78 year old male CC: Dizziness

Hot on the heels of the last case is another great case study, this one is from a reader named Baby Medic. I hope you enjoy it!

It is a busy Halloween night, when you and your EMT partner are dispatched to an outlying address in your service area for a 78 year old male complaining of dizziness.

After navigating a mess of rural farm roads, you arrive at a small house off a long dirt driveway. Out front you are met by the patient’s wife, who frantically directs you inside and down to the basement. There you find your patient, a noticeably larger man, sitting in a recliner with one hand on his chest. As your partner kneels down to obtain vitals, you ask him what is going on.

Onset: Chest pain started about 15 minutes ago, while watching TV
Provocation/Palliation: Nothing makes it better or worse
Quality: “Something is pushing on my chest”
Radiation: The pain is only localized retrosternal
Severity: 10 of 10
Timing: The pain is constant

Your partner briefly interrupts to say he cannot find a radial pulse. You continue with your history.

Allergies: NKDA
Medications: He can’t remember (you send his wife to find them)
Past Medical History: Extensive cardiac history, including CABG, HTN, and he was recently discharged from the hospital after carotid artery surgery
Last Ins/Outs: Normal dinner
Events: “Sitting in my chair, watching TV, got real dizzy and then the pain started.”

Your partner anxiously relays the patient’s vitals while he attaches the cardiac monitor.

Pulse: Could not palpate a radial pulse
BP: 82/54
RR: 24, labored; lungs clear and equal bilaterally
SaO2: Beeps and displays E34

A physical exam reveals no JVD, a soft, non-tender obese abdomen, and good pulse/sensory/motor in all extremities. The only remarkable feature is dusky, cool, diaphoretic skin.

An alarm sounds on the cardiac monitor as the initial rhythm strip is printed.

All Hallows' Eve - Initial Strip

Your partner acquires a 12-Lead ECG while you interpret the rhythm strip.

All Hallows' Eve - Initial 12-Lead ECG

What rhythm is present? Does the 12-Lead ECG help with your interpretation?

You’re 20 minutes from the nearest hospital and 45 minutes from a PCI capable facility. How would you treat this patient?

See Also:
78 year old male CC: Dizziness – Conclusion

48 Comments

  • Brian H. says:

    **zzzappp**
    Don’t worry ma’am. The smell of your husband’s burnt chest hair will clear soon.
    That pressure and constellation of symptoms = unstable.

  • eff dog says:

    12 lead definately helps. lead II might just be supra ventricular with a bundle… but v1 being positive and v6 negative suggests ventricular origin :-)

  • Bobby Pleasant says:

    Is ECG shows signs of VFIB, i think he would need defibalated to regulate his heart rhythm.

  • Patrick F. says:

    wide complex tach. put pads on iv and get ready to cardio vert. 150 amio. I don’t think going to a pci is a good idea espically is pt gets worse and there is only two of you.

  • Pat says:

    The ECG appears to be ventricular tachycardia. Even if it isn’t, it is regular, wide, and fast, and the patient is hemodynamically unstable. I would cardiovert the patient and consider air transport to the PCI center.

  • jmorrison349 says:

    I agree with pat.

  • akroeze says:

    Is air transport really justified (assuming you are set on a PCI facility)?

    Let say at a BARE minimum it will take them at LEAST 10 minutes to get to the scene (probably longer unless they were already in the air), then they have to reassess the patient, get him on their equipment, load, etc. Lets be totally honest here and say that will probably take 15-20 minutes. So now you are half an hour in, then you have to add their flight time…. where have you done anything to help the patient by calling air? You have given them the same length of transport (if not longer) and increased the cost hugely.

  • EMT2B says:

    At first glance it looks like it could be vTach but I think it could be Atrial Flutter (they are still Pwaves). I would agree with Pat and would prepare to cardiovert if vTach, Oxygen, transport, continued reassessment. But if the latter O2, transport, continued reassessment (calcium channel blockers or beta-adrenergic blockers could be used to slow the heart rate).

