zzyzx Posted November 20, 2009 Share Posted November 20, 2009 I've been discussing this scenario with a co-worker. I'd like to know what you guys would do: You have resuscitated a patient who was in PEA. He's now in a normal sinus rhythm with pulses. As you are transporting the patient, he goes into a wide-complex tachycardia that looks exactly like VT (perfect sine waves), but at heart rate of 120, and he still has pulses. Would you cardiovert? My thinking is that no, you should not, because you can't be sure if it's VT, and that even if it is, the rate isn't so fast as to affect cardiac output. I actually had a similar scenario where I had a critical patient who went from a brady sinus rhythm with narrow complexes to a wide-complex tachycardia at a rate of 120 (with pulses). I held off doing anything and about a minute later the patient converted back into a sinus rhythm. My co-worked argued that if the apparent VT was sustained, it should be cardioverted because it could soon deteriorate into VF or a much faster VT. What do you guys think? Let's say you have no access to a 12 lead. Link to comment Share on other sites More sharing options...
Jwade Posted November 20, 2009 Share Posted November 20, 2009 I've been discussing this scenario with a co-worker. I'd like to know what you guys would do: You have resuscitated a patient who was in PEA. He's now in a normal sinus rhythm with pulses. As you are transporting the patient, he goes into a wide-complex tachycardia that looks exactly like VT (perfect sine waves), but at heart rate of 120, and he still has pulses. Would you cardiovert? My thinking is that no, you should not, because you can't be sure if it's VT, and that even if it is, the rate isn't so fast as to affect cardiac output. I actually had a similar scenario where I had a critical patient who went from a brady sinus rhythm with narrow complexes to a wide-complex tachycardia at a rate of 120 (with pulses). I held off doing anything and about a minute later the patient converted back into a sinus rhythm. My co-worked argued that if the apparent VT was sustained, it should be cardioverted because it could soon deteriorate into VF or a much faster VT. What do you guys think? Let's say you have no access to a 12 lead. Well, 1. You can use a 3 lead to see what is happening in more than lead II, so a 12 lead while nice, is not an absolute necessity and you have to be able to interpret the 12 lead based on what you see, not what the nice little printout on the top says. 2. Let's discuss indications for cardioversion. a. V-tach with pulse - Stable = Meds / Unstable = Cardioversion / then if continued refractory to meds, cardioversion is indicated. b. You fail to mention if you have qualified your patient as stable or unstable? 3. What was LOC? ( I am making the assumption of unconscious), What was his BP? What did he or she look like clinically? People do some really weird crap post-resuscitation, so, my initial reaction is to say NO, i would not have cardioverted, but I don't have all of the info yet. Respectfully, JW 1 Link to comment Share on other sites More sharing options...
Kaisu Posted November 20, 2009 Share Posted November 20, 2009 Something made this guy arrest in the first place. PEA is a crummy rhythm to have and he is headed there again. What did you find out about the Hs and the Ts? Is he having perfusion issues? What is the BP? Any shortness of breath? I would administer a ventricular arrhythmic, specifically amiodarone. Link to comment Share on other sites More sharing options...
kevkei Posted November 20, 2009 Share Posted November 20, 2009 I'd tend to agree with John. Post resuscitation dysrhythmias are very common and it is recommended to put your hands in your pockets and watch, no electrical or chemical cardioversion right away. 1. How long after you got pulses back would this be? Short time vs long time. What was the PEA, narrow/wide, fast/slow? This wide complex tachycardia of unknown origin, are there P waves present? Is it VT or is it a LBBB? Does this rhythm closely resemble what the PEA rhythm looked like? 2. As above, quantify vital signs (BP, SpO2, EtCO2, BGL). If he is stable, he can wait, treat potential underlying causes hypoxia, respiratory acidosis, hypovolemia, etc). If not stable, then you need to treat the rhythm. Sustained I would suggest would be a couple of minutes. If VT, it tends not to sustain for long and will deteriorate to pulseless VT or VF. 3. Is he intubated? How old is the patient? Any meds? Previous medical history? 4. Anything else remarkable on physical exam from head to toe? What I don't like about Amiodarone is the time to infuse as with Procainamide. I do like Lidocaine because I've found it works well in refractory VF/VT, and it is single dose IVP. It's also a nice option if you do decide to cardiovert to pre treat with the Lido. Link to comment Share on other sites More sharing options...
