meds knowing so little about what's going on with your patent's heart. I only give NTG without an IV if I've seen the 12 lead, and even then you need to be cautious.

There are also other assessments that are particularly pertinent here as well: lung sounds? JVD? Distal edema? Skin color/temperature/condition, etc etc.

[tniuqs]

I'd call it sinus tachycardia with a BBB, but withhold absolute interpretation until more leads are made available.

In late:

But I agree with AZCEP ie the BBB (notching S wave) or possible indication of some type of LV Hypertrophy, question is this new BBB ? but the tachy cardia is still unexplained.

I would do a wee fluid challenge, as the elderly can frequently be dehydrated, get a line in asap.

12 lead absolutely and maybe do a bed side troponin if you have that capability.

If you don't have a line, 12 or bedside stuff ... get going to ER, if the pt has already taken Nitro check the expiry dates, and if her BP and LOC are ok let her try another spray ...

cheers

[BEorP]

There are also other assessments that are particularly pertinent here as well: lung sounds? JVD? Distal edema? Skin color/temperature/condition, etc etc.

Lung were clear, no JVD, there was some peripheral edema, skin was a bit pale but normal other than that.

If you don't have a line, 12 or bedside stuff ... get going to ER, if the pt has already taken Nitro check the expiry dates, and if her BP and LOC are ok let her try another spray ...

Appreciate the feedback. Would you have been comfortable giving this patient nitro without an IV? (with no further rhythm info available due to the lack of 12 lead capabilities) Her BP was about 110/60.

Edited March 22, 2009 by BEorP

[FL_Medic]

Negative... that pressure would make me have an IV prior to NTG administration. I think I would try and slow the rate down first too. Sometimes an accelerated rate can cause angina. I think that rate is pretty fast for an old lady. Why is it fast, that's the question. Not whether I'd give NTG prior to IV.

Edited March 22, 2009 by FL_Medic

[BEorP]

Any other thoughts on whether nitro was appropriate for this patient? (just to reiterate, no IV access or 12 lead available)

Edited March 23, 2009 by BEorP

[wrmedic82]

Im assuming ( i hope lightning doesnt strike me by saying this) this is a 3-lead strip. Since 12-lead is unavailable. I would say you can take the LA lead and place it where V1, V2 ect to look at individual leads. Takes more time and not as reliable..but its something to go by to give you an idea.

Now as far as giving nitro to the patient w/o IV access. Thats a judgement call you would have to make based on how the patient presents to you. If they are a bit tachycardic and they have the systolic above 110, you can give probably 1 spray and might be able to get away with it. However you leave yourself vulnerable if it just so happen to work a little too well.Its also possible the only way the patient is compensating to sustain that pressure is because of the tachycardia. Trendelinberg could be an option to help raise BP, not that Im a big fan of trendelinberg as I have read in a study that it can cause more harm than good.

(in a nutshell by placing patient in trendelinberg, fluid shifts to the torso, thus tricking the body to thinking it is ok, and stopping the release of catechlomines. so once patient returns in the ER to a semi fowlers postion, the body has a difficult time catching up)

And for those spell checkers out there I will say this in advance.. Bite me lol

Have a good night.

[Camulos]

Any thoughts on what this is though?

Looks like a rhythm strip to me. Jokes!!!!

I agree with fiznat - SVT with aberrancy - probably a RBBB due to the deep S wave. Would need a 12 lead to assist with confirmation though.

Stay safe,

Camulos - The member formerly known as Curse

[snakemedic]

Looks like a rhythm strip to me. Jokes!!!!

I agree with fiznat - SVT with aberrancy - probably a RBBB due to the deep S wave. Would need a 12 lead to assist with confirmation though.

Stay safe,

Camulos - The member formerly known as Curse

To answer your question of giving NTG without IV, I would say if that is the road you are persuing then yes, I would be comfortable giving NTG without IV. Her sysstolic is 110 and her map acceptable to give nitro. How did she respond to her own ntg, did she fall on the floor? Her chest is clear so if you need to lay her down because she drops her pressure you can do that. This stuff is not etched in stone, you need to think about what your trying to accomplish, take the workload off the heart, but , don't increase the MVO2 by dropping the pressure to far (risk/benefit). If it was her first time ever with NTG I would be more concerned with a possible pressure dump but....that's what they pay you to do, think. I would stay away from the MSO4 until having a line the concurrent histamine release might be more deleterious than uselful. In the end try to do the best you can for the patient like they were your own family. Out of curiosity, did you ask the Dr what they think about the NTG without a line?

Snake

[crotchitymedic1986]

Sinus tach with BBB, probably another pt on digoxin.

[HellsBells]

Any other thoughts on whether nitro was appropriate for this patient?

I would say that its a judgement call. 110 is a borderline pressure, I'd feel much more comfortable with a line in at this pressure, but its still in the acceptable range. As an above poster said she is on her home nitro, but this may not just be her usual angina. Does her chest pain usually go away after one spray of nitro? Is the current pain different than usual? When did her pain start? Is she normally hypertensive?

Another consideration for you to make is to think of the long term outcome for the patient. If she is having an MI, ASA is a much more important drug than nitro in reducing overall mortality. So if you carry ASA, make sure to give it before you worry about nitro.