  • JR says:

    1. Call fire dept. to extricate patient from the basement on a Reeves. They like to lift things up and put them down.;-)
    Looks like wide complex V-tach but monitor says atrial flutter. Are those P waves I see?
    Normally we wouldn’t cardiovert long-standing a-flutter or a-fib due to possibility of throwing a clot. We assume he’s under a cardiologist’s care due to the CBAG. I’d want to see his list of meds – digoxin? coumadin? diltiazem?
    On the other hand, since he’s circling the drain, an embolism may not be his biggest problem.
    IV, O2, Versed, cardiovert. Be ready to switch to defib.
    If the full range of cardioversion power levels doesn’t work, at this point in our protocol we have to contact medical. They may order Amiodarone.
    Load him in the bus and run for the nearest hospital.

  • Danny Altman says:

    I see elevation all leads, I think this is Peracarditis ,though still unstable and Cardioversion is in order.
    Defif. This Patient and you’ll put him in the ground.

  • N00bMedic says:

    Highly symptomatic patient, wide QRS complex, no BP = bad day. Couple of big IVs. Amiodarone 150 mg over 10 minutes, get the big pads out and be ready to cardiovert or defibrillate if the pulse disappears.

  • Jeremy says:

    Can anyone explain to me or point me to a link of what the “P-QRS-T Axes” mean on the print out?

    Thanks

  • Jeremy,

    Those are the axes in degrees in the frontal plane. QRS: -30 to +90 is a normal axis, -30 to -90 is Left Axis Deviation, +90 to +180 is Right Axis Deviation, and -90 to -180 is Extreme Right Axis Deviation or “No Man’s Land”. The P and T axis are lesser used in the field.

    For a great review of the subject, check out Tom’s series on Axis Determination.

  • Brandon Oto says:

    Actually I’d be very interested if anyone knows the clinical value of exact P and T axes…

  • Fm says:

    Yikes good case. Looks like av disassociation to me in avl most clearly. In any case I’ve long since given up trying to diagnose svt w/ab vs vtach. Always always always default to calling widecomplex tach vtach, there is no downside… And definitely never give ccb if you arent 110% sure its not vtach.

    I think this patient presentation warrants immediate cardioversion. I would try a fluid bolus and give analgesia if it wouldnt cause a significant delay. Possibly use a sub disassociative dose of ketamine. Otherwise a small dose of fentanyl or versed.

  • Rm says:

    I should add to my above post that amiodarone or procainamide would be a consideration if the patient was in your judgement stable or shock refractory. Tough call when youre not there, but hypotension with no radials and poor perfusion (grey diaphoretic) and significant chest pain paint an unstable picture to me.

    I believe a P axis can be used to determine where p waves are originating from. I believe a widened qrs/t axis is indicative of a ventricular origin, paced rythym or presence of an ivcd.

  • Dialysistaxi says:

    I’d like to know about his fluid intake ;)

    But O2 and likely cardioversion is in order to (hopefully) slow the rate down and determine if that is a massive STEMI

  • NHMEDIC says:

    Wide complex tach, upright in I II III with a normal axis, maybe WPW, thinking re-entry problem causing SVT? Still, unstable so O2 IV Versed Sync cardiovert. Would it hurt to try adenosine?

  • Dustin says:

    Adenosine would tell you if its V-tach or not(as long as no history of WPW)… If no change after 6 12 12 of adenosine then lidocaine or amiodarone would work. With this patient I would sedate and cardiovert. I think this patients warrants electricity first then meds

  • das boot says:

    I don’t believe adenosine would work, however, I dont think it would hurt. As far as adenosine being the treatment, no. Cardioversion is what is needed. O2 and other stuff (premedication, fluids, etc) as per your local protocols.

    I’m having difficulty determining if this is ventricular or supraventricular (or as suggested above, disassociated). Great learning opportunity here!

    The axis is normal. I do see an upright p wave along with an extra in a few leads. And that’s all I’ve got.