Jwade Posted November 21, 2009 Share Posted November 21, 2009 I'd tend to agree with John. Post resuscitation dysrhythmias are very common and it is recommended to put your hands in your pockets and watch, no electrical or chemical cardioversion right away. 1. How long after you got pulses back would this be? Short time vs long time. What was the PEA, narrow/wide, fast/slow? This wide complex tachycardia of unknown origin, are there P waves present? Is it VT or is it a LBBB? Does this rhythm closely resemble what the PEA rhythm looked like? 2. As above, quantify vital signs (BP, SpO2, EtCO2, BGL). If he is stable, he can wait, treat potential underlying causes hypoxia, respiratory acidosis, hypovolemia, etc). If not stable, then you need to treat the rhythm. Sustained I would suggest would be a couple of minutes. If VT, it tends not to sustain for long and will deteriorate to pulseless VT or VF. 3. Is he intubated? How old is the patient? Any meds? Previous medical history? 4. Anything else remarkable on physical exam from head to toe? What I don't like about Amiodarone is the time to infuse as with Procainamide. I do like Lidocaine because I've found it works well in refractory VF/VT, and it is single dose IVP. It's also a nice option if you do decide to cardiovert to pre treat with the Lido. Excellent questions that need answered for sure.... One question with regard to the highlighted area above. Can you explain your rationale for pretreating with LIDO for cardioversion? Respectfully, JW Link to comment Share on other sites More sharing options...
ukcanuck Posted November 21, 2009 Share Posted November 21, 2009 I too agree with the if it ain't broke don't go fixing it cause you might break it school. It could well be that the WCT that you are seeing is a reperfusion rhythm. The myocardium will be hypoxic and there fore VERY irritable even with good airway and ventilation. Let the heart try to get back to normal before doing anything heroic. Don't get me wrong - I would still be ready for this guy to arrest again but just would not be too agressive with hitting him with anything as his heart is very fragile post ROSC. If the patient is perfusing adequately I would be tempted to get the meds ready that would be indicated for WCT ie Amio/Procainamide/Lido and administer after you have given the heart time to stop doing whatever it is doing. That will be be just after you think it has been long enough and your sphincter starts to tighten If it looked like he was going south with a symptomatic WCT then cardiovert. I would get a 12 lead ASAP to try to look at whether it is actually a WCT or a NCT with aberrant conduction which could be a possible as someone said something put him into arrest. Was that an AMI that has now stuffed a conduction pathway? If the pt is tubed paralysed and sedated I would watch my meds carefully so as not to cause a hypotensive event. I would also watch his tidal volume to not put too much pressure on his heart by blowing his chest up like a balloon. I am reliably informed that is bad....... Any way you choose - meds or energy or leave alone - its a bit of a crap shoot as these pts tend to do what ever they want despite what we do. You did well going from PEA to a ROSC big pat on back!!!! Link to comment Share on other sites More sharing options...
zzyzx Posted November 21, 2009 Author Share Posted November 21, 2009 Okay, to clear things up, let's say that after you have resuscitated the patient, he has barely palpable pulses. You're on your way to the ER, busy hanging a dopamine bag and probably doing ten other things at once, and you see him suddenly going from a narrow complex sinus rhythm at a rate of 80 into a wide-complex tachycardia that looks EXACTLY like VT. He still has barely palpable pulses. The heart rate is 120. Link to comment Share on other sites More sharing options...
