Strip Tease 7

[Niftymedi911]

And for the record Adam,

I did not read your blog prior to posting. Cardiogoly is my niche, I love it. I'm not saying I'm the best either, but I could see the delta waves in numerous leads. It was plain obvious with the irregularity that was there.............

[FL_Medic]

And for the record Adam,

I did not read your blog prior to posting. Cardiogoly is my niche, I love it. I'm not saying I'm the best either, but I could see the delta waves in numerous leads. It was plain obvious with the irregularity that was there.............

didn't say you did.

[Tom B.]

Also look at the axis. Right shoulder axis deviation is typically highly suggestive of a rhythm originating in the ventricles. Ventricular tachycardia, for example. For right shoulder axis deviation to exist, the QRS morphology in leads I, II, & III should demonstrate negative deflection. Lead I is clearly positive, so this rules out right shoulder axis deviation and most likely rules out a rhythm that originates from the ventricles.

I'd like to make a minor correction.

While a right shoulder (right superior) axis can be suggestive of VT, it's not true that rhythms with an other-than-extreme axis are unlikely to be VT.

With VT, you can have a normal axis, left inferior axis, right inferior axis, or right superior axis.

I apologize for nitpicking, but it's an important point.

Tom B.

Ventricular rhythms do not always present with extreme right axis deviation, be careful.

Maybe I should have read through all the comments before I hit reply!

Tom B.

As a final thought, whenever the shortest R-R interval is 6 small blocks or less, there's an excellent chance you're dealing with an accessory pathway! My dept's protocols do not allow antiarrhythmics in the presence of delta waves, heart rates that = or > 250, or shortest R-R interval of 240 ms or less.

Tom B.

[Mateo_1387]

STAY AWAY FROM AV SLOWING AGENTS.

I wouldn't give any drugs to these patients. Shock them! Procainamide is the safest if you have to give drugs. Amiodarone is controversial, but second safest (if you are going to convert them you might as well zap them). C+ Channel blockers or Adenosine will effectively kill them.

Why do you say amiodarone is contraversial? It is the everything channel blocker (in essence) applying the breaks to the whole truck, and not just the front set of breaks...

Also, as for Adenosine, the drug card that comes packaged with Adenosine says that it can be used with WPW. Why do you say it will kill them?

[Tom B.]

Why do you say amiodarone is contraversial? It is the everything channel blocker (in essence) applying the breaks to the whole truck, and not just the front set of breaks...

Also, as for Adenosine, the drug card that comes packaged with Adenosine says that it can be used with WPW. Why do you say it will kill them?

Adenosine might work for an antidromic AVRT, but it's a risky drug that can trigger VF, especiallly in the setting of AF/WPW.

As for amiodarone, consider this transcript from Amal Mattu M.D.'s December 2008 podcast at EMedHome.com:

Another concern that you need to be aware of is, if you have a patient who has AF with WPW, stay away from amiodarone. Even now, AHA continues to list amiodarone as a viable option, but it’s not a viable option. In fact, the only published reports on using amiodarone in rapid AF and WPW have indicated that amiodarone is associated with adverse outcomes. There’s a handful of case reports of patients that had rapid AF and WPW. They got amiodarone and they decompensated. There are, to my knowledge – and I’ve looked through the literature in detail multiple times – and I have yet to find even a single case report or a single case series or a published study saying, “I had a patient with rapid AF and WPW, I gave him amiodarone, and they did well.” Not a single publication that I can find. The only publications on that particular scenario that have ever been published in the literature are "patient did worse" so my recommendation and a handful of other peoples’ recommendations also; "Stay away from amiodarone if you’re taking care of a patient with rapid AF and WPW."

[fiznat]

Adenosine might work for an antidromic AVRT, but it's a risky drug that can trigger VF, especiallly in the setting of AF/WPW.

