Jump to content
Sign in to follow this  
FL_Medic

Strip Tease 2

Recommended Posts

My training captain has provided another one. Please provide your impressions.

87 y/o M c/o weakness & near syncope for the past 18-24 hours. Denies CP or SOB. HR matches monitor. 132/72 supine. Pale & clammy.

WAP.jpg

Share this post


Link to post
Share on other sites

I guess i'll give it try. At first glance it looks like a sinus rhythm with runs of V-Tach, occasional PVC and I also see a PAC in there. Looks like he is pretty ischemic with those sloped s-t segments. CAD.

After looking at it for a while, maybe its just periods of s-t elevation? doubting the v-tach now.

Edited by OHMEDIC187

Share this post


Link to post
Share on other sites

underlying is sinus with a sinus pause and an escaoe rythym - possibly junctional....

Share this post


Link to post
Share on other sites

I haven't received the answer yet but I am going to post what I responded with. This was my emailed response: I don't think I am right, but why not try?

Well, the first thing to ask would be if the patient has a pacemaker.

Rhythm: There are at least three different morphologies that appear to be atrial, including a very wide complex, and one that appears to be ventricular. One ventricular morphology appear to have possible p waves with a very short pr-interval. One may even have the p buried in the R wave. Since the P waves vary in morphology as well I'd say this is some sort of atypical wandering atrial pacemaker. It's possible that this is an AV block but it doesn't meet any classic criteria. Side note: I think I even see some U waves in there

Treatment: Treat the patient not the monitor. He is hypoperfusing. His rhythm may have PVCs but lidocaine would leave his HR far too slow. O2 would be initial treatment with continued supine/trendelenberg positioning. A 12-lead and family Hx would be good as well. I would feel for a mechanical pulse to see if those wide complexes are perfusing. It's possible that his pulse is slower than his HR and that BP is compensatory due to increased vascular resistance. I think that is probably the case, and if so, the patient should be treated per the symptomatic bradycardia guideline. Atropine, TCP, Dopamine, Epinephrine. The treatment goal here is to get the SA node back to it's position as the lead pacemaker.

Hope I'm right, but if not I would treat with diesel fuel.

Share this post


Link to post
Share on other sites

Man, I keep going back to those wide complexes being two Salvo runs, a pvc and a couplet on the second strip. Although, that would be too easy. Im probably way off.

Im curious what the answer is!!

Share this post


Link to post
Share on other sites

SR with junctional, possibly AIVR, escape beats.

O2/IV/12 lead/transport

Share this post


Link to post
Share on other sites

SinusBradyVentricularEscape.jpg

THE ANSWER

Sinus Bradycardia with ventricular escape beats. You can see a slowing SA nodal discharge rate util no p-wave is seen. The ventricular complexes are late cycle, not premature like a PVC. The patient should not be treated with antidysrhythmics. O2, Fluid bolus, positioning. If still unresolved treat with Atropine then Pace if unchanged.

The wide complexes with p-waves are fusion beats. Fusion beats are common when ectopic site fires while ventricles are already being activated from primary pacemaker.

Unfortunately this patient was treated with Amiodarone.

Edited by FL_Medic

Share this post


Link to post
Share on other sites

I'll be man enough to admit that I might have treated that patient incorrectly. Obviously I don't know for sure what I would have done but salvos of V-tach was my thought process.

Share this post


Link to post
Share on other sites
This thread is quite old. Please consider starting a new thread rather than reviving this one.

Join the conversation

You can post now and register later. If you have an account, sign in now to post with your account.

Guest
Reply to this topic...

×   Pasted as rich text.   Paste as plain text instead

  Only 75 emoji are allowed.

×   Your link has been automatically embedded.   Display as a link instead

×   Your previous content has been restored.   Clear editor

×   You cannot paste images directly. Upload or insert images from URL.

Sign in to follow this  

×
×
  • Create New...