  • Chris T says:

    Im going to go with presents of Delta wave, so WPW syn with
    Atrial flutter and a rapid ventricular response.
    Ill be honest im having trouble determining ST segments at this rate, but I think some of the ST abnormalities that appear to be significant could be partially related to rate.
    Reguardless of what it may be here goes my treat Dx
    Wide complex tachycardia with ventricular rate over 200 and notable what I believe to be P waves. Reentry prolem with this rate seems likely until i learn something new about rapid ventricular response. I am going to place pads and not pace until he has decrease in mentation. I will first do bilateral fluid bolus(might help bring rate down too) check LS, at same time ill likely piggyback amioderone 150mg over 10min. 4 lpm 02. repeat 12 lead if any changes and post interventions. Notify hospital early. Hope to hear back and learn from my mistakes. Thanks

  • FB says:

    Etomidate/Fentanyl (maybe stay away from ketamine as it causes a release of catecholamines, if you can bolus dose a pressor that could help the pressure while sedating them). Cardiovert. Doesn’t matter what the rhythm is (because there’s no way to be 100% sure at this time). Get anothe 12-lead after rhythm converts to look for WPW/delta wave. Then you can decide on PCI vs. closest facility. (If V-tach patient gets a trip to the cath lab anyway (and later AICD) placement though if WPW gets a trip to the EP lab which is probably at the hospital with a cath lab). You can try adenosine because its safe/quick and rhythm is regular (and some V-tachs are sensitive to adenosine). 210 could be slightly fast for V-tach but it doesn’t really matter what the rhythm is once the 12-lead is documented. History of CAD/CABG predicts V-tach as does QRS>.140. In the end, I’d guess aberrant conduction, though I’d still prefer to cardiovert this guy.

  • eff dog says:

    @brandon oto- I guess you could use the extreme right axis deviation of a P axis to tell you that it starts low and goes up to the right- probably junctional…. of course, you could also look at it manually and notice it is inverted!

  • Chris T says:

    ooooops, I definatly meant to say cardiovert not pace.

  • Brandon O says:

    eff dog, that’s what I mean — sure, upright vs inverted is useful, but when have you ever wanted to know how many degrees your P wave has?

  • Chris T says:

    what about MAT caused by WPW with RBBB and possible MI new? aggravated or caused by recent Hx of surgery possibly being the key?
    This is after thought and research. We will see!

  • Rm says:

    Great comments! Didn’t consider catecholamine release of ketamine. Bolus pressor would be great if you had something with primarily alpha effects like phenylephrine… I wonder about avoiding mixed a/b pressors in push dose in this setting?

    Just to be clear when I mentioned possible av disassociation in this context it’s indicative of vtach.

  • Rm says:

    Oops wanted to add if you see p waves you can’t call this afib with rvr due to an accessory pathway….

    Massive ste can cause the illusion of vtach but not a rate this fast.

    And adenosine response cannot be used diagnostically. Some vtach will respond to adenosine although most will not. Many svt will not convert with adenosine.

    It all comes back to default to treating like vtach, and play it safe.

  • Chris T says:

    Thought I could see several P waves thats why MAT fits better I think.

    Advanced Life Support Protocols
    Cardiac Protocols: Dysrhythmia Protocols
    ATRIAL FIBRILLATION/FLUTTER WITH RAPID VENTRICULAR RATE

    Treatment
    1. Oxygen Therapy.
    2. Cardiac monitor, rhythm strip and 12 lead EKG.
    3. NS IV/IO or saline lock.
    4. If patient is unstable or symptomatic consider the following:

    a. Verapamil 5 – 10 mg slow IV/IO push. Give only if QRS complex is narrow (<0.12 ms). Note: Verapamil is contraindicated for patients < 1 year of age.
    b. Cardioversion if patient is unstable and time does not permit Verapamil therapy. Sedate patient with Midazolam and/or Dilaudid as indicated.
    i. Morphine Sulfate may be used as an alternative to Dilaudid.
    c. In patients with wide complex atrial fibrillation with rapid ventricular response, who do not require immediate cardioversion, consider Amiodarone 150 – 300 mg IV/IO slow infusion (pediatric: 5 mg/kg IV/IO).
    i. An alternative is Procainamide in 100 mg boluses slowly IV/IO at a dose of 20 – 30 mg/min until desired effect (control of dysrhythmia) achieved or total of 17 mg/kg administered (total should not exceed 1,000 mg). An alternative administration is a 1 g drip at 4 mg/minute.

  • Wide and fast: NEVER CCBs (verapakill, cardizem, etc), and usually never Beta Blockers (somewhat debatable, but not for over 200).

    Prefer: procainamide, amiodarone, lidocaine (in that order per conversion rates, my list will be controversial I’m sure).

