Interesting EKG from yesterday

[fiznat]

I bet he was wondering himself after this patient coded! :shock:

No no! haha looking back at the strip I can see why you guys think that but no, the patient never arrested! The top line in the last EKG is his new rhythm, showing with very low amplitude. You can actually see the tiny pacer spikes in there as well. The bottom line, as I guess I should have explained haha, is simply a pleth wave from the monitoring of his respirations. lol

The patient felt "much better" with his new rhythm haha... not worse!

I am not thoroughly convinced that it was WPW, usually one will have a ( -) delta "B" wave in the V [sub:0e7de2a45c]1[/sub:0e7de2a45c] V[sub:0e7de2a45c]2[/sub:0e7de2a45c] leads. Usually you will see type "A with a + in precordial leads.

I wish I could have got a copy of the 12 lead but I couldnt. The doc made this judgment based on a rhythm strip only, so thats what we have.

[AZCEP]

Nope, nope, nope. Don't buy it for a second.

If the best strip you got was what you are showing here, then I have a hard time believing that anyone else got anything much better. There could be all types of different electrophysiologic changes going on, but from what is here WPW isn't one of them.

[EMS49393]

Where is the 12-lead? I don't see WPW, but I hardly see anything but asytole or v-fib without a 12-lead.

[fiznat]

Nope, nope, nope. Don't buy it for a second.

If the best strip you got was what you are showing here, then I have a hard time believing that anyone else got anything much better. There could be all types of different electrophysiologic changes going on, but from what is here WPW isn't one of them.

Well, why not? I'm interested in hearing the why... thats how I learn about this stuff.

I suppose it didnt matter as much in the ED, as Amio would have worked for either WPW or VT. Would be nice to know what the rhythm actually is, though... Thats why I phrased the question spicifically for EMS, where - in my system at least - we dont carry amio yet. My initial impression was "why didnt this guy get lidocane from EMS?" ...But that was before someone pointed the possability of WPW out to me.

I will try and get more followup on the patient if I can. Last I heard is he slipped back into the VT (or whatever it was), which was resolved by upping his dosage of the amio. He remained with stable VS throughout, and was admitted to a cardiac floor.

Where is the 12-lead? I don't see WPW, but I hardly see anything but asytole or v-fib without a 12-lead.

I wish I could have got a copy of the 12 lead but I couldnt. The doc made this judgment based on a rhythm strip only, so thats what we have.

[AZCEP]

As Rid and mike already said, there doesn't appear to be any delta waves in the leads provided. This does not mean they aren't there, they just aren't in the leads you are dealing with.

I would also expect to see some degree of irregularity in the rhythm during the tachycardia with WPW. Most commonly it will be associated with an atrial ectopic rhythm, and that just doesn't present here. The use of Amiodarone would be reasonable if you have it available, but as you can see, it can slow the underlying rhythm down to much. At least they did not use a calcium channel, or beta-blocker for this patient. Those agents would have made things entirely too interesting. Procainamide would be a consideration, since you are able to measure the underlying QT interval. Lidocaine really won't do much to help if it is in fact WPW, but since we can't reliably use the information provided, it would be considered as well.

[fiznat]

Dammit I'm gonna have to get me that 12 lead. I know what ambulance the patient came in on, I bet I can pull it out of the lifepack's archives. I'll give it a shot tomorrow at work haha.

[Ridryder 911]

Well the strips you are showing does not reflect "capturing" by a ventricular pacer. Even if their are "blips" the QRS is too wide as well as there is no pace spike at the beginning, then look at the rate. No pace maker is usually set so low, as well as amplitude. Unless, you are calling those little "fib" waves as QRS. It appears to be it can be an idioventricular rhythm, or possible a LBBB. This is what I seen, that might had made the possible "delta" wave and can be misinterpreted as WPW. Mike Taigman has an excellent section in his book as well as Bob Page discusses the misinterpretation of WPW in his as well.

If you can get additional strips (especially XII lead that would be great!)

R/r 911

[1EMT-P]

It's hard to say what this is w/o having a 12 lead, but I seriously doubt that this is WPW. I suspect that this patient is either experiencing a possible pacemaker failure or that his pacer needs to be adjusted. I would like to know what he was doing prior to this episode and also how long ago his pacer was implanted. Typically pacer batteries are only good for about 10 years!

[firefighter523]

Definitely NOT WPW, not wide enough, I would guess, you could have an incomplete BBB. If this pt was "so stable in the field", one would definitely do a 12 lead, and from there differentiate VT from SVT with aberrancy. Look for the extreme right axis deviation. (Negative QRS in leads 1 and AVF) Treat accordingly, rule out an underlying MI and go for the Lido if it is VT. We all know what happends when you give an already hypoxic heart lidocaine. Could cause conduction deficits, and re-entry, hence possible VF.

[boneknuckleskin]

disregard