1EMT-P Posted November 21, 2009 Share Posted November 21, 2009 I would like some additional information about this patient, including his Signs, Symptoms, Allergies, Medications, Past Medical History, Last Intake & Events prior to the arrest. I would also like to know his vital signs & what treatments he has received. Instead of starting Dopamine, I would probably give this patient a 500 ML fluid bolus of LR or NS first & treat any hypovolemia before I started Dopamine, I would also consider giving him a trial bolus of Lidocaine 1 mg/kg. Lidocaine supressess ventricular ectopy, increases the ventricular fibrillation threshold, it also reduces the velocity of electrical impulse through the hearts conduction system. Lidocaine can be used in Wide Complex Tachycardia of an uncertain origin. If the heart rate was 150 or greater then I would consider cardioversion. Link to comment Share on other sites More sharing options...
prisonmedic Posted November 21, 2009 Share Posted November 21, 2009 (edited) From the initial comment there are A few things I would insure before shooting electricity through the patient. 1. Check equipment? is there a loose lead or malfunction? 2. How is the patient? Symptomatic? 3. Wide complex QRS (over 0.12ms) is of a ventricular origin. The ventricular rate is 30 to 40 any wide complex over this rate can be considered V-tach as long as there are no P-waves. Maybe even torsades de pointes. 4. Is there a BP or pulse? IF only the ventricles are beating the cardiac output will be bad in a mater of seconds. In this case after CPR and conversion of PEA I would have my pads connected to the patient and lidocaine or amioderon ready to go in case of a deterioration. Remember a symptomatic patient get juice either synchronized or not depending on the pulse. New AHA guidelines state CPR should be performed for two minutes after a rhythm change regardless of pulse due to the lake of oxygen and to help the tired heat muscle. I've been discussing this scenario with a co-worker. I'd like to know what you guys would do: You have resuscitated a patient who was in PEA. He's now in a normal sinus rhythm with pulses. As you are transporting the patient, he goes into a wide-complex tachycardia that looks exactly like VT (perfect sine waves), but at heart rate of 120, and he still has pulses. Would you cardiovert? My thinking is that no, you should not, because you can't be sure if it's VT, and that even if it is, the rate isn't so fast as to affect cardiac output. I actually had a similar scenario where I had a critical patient who went from a brady sinus rhythm with narrow complexes to a wide-complex tachycardia at a rate of 120 (with pulses). I held off doing anything and about a minute later the patient converted back into a sinus rhythm. My co-worked argued that if the apparent VT was sustained, it should be cardioverted because it could soon deteriorate into VF or a much faster VT. What do you guys think? Let's say you have no access to a 12 lead. Edited November 21, 2009 by prisonmedic Link to comment Share on other sites More sharing options...
Jwade Posted November 21, 2009 Share Posted November 21, 2009 Okay, to clear things up, let's say that after you have resuscitated the patient, he has barely palpable pulses. You're on your way to the ER, busy hanging a dopamine bag and probably doing ten other things at once, and you see him suddenly going from a narrow complex sinus rhythm at a rate of 80 into a wide-complex tachycardia that looks EXACTLY like VT. He still has barely palpable pulses. The heart rate is 120. Not sure your post clears much up, sorry.... In my 18 years of experience, most ROSC have weak pulses and low bp to start with, so this is nothing out of the ordinary. Again, the heart muscle is irritated to say the least, so I would expect potentially weird things to go on from time to time. 1. What EXACTLY is the time frame in seconds you watched this run of " VT"? 2. Here is what I would NOT do. My guess is his BP is low, hence the dopamine drip you are attempting to initiate. Giving a bolus of LIDO could further drop his BP, so that is clearly out until I have a decent BP to work with. 3. Again, one should not get so tunnel visioned on RATE. VT @ 120 or 200 is still VT. The question you have to ask is STABLE or UNSTABLE! I was not there, so I can not say for sure. 4. In the context of your information and the scenario given, I would have NOT cardioverted right away. I would have given the patient a few minutes to get his BP somewhat stable, and see if his heart " calms " down a bit......Chances are things would change on you again. 5. I would have the AMIO or LIDO ready and avail should i need it later on for sure. 6. Remember, BP = Brain Perfusion. Runs of VT are fairly common sometimes. You would be amazed at some of the stuff you see in an EP lab. Respectfully, JW Link to comment Share on other sites More sharing options...
Recommended Posts