This is the conclusion to 74 year old female CC: Chest pain.
As usual I enjoyed reading the comments! My goal is to get you guys thinking and it’s nice to see you discuss “stable versus unstable”, the need for sedation, and the importance of considering the Hs and Ts!
Let’s take another look at the 12-lead ECG.
This is an unstable wide complex tachycardia which we must presume to be ventricular tachycardia.
We presume it is ventricular tachycardia because that is our default ECG diagnosis for “wide and fast” rhythms.
The fact that she has a history of MI makes VT all the more likely.
We need to avoid the temptation to over-think heart rhythms like this! As much as 12-lead ECGs have advanced the EMS profession, this is one small area where we have taken a step backward, IMHO.
Before 12-lead ECGs a “wide and fast” rhythm like the one you see above was VT. Now you can’t turn around without someone labeling a clear-cut case of VT as “SVT with aberrancy.”
However, in this case (hopefully) the debate is irrelevant because the patient is unstable.
Because the patient is experiencing chest pain, radial pulses are absent, the patient looks “shocky” and the level of consciousness is diminished.
Immediate synchronized cardioversion is indicated. That’s exactly what this crew decided to do.
About a minute later the rhythm started to stabilize.
What should the crew do next?
If you said, “Obtain a 12-lead ECG!” move to the head of the class!
Now we have some insight as to why this patient was in VT!
Vital signs are re-assessed.
SpO2: 100 with O2 via NRB @ 15 LPM
If this was your patient what would you do next?