  • Chris T says:

    yes for this case CCBs are contraindicated. I indicated above i would treat with Amioderone

  • Chris T says:

    That protocol is for narrow QRS less .12

  • Chris T says:

    at least now i know how to get your attention Christopher. Joking

  • Brandon O says:

    I vote flutter. You can’t squint those P waves away. Slurring, tight PR, and wide QRS suggests WPW, which could be contributing to the RVR.

    With that said, that is a VERY wide QRS, which makes this whole theory sort of iffy. The width is the best argument for VT even though everything else points away from it. The rate is also a bit odd for flutter.

    In any case, hard to argue with giving The Shocker. Certainly I wouldn’t look too closely at any ST segments until you get the rate down.

  • Chris T says:

    Brandon, i still dont know if right or not but our thinking on the EKG seems simmilar. IF there were a BBB im thinking RBBB possibly even though it may be a mimic, could the widening of the QRS be from the BBB not from VT? Yes I realize it doesnt matter. Cardioversion and/or ami would still be the treatment wouldnt it. We all agree no CCB on this rhythm. Plus there is what looks very much like a delta wave, but maybe its some flutter waves making it through? Thoughts?

  • Mike says:

    regular rythm, RBBB morphology QRS>140ms, R>R’, R S width in any precordial lead >100ms yes V5 and V6, S>R or QS in V6 yes, monomorphic R or biphasic R in V1 yes, as well as pt history of MI all favors the diagnosis of V tach. With the patient presentaion of 10/10 chest pain hypotension and skin that is dusky cool and diaphoretic. Cardioversion Immediately.

  • VinceD says:

    Mike, well stated on the reasons supporting V-Tach, and I agree with you completely. These cases make wish I had ketamine because I hate torturing patients and don’t like most of my other options. My protocol has me calling med control, so I’d see how they feel about etomidate and I’d make a good case for using it, but we all know it’s a crap-shoot depending on which doc picks up.

    Of course I’d treat it as V-Tach, but since we have time to dissect the tracing, I’m very intrigued by what appear to be p-waves following every-other QRS complex in III and aVL. Part of me wants to call it AV-dissociation, but these waves, like the wide complex rhythm, are perfectly regular, and appear at the same interval in both the 12-lead and 3-lead. It seems very unlikely to me that a sinus rate would fire at EXACTLY half of the ventricular rate for so long.
    I considered a-flutter with 3:2 conduction to account for the pattern of the waves, but I’ve really scrutinized the tracings and can’t find even a hint of the bigeminy to the QRS complexes I’d expect with such conduction.
    I’m leaning more towards 2:1 VA conduction coming back up from the ventricles, but since these mystery waves are upright in III and aVL, it would seem they have a normal axis, which I wouldn’t expect with retrograde conduction. In summary, I don’t know what they are…

  • VinceD says:

    Oh and I forgot to say that what I think a lot of folks are seeing as p-waves with a short PR are actually part of the QRS complex. It seems that if you march them out from the limb leads they don’t match up with the pseudo p-waves in the precordial leads and actually fall in the QRS complexes. Of course this is tough to discern with such wide complexes when we can’t even really tell where they truly begin and end, but I’d like a couple other people to take a look and see if they concur. I’ve seen this a few times in V-tach tracings where the first part of the complex seems isoelectric or small in comparison to the overall complex, fooling the eye into thinking there’s less QRS than there really is.

  • tsalva says:

    As far as STE its too hard to say definitively but all leads compared to eachother, i see changes in everything but inferior leads. And with the bundle branch looking notched QRS complexes id say this uis a proximal LCA occlusion with a bundle branch. If it is a bundle branch and a major occlusion it would make since that pissed off ventricle would be in vtach. I think trying to decide whether its supraventricular or not would be a waste of time this guy Dosnt have. New guidelines say you could throw adenosine at this, and the risks of doing that don’t matter either because those risks would pertain to a stable patient. This patient is not stable, and gets synchronized cardioversion. In my opinion that’s the bottom line. After whatever rhythm it is breaks and/or the rate slows down it would be possible to see whats going on and treatment would go from there, and chances are the rhythm it gets cardioverted into is going to be much easier to manage than what it is now:)

  • Firemedic24 says:

    First time poster, long time reader! I think the question is weather this rhythm is svt w aberrancy or vtach.

