Ok Ghettomedics what do you think?

[PSYCtest040]

Here is an initial rhythm and 12 lead of 56 year old male c/c chest pain. Past hx AMI 20 years ago. Mentating fine, Pulse 220, b/p 107/64, rr 18, good distal pulses sp02 98.

[FF/EMTP1317]

I can't make the pictures big enough to see even when I click on it to make it bigger.

[wvditchdoc]

I can't make the pictures big enough to see even when I click on it to make it bigger.

Yep, what she said. If I try to save and zoom in it is too blurry.

[fdnyemt5330]

Here is an initial rhythm and 12 lead of 56 year old male c/c chest pain. Past hx AMI 20 years ago. Mentating fine, Pulse 220, b/p 107/64, rr 18, good distal pulses sp02 98.

3523

3524


I can't make the pictures big enough to see even when I click on it to make it bigger.


Yep, what she said. If I try to save and zoom in it is too blurry.

What they said, but I'll say it's ecto-poopy; you know, where you look at it and say " Awwwwwwww shit."

[traumajunkyems/fire]

Here is an initial rhythm and 12 lead of 56 year old male c/c chest pain. Past hx AMI 20 years ago. Mentating fine, Pulse 220, b/p 107/64, rr 18, good distal pulses sp02 98.

3523

3524

I can't get it big enough to read... but with the story it is V-tach until proven otherwise... 'cause that's what Peter's voice is popping into my head! Unless the guy is that less than 0.5% that has a BBB and a pre-excitation condition...

[PSYCtest040]

Ahhhhh hell..... Alright let me try uploading it to my photo album and link it.

**Edit** Ok I think I got it. Let me know if it's any better. Pictures are attached to original post.

[BCoFD vollie]

I can't get it big enough to read... but with the story it is V-tach until proven otherwise... 'cause that's what Peter's voice is popping into my head! Unless the guy is that less than 0.5% that has a BBB and a pre-excitation condition...

that was my first impression too, however look in your inferior leads plus AVL and V1, it is narrow complex SVT. I do not see a bundle branch block. Not really sure what to make of V2-V6, hypertrophy maybe?
O2, fluids and adenosine would be my treatment. Cardioversion if necessary. Consider tx for chest pain if it persists after conversion.
My .02 feel free to beat me about the head with any mistakes.

[Cowboy Medic10]

When did it start and how long has he had this chest pain?

[wvditchdoc]

that was my first impression too, however look in your inferior leads plus AVL and V1, it is narrow complex SVT. I do not see a bundle branch block. Not really sure what to make of V2-V6, hypertrophy maybe?
O2, fluids and adenosine would be my treatment. Cardioversion if necessary. Consider tx for chest pain if it persists after conversion.
My .02 feel free to beat me about the head with any mistakes.

Agreed with the SVT DX. There are P waves buried in there.

I am not sure what I'd do for this guy. Probably go with Adenosine first, given the fact he is still mentating well, no pulmonary edema, diapohoresis, only borderline hypotensive, or anything other than the CP complaint. Any sign of shitting himself would get Cardioverted ASAP.

[KSEMT]

It's definitely not V-Tach, so ruling that out immediately.

Secondly there's some ugliness to this that I tend to look for due to how our protocols are written. Let's put it this way, he becomes less than stable, I'm gonna light this guy up like a roman candle! So going on from there, let's see what we got.

P waves are present, although buried amongst the other complexes, so this rules out A-Fib with RVR. PR interval..well it's without a doubt short, which leads me to look at some other stuff that'll be covered with this QRS stuff.
QRS complex, well without a doubt definitely there, but taking a closer look, I'm seeing some slope (possible delta wave) to this guy's complex, which makes me go...hmm, surely the cardiologist would have caught a WPW with his AMI history, but it could be a nasty little surprise.
T wave, I'm sure it's there, just buried in the shit-storm that is a rapid QRS.

So treatment, well that's where stuff is going to get interesting. First off, this fellow have any history of this shit-storm of rapid beats? If he does, what the hell did they do last time to fix it? Secondly, are all these lovely little QRS complexes actually resulting in perfusion, pulse correspond with the monitor? What caused it comes to mind as well? Was he doing wind sprints? Did he just do a 8-ball of cocaine? Sitting on his ass?

