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Bieber

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Narrow complex tachy, regular rhythm, see some P waves in leads II and III, no delta waves. I'm calling it a SVT.

good eye sight.....280 HR on ecg and you can pick out P waves....impressed

narrow, tachy, regular..........SVT..........no need for P waves on that....

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This is really fast for a 35 year old. I'm surprised that it's narrow and there's not some sort of rate-dependent bundle-branch block. I'd also be suspicious of any illicit drug use, or the presence of a concealed accessory pathway -- otherwise this guy's got an impressive AV node.

I think I'd get the 12-lead first if he's "stable"-ish. although the information provided didn't give us much.

Differentials:

AVNT, AVRT, atrial tach, a.fib,

I see where craig's coming from the cardioversion, and it's not a bad idea --- this is scenarioland, I bet the guy has WPW -- , but I think I'd go the vagals/adenosine (12mg) route, and see what we see. If he decompensates we can re-evaluate cardioversion,

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Hello,

I agree that he is stable-ish as well.

He has an anxiety disorder. I has been worse over the pat 3-4 months. These worsening episodes of anxiety could be cardiac in nature (as suggested by numerous posters) or their could be some other internal medicine type cause such as hyperthyroidism. It is hard to say.

This is my weak point. But, I though WPW had a shortened PR intervial? We can not see the PRI due to the rate. But, if we change the EKG speed we may be able to see if their is a P wave. I have seen Cardiology do this trick before.

I would load him on the cot, connect the monitor and get a line going. Give him some Ativan SL or IV and get the Adenosine ready.

Cheers

Edited by DartmouthDave
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either way at a rate of 280 i dont think that the patient is 'some what stable' considering his other signs

to further my previos post, unless you are going to sedate be for cardo version he has to be at least unconscious before you zap him.

other than that morphine/ midazolam to sedate and away you go................hit the charge button boys............YEEHA

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Hello,

His GCS is 15 and he has a good pressure and SpO2. So, he is stable at the moment. I am not saying that you do nothing and drive slowly to the hospital. But, if you have a time to assess and think about the situation you should take it. Get a 12-lead, give something for the anxiety and ask a few questions. Give some Adensosine IV and see if it converts or if it shows us what is going on.

Why?

Well, I have seen S.Tachycardia cardiovert by EMS because it was a narrow rapid tachycardia and the patient was deemed 'unstable'. Or, a hyperthyroid induced tachycardia that was zapped a few times. Plus, a few rapid 1:1 or 2:1 A.Fibs as well. Most recently, a septic lady. She had a temp (39), a low pressure (80's) and an alterted LOC (GCS 12-13). But, look, a rapid norrow tachycardia on the monitor......this is an unstable tachycardia..the patient is unstable...cardiovert.

I have seen bad things happen in the hospital as well. It isn't just EMS.

Thank you,

David

Edited by DartmouthDave
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Hello,

I would stay away from a CCB in this a most situations. A constant, non-varying rate of 280 in a otherwise healthy 35 year-old male makes me think a reentry or assessory pathway is at work here.

So, slowing AV conduction could cause a paraadoxical increase in the heart rate. It could be an ugly time.

I still think a trial of Adenosine is worth an effort. It may convert the tachycardia. Or it may show you what you have. See what the PRI is and so forth.

Or, slow down the EKG speed so their is more space to see what is going on. I have seen this work nice of 1:1 flutters and such.

Have the pads ready just in case.

Thank you,

David

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