Narrow complex tachycardias – Part II

Here’s a call that was very well executed.

The patient was a 35 year old Hispanic female; walk-in patient at a volunteer clinic.

Through an interpreter it was learned that the patient was complaining of palpitations and slight chest discomfort.

The onset was sudden.

The medical history was significant for “arrhythmias”.

No medications.

Skin: warm and dry with pink oral mucosa

Vital signs were assessed.

Resp: 20
Pulse: Too rapid to count
BP: 104/58
SpO2: 97 on RA

The cardiac monitor was attached.

A 12 lead ECG is captured.


Here is the rhythm strip.


It is very important to document cardiac arrhythmias in 12 leads whenever possible.

Once the arrhythmia resolves (on its own or with our help) the opportunity to document the arrhythmia is gone.

The 12 lead ECG can be invaluable to the cardiologist/electrophysiologist who follows up on the patient!

It can also be invaluable to YOU when you’re trying to figure out what you’re dealing with.

The patient was placed on oxygen.

An IV was started and labs were drawn.

The paramedic in charge of the call reviewed the Hs and Ts and found no evidence that it was a compensatory tachycardia.

6 mg adenosine was given rapid IV push followed by a 20 ml bolus of 0.9% NS.

The paramedic remembered to press the PRINT button prior to giving the drug.

The following two rhythm strips are continuous.


Sinus rhythm was restored and the patient reported relief of her symptoms.

As a side note, I like to show these rhythm strips to new paramedics and ask them to interpret the heart rhythm. :)

Since the monitor was already attached, it was a simple matter to capture a post-conversion 12 lead ECG.


The patient was transported to the emergency department and the paramedic was able to provide excellent documentation of the prehospital interventions, with outstanding data quality.

See also:

Narrow complex tachycardias Part I

Narrow complex tachycardias Part II

Narrow complex tachycardias Part III

3 Comments

  • Shaggy says:

    As we venture away from using the generic term SVT as a term for a specific rythm, what should be the correct terms. I must admit, after all these years, I am still a little weak on differentiating MAT from AVNR and A-tach. I have to admit, I go with "narrow complex tachycardia" when I am unsure.

  • Tom B says:

    What's wrong with that? Narrow complex tachycardia a great term to use when you're unsure! Once you rule out (or attempt to rule out) a compensatory tachycardia, the next thing to decide is whether or not it's atrial fibrillation or atrial flutter.Again, the treatment should be targeted toward the underlying cause. A CHF patient who presents with hypertension, shortness of breath, adventitious breath sounds, and AF w/RVR needs oxygen (preferably by CPAP) and nitroglycerin as a front line treatment.Then you can consider AVNRT (or a reentrant tachycardia for which adenosine may be indicated).I have my doubts as to whether or not prehospital antiarrhythmics are necessary or helpful, but if we're going to use them, we need to use them intelligently and responsibly.Part of that professionalism is documenting what we've done. This EMS crew did an outstanding job, but this should be the rule not the exception.Tom

  • bato says:

    possib. NSTEMI-infarctus myocardy.need for more lab diagnosis. troponin and myocardial enzyme to distinguish it from supraventricular tachycardia…bato

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EMS 12-Lead

Cardiac Rhythm Analysis, 12-Lead ECG Interpretation, Resuscitation

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Comments
Jared
59 Year Old Male: Unwell
Field Dx: Uncompensated cardiogenic shock. Tachycardia caused by compensation mechanism. Probable cause: Complete heart block due to the global nature of the changes. Tx: O2 @ 15 lpm NRB and possibly CPAP if pressure rises enough, 324 ASA, amio drip, possible norepi, and diesel. Put pads on in case he tanks. Definitive Tx: Needs cathed.
2015-07-02 17:46:57
Jonas
59 Year Old Male: Unwell
CPAP. IV. Nitro if BP can be controlled. Kidneys may be in acute failure causing extra fluid, or CHF, or both. Big ole triangular looking t-waves would have me thinking calcium. Monitor to see if conditions improve with CPAP. Place pads on patient, and have help with you in the ambulance.
2015-07-02 17:17:30
Brian Brubaker
59 Year Old Male: Unwell
At a quick glance it looks like tombstones (R on T). At closer look without calipers, it appears to be accelerated ideoventricular rhythm due to complete heart block. Not enough information to go off of, so cardioverting or pacing might just kill the patient quicker than anything. Transport immediately since his sick heart could stop…
2015-07-02 05:49:02
Holden
59 Year Old Male: Unwell
I've only studied cardiology for a few months and have read Dubin's book 1.5 times so I'm not an expert by any means. However, can a possible interpretation be a junctional tachycardia with aberrant ventricular conduction and a STEMI? No P waves and aberrancy causing a slightly wide QRS (but not wide enough for V-Tach).
2015-07-02 00:50:22
James
59 Year Old Male: Unwell
This is a ugly EKG. Wide complex irregular tachycardia around 150's. A-fib and a-flutter are possibilities. He's severely symptomatic. At this point, all treatment is same, electricity. If A fib, it may not want to "shock out" easily. This may be a case where initial cardioversion at max joules would be prudent. Pulmonary edema likely…
2015-07-01 22:00:13

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