Interesting EKG from yesterday

[fiznat]

Take a look at this guy. 76 y/o male presenting to the ED (I was doing clinical rotations there) with "a fluttery feeling in my chest." VS: BP 137/82, RR 20, HR: see the strip. AOX4, skin warm/dry/pink. Pt has a pacemaker/ICD placed 2 years ago for "this same thing." Prehospital interventions were limited to IV/O2/Monitor.

Heres the strip:

He was constantly coming in and out of this rhythm. Sometimes it would run for 6+ seconds, then break, then come back.

We treated this rhythm in the ED, but I'd like to hear what you guys think about it first. Consider that it might not be as obvious as it seems.

[Ridryder 911]

It is not so much the run of V-tach concerns me as the PVC's that are occurring close to the T-wave. Now, I am wondering why the ICD did not convert him unless his pacemaker/ICD failed to capture and the pacemaker failed itself. Without the base ventricular rate, I cannot detect if the PVC's were fusion beats to increase the ventricular rate or not?

If he was brady then I would had proceeded to that accordingly, not "knocking" out ventricular firing.

R/r 911

[fiznat]

Heres more of that since you mentioned it:

The ICD, I beleive, did go off a number of times. I dont know why it didnt in this particular strip, but I overheard that he had been shocked in excess of 70 times based on data removed from the device. It may have only been transiently functional.

The R and T proximity are worrysome, but I actually posted this because of an anomoly in the rapid section of the strip that was a topic of discussion in my post-clinical meetings. See what I'm talking about?

[AZCEP]

Are you referring to the polymorphism, or the changing amplitude of the ventricular complexes?

[Resqdivemedic]

Just a guess, is it a WPW causing a run of abberantly conducted SVT?

[tniuqs]

Again guessing and "not to treat the strip but the patient"...if the ICD is in a non operative mode and the history preceding may be a hint..

A question would be are these beats perfusing?...I suspect so if his LOC remains a GCS of 15??

If this fellow is paced previously, as I am seeing zip for spikes...perhaps off to cardiology to tweek up the rate a bit... perhaps check the implant leads as well, I am confused as to your statement the data was removed?

A rate increase "may" reduce the break thru ectopics, the rational would be that hypoxia could be part of this? dunno.

Your senario did not include Sao2? how come?

If they did an ABG and stat electrolytes that would be helpful as well, mag and ionised calcium would be nice, you are in the ER?

cheers an interesting strip.

[fiznat]

Just a guess, is it a WPW causing a run of abberantly conducted SVT?

Yes!

I didnt see this at all the first time I looked at the strip. ...Pretty much it got a glance and, "oh yeah, thats VT." Nope. ER Doc took a look at this, noted those delta waves and called it a transient SVT with WPW.

150mg of Amio over 10 minutes and then 1mg/min infusion converted the patient's rhythm to this:

The reason I posted this is because I beleive it is questionable whether this is WPW or not. I was convinced it was runs of VT at first glance, but even with a closer look I wonder if that "delta wave" is just the specific morphology of that particular ventricular beat. ...The fact that the tachycardia is transient is also a point against WPW, I think. The fact that Amio converted the rhythm is of course of no help at all. I was looking at this and wondering, since my service does not have Amio for all our ambulances yet, would this rhythm get lidocane? Watcha think?

EDIT: also, yes, I know that 1mg/min infusion is not the correct dosage for Amio maintenance (its 0.5mg/min)--- but the doc gets what the doc wants, I guess. haha

[Ridryder 911]

I am not thoroughly convinced that it was WPW, usually one will have a ( -) delta "B" wave in the V [sub:9ad21d514a]1[/sub:9ad21d514a] V[sub:9ad21d514a]2[/sub:9ad21d514a] leads. Usually you will see type "A with a + in precordial leads. One needs be very cautious in the treatment of such if you really think it is, as you can see bradycardia can result. Most WPW is associated with A-Fib with rates > 250/min. Now, it looks like the pacer needs to assessed why it is not firing and capturing as well.

R/r911

[tniuqs]

Interesting and terrific methodology here..... knock out perfusing ectopics to determine an underlying rhythum?.....just what heck was this ER MD thinking? Certianly looks as if the pacemaker needs a bit of maintnence now. I bet the Patients Cardiologist is suitably impressed.

Question so just how did the arrest work out?

I highly suspect that the next thing you observed is tombstone "T" waves.

[paramedicmike]

I'm with Rid. I don't think it's WPW either. Was the doc looking at the PVCs to determine a D wave? I bet he was wondering himself after this patient coded! :shock:

Interesting strips, though. If you get more follow up let us know! I know I'd be interested to hear.

-be safe.