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
Comments
Jewel
53 Year Old Male: Severe Leg Pain
Hmm it appears like your site ate my first comment (it was extremely long) so I guess I'll just sum it up what I wrote and say, I'm thoroughly enjoying your blog. I as well am an aspiring blog writer but I'm still new to the whole thing. Do you have any helpful hints for…
2014-08-31 17:51:28
David Baumrind
All that wiggles isn’t Wellens’
@Gary, by all means, nitpick all you like. I agree with your assessment, and the post has been modified. Thank you for the feedback!
2014-08-30 17:28:16
Gary Huntress
All that wiggles isn’t Wellens’
Not to nitpick but is this really a "slightly leftward axis"? I and AVF are both positive. I put it at about +20 degrees, not leftward.
2014-08-30 11:49:35
Handsome Robb
87 YOM COMPLAINING OF CHEST DISCOMFORT AND DYSPNEA
CHF. 12-lead shows a sinus Tachycardia in the 120s with PACs, besides the anterior leads there's diffuse ST depression, the STE in the anterior leads can be explained by the LBBB, axis is good as well. I wish they posted the EtCO2 waveform so we could see but I'm assuming it's non-obstructive. The elevated EtCO2…
2014-08-30 08:08:22
Christopher Watford
“Bad heartburn” – 82 y.o. female without chest pain.
Brooks, Firstly, thank you for the warm welcome to the club. Secondly, the Glasgow algorithm's only published sens/spec for AMI is 51.6%/97.6% respectively (Tuscon STEMI Database). I've not been able to find any other publications. The GE Marquette 12SL algorithm has been widely studied, but is much older, and ranges in sensitivity from 48% to…
2014-08-29 16:50:14

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