So, let's say that none of these things bring anything to light. So we'll just go with what we got.

Start off with vagal manuvers, even though they rarely work, I've seen it happen, and seen stranger shit than even that. If that doesn't work hitting him with some Adenosine...if that works, great, but I'm having doubts. If it doesn't work, maybe it'll give me a better look at what the underlying cause really is. If that doesn't work, well then let's see what other drug choices we have. Diltiazem, definitely an option, not going to go with that great ball of fire, just on the off chance he does have undiagnosed WPW. So next, we have Procainamide...this is probably what I'm going to be looking at to rectify our lovely little situation. Of course he's gonna get the standard O2 with this, just to keep things gravy. So that's kinda the route that I'm gonna go, and we'd see where we were after that.

[bakerotfd]

Agreed with the SVT DX. There are P waves buried in there.

I am not sure what I'd do for this guy. Probably go with Adenosine first, given the fact he is still mentating well, no pulmonary edema, diapohoresis, only borderline hypotensive, or anything other than the CP complaint. Any sign of shitting himself would get Cardioverted ASAP.

I agree. It apperas to be a narrow complex tach. with good distal pusles. If the pressure is "stable" I would start with adenosine and go from there. In consult with Med. control I may head into Lopressor or cardiversion dependent on the CP and other factors.

[PSYCtest040]

First of all this wasn't my patient. The Medic that transported handed me the strips, gave me a brief history and treatments and left for vacation. He did tell me he tried adenosine x2 with no changes and 150 of amio with no change. He was on the phone with med control as they were pulling into the hospital parking lot. What I heard from the basic tech was the patient started decompensating in the ED and was successfully cardioverted.

I do agree its a supraventricular rhythm but with vagle and adenosine not showing the underlying rhythm I cant say if its a pre excitation, afib with rvror, as out in the woods it may be, a flutter. I wish the Medic gave me more info but he was in a rush to get home and make his flight.

[wvditchdoc]

First of all this wasn't my patient. The Medic that transported handed me the strips, gave me a brief history and treatments and left for vacation. He did tell me he tried adenosine x2 with no changes and 150 of amio with no change. He was on the phone with med control as they were pulling into the hospital parking lot. What I heard from the basic tech was the patient started decompensating in the ED and was successfully cardioverted.

I do agree its a supraventricular rhythm but with vagle and adenosine not showing the underlying rhythm I cant say if its a pre excitation, afib with rvror, as out in the woods it may be, a flutter. I wish the Medic gave me more info but he was in a rush to get home and make his flight.

Just for my own morbid curiosity, wonder why he didn't go ahead with the third dose of Adenosine? I have had several that took until the third dose to break.

I don't think, personally, that it is Flutter or Fib. Everything marches out too perfectly. As for the shortened P-R someone mentioned before, it is very difficult with something that fast to tell if it is shortened or the heart is just basically firing the atria and ventricles almost simultaneously. It also looks like there is some aberrant conduction? The QRS is a little wider than is typical with an SVT.

Anyway, cool strip.

[PSYCtest040]

Just for my own morbid curiosity, wonder why he didn't go ahead with the third dose of Adenosine? I have had several that took until the third dose to break.

I don't think, personally, that it is Flutter or Fib. Everything marches out too perfectly. As for the shortened P-R someone mentioned before, it is very difficult with something that fast to tell if it is shortened or the heart is just basically firing the atria and ventricles almost simultaneously. It also looks like there is some aberrant conduction? The QRS is a little wider than is typical with an SVT.

Anyway, cool strip.

Basically it all comes down to Protocol. Our Protocol is for on line orders for undifferentiated wide complex tachycardia. First dose 6mg rapid IVP followed by 10cc NS flush and second dose two minutes later 12mg rapid IVP with 10cc NS flush. Some docs may order a third and some may not.

[wvditchdoc]

Basically it all comes down to Protocol. Our Protocol is for on line orders for undifferentiated wide complex tachycardia. First dose 6mg rapid IVP followed by 10cc NS flush and second dose two minutes later 12mg rapid IVP with 10cc NS flush. Some docs may order a third and some may not.

Fair enough, just wondering.