As for amiodarone, consider this transcript from Amal Mattu M.D.'s December 2008 podcast at EMedHome.com:

Another concern that you need to be aware of is, if you have a patient who has AF with WPW, stay away from amiodarone. Even now, AHA continues to list amiodarone as a viable option, but it’s not a viable option. In fact, the only published reports on using amiodarone in rapid AF and WPW have indicated that amiodarone is associated with adverse outcomes. There’s a handful of case reports of patients that had rapid AF and WPW. They got amiodarone and they decompensated. There are, to my knowledge – and I’ve looked through the literature in detail multiple times – and I have yet to find even a single case report or a single case series or a published study saying, “I had a patient with rapid AF and WPW, I gave him amiodarone, and they did well.” Not a single publication that I can find. The only publications on that particular scenario that have ever been published in the literature are "patient did worse" so my recommendation and a handful of other peoples’ recommendations also; "Stay away from amiodarone if you’re taking care of a patient with rapid AF and WPW."

There is this, and there is the AHA. I guess you need to decide which to believe, and follow your protocols. Neither this statement nor the AHA's is backed up with actual objective research, but that is because it doesn't seem like such research actually exists right now. In choosing between two sources of anecdotal opinions like this, paramedics probably should just pick the one that favored most in your local area. My protocols say to give amiodorone, so that is what I will do (if it can't be avoided).

[Tom B.]

There is this, and there is the AHA. I guess you need to decide which to believe, and follow your protocols. Neither this statement nor the AHA's is backed up with actual objective research, but that is because it doesn't seem like such research actually exists right now. In choosing between two sources of anecdotal opinions like this, paramedics probably should just pick the one that favored most in your local area. My protocols say to give amiodorone, so that is what I will do (if it can't be avoided).

In the absence of evidence that it helps, and with anecdotal reports of possible harm, why give it? Synchronized cardioversion is a perfectly viable option (and so is supportive care for hemodynamically stable patients). The first rule of medicine applies.

Tom B.

[FL_Medic]

There is this, and there is the AHA. I guess you need to decide which to believe, and follow your protocols. Neither this statement nor the AHA's is backed up with actual objective research, but that is because it doesn't seem like such research actually exists right now. In choosing between two sources of anecdotal opinions like this, paramedics probably should just pick the one that favored most in your local area. My protocols say to give amiodorone, so that is what I will do (if it can't be avoided).

No one is telling you to stray away from your protocols Fiz. You should do exactly what your medical director expects of you. Keep the combo pads nearby though. As for Tom's post, Amal Mattu is an emergency physician that has become a near expert in electrocardiography. He may not have it written down as a scientific method, but doing something that has shown no improvement but has shown potential harm is lunacy. This is why the Trendelenburg position is soon to fall out of favor. AHA will be renewing their guidlines next year, I predict Amiodarone will be sitting in the backseat this time around.

Read this post on Ambulance Driver's blog, He explains the over use of "selective cardiotoxins".

[Tom B.]

No one is telling you to stray away from your protocols Fiz. You should do exactly what your medical director expects of you. Keep the combo pads nearby though. As for Tom's post, Amal Mattu is an emergency physician that has become a near expert in electrocardiography. He may not have it written down as a scientific method, but doing something that has shown no improvement but has shown potential harm is lunacy. This is why the Trendelenburg position is soon to fall out of favor. AHA will be renewing their guidlines next year, I predict Amiodarone will be sitting in the backseat this time around.

Read this post on Ambulance Driver's blog, He explains the over use of "selective cardiotoxins".

My views on these types of topics are constantly changing. Five years ago, I wouldn't have had any idea what AF/WPW looked like, let alone how to treat it (or not treat it). I'm not a huge fan of prehospital antiarrhythmics in the first place. At least for regular wide complex tachycardia, you probably won't harm the patient by trying 150 mg of amio over 10 minutes. Of course, with AF/WPW you have the same concerns about symptom onset < 48 hours that you would have with any other AF. Like I said, I just don't care for prehospital antiarrhythmics, so I wouldn't feel comfortable monkeying around with AF/WPW. If it's unstable, I'll shock it. If it's stable, I'll let the ED physician (or a cardiology consult) figure it out. I wouldn't judge someone for giving amio since it's an option in the AHA ECC 2005 guidelines for irregular wide complex tach. I just wouldn't do it based on the possibility of causing harm with no clear evidence of benefit.

Tom B.

[fiznat]

I'm not a huge fan of prehospital antiarrhythmics in the first place.

Any antiarrhythmics? I've had some really good luck with both Adenosine and Cardizem.