    Findings supporting svt are:
    Normal axis deviation and p waves

    Findings supporting v tach:
    Morphology of v1 and negative deflection in v6. Also, the notch in the s waves (Josephson’s sign) support vtach.

    Either way initial treatment is the same. I think most people here agree cardioversion is necessary. Hopefully whatever the next rhythm is it is a little easier to treat.

    I personally would lean more to svt w aberrancy, but this one is difficult. I don’t think it is MAT because the morphology of the p waves are the same. Also the rhythm is regularly regular which doesn’t favor afib

  • medicff107 says:

    If you simply go by some simple rules the DX of rhythm makes itself easy. First off look at rate; over 200. then look to see if it is regular which it is so that rules out afib w/bbb and svt w/berancy. So then we look at the QRS width which is almost double its normal value at .22 . So this alone tells us that we have a wide complex tach. keep in mind that even with V-tach you can still have p waves,fusion and capture beats. All which help us DX v-tach. Next if you follow a few simple rules by Bob Page by looking at V1 we can determine that this is V-tach and here they are.
    1. extreme right which we do not have
    2. peak morphology in V1 which we do meet in larger peak small peak
    3. any negative complex in V6 which we also have
    4.concordance in precordial leads
    so looking by these criteria and what is present on the 12 lead we can determine that this rhythm is ventricular in origin and DX as v-tach.
    as far as TX a good H/P would be appropriate so we know where the patient sits pmhx wise and also a current list of meds and allergies to know what our options are. simply by vs and presentation with chest pain and fact 10/10 cp this pt is unstable and is prime candidate for 2 large boor IV’s, combo pads and some synch cardioversion starting at 100j increasing in 100j increments to highest factor recommended setting, and consider some pre-medication depending on local options versed,valium,fentanyl,morphine etc. patient is at HIGH risk to deteriorate to a less desirable rhythm so aggressive TX is required.
    just my thoughts and rational…

  • Chris T says:

    is there by chance a post cardioversion EKG Christopher? Or is that part of the conclusion?

  • VinceD says:

    Medcliff, you were spot on until #4 in your list; it actually switches from a positive QRS in V1 to a negative in V6. I still agree with your conclusion though.

  • Terry says:

    Garcia and Miller state:
    “If you are faced with an untypable wide-complex tachycardia, you should treat it as if it were ventricular tachycardia. Statistics would be on your side since over 80% of the wide-complex tachycardia are VTach. Missing this arrhythmia and treating it as if it were SVT with aberrancy could be a very costly mistake.”

    With that said I would cardiovert. BUT– I think it is atrial in origin– the axis doesn’t support vtach and there are p waves before each qrs complex. If this is Antidromic AVRT and you give CCBs even adenosine you could have a disaster on your hands. That is why AHA and Garcia and Miller recommend cardioversion.

    I am not a gambling man and if I were the patient I would go with the 80% odds.

  • Robert F. says:

    I’m with Terry :)
    “Without clinical information, it is estimated that > 80% of the time these rhythms are confirmed as VT.”(ECG’s for the Emergency Physician Book 2 by Dr. Amal Mattu)

    Given the extensive clinical information of the patients cardiac history, certainty that this is vtach is around 100%.

    Analysis: Primary considerations for WCT are VT, SVT w/ abberancy, and ST w/ Abberancy. ST is excluded due to 220-age. WCT’s should almost always be assumed to represent vt, even in pt’s that are relatively young. ECG findings that further confirm VT is AV Dissociation, A taller left “rabbit ear” morphology of the QRS in lead V1, and S>R in V6.

    Again, “VT should always be preferentially chosen and treated rather than SVT, treatment of an SVT as if it were VT is generally safe;however, if VT is mistakenly diagnose and treated as SVT, the results can be deadly.” (Dr. Amal Mattu)

    Cheers.

  • medicff107 says:

    VinceD,
    I was pointing out the list i use. you are right there is no concordance that is why i didnt add at the end which is present like the others.. ;)

  • VinceD says:

    oooh gotchya, my bad. I won’t doubt ya again

  • Andrei says:

    Give sedation with midazolam and fentanyl then administer electric shock with 150 J

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EMS 12-Lead

Cardiac Rhythm Analysis, 12-Lead ECG Interpretation, Resuscitation

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