74 year old female CC: Chest pain – Conclusion

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.

Why?

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.

RR: 20
Pulse: 86
BP: 138/92
SpO2: 100 with O2 via NRB @ 15 LPM

If this was your patient what would you do next?

28 Comments

  • DaveOC says:

    Couple of big bore IV’s TKO initially. 150 mg Amiodarone over 10 mins. Posterior and R. side EKG’s. 324 mg ASA. Nitro cautiously if there’s chest pain. Ride to cath lab.

  • Caleb D. says:

    15-lead EKG is without a doubt indicated as it’s next best thing to a guaranteed right side MI. IV, O2, Aspirin, Nitroglycerin drip starting at 10mcg (titrate to pain/blood pressure), fentanyl, med control for heparin, if out in the far reaches of the county, consider med control for retavase, early notification to the receiving hospital for cath activation, PUHA (pick up, haul ***) to the hospital.

  • Chad B. says:

    I would treat with Bilateral IVs 18+ size, peripheral if possibal try to avoid the AC’s if I could. ASA 324 mg, In our system we use Lidocaine, and treat the pain with nitro monitor the vitals and some morphine. And recheck about every 5-10 mins for changes.

  • Chad B. says:

    Sorry for the spelling errors. This is my post.
    I would treat with Bilateral IVs 18+ size, peripheral if possible try to avoid the ACs if I could. ASA 324 mg, In our system we use Lidocaine, and treat the pain with nitro, monitor the vitals and some morphine. And recheck about every 5-10 mins for changes.

  • Josh says:

    Status 2 pt. Pt is a STEMI alert. Send 12 lead to hospital along w/ a posterior view. Start distal 18-20ga IV’s in each hand or forearm. An AC line would be appropriate in one arm if needed. 324mg ASA. 150mg Amiodarone in a 100cc NS bag dripped over 10 min. (if that is what was used) Consider nitro. Fentyal 25mcg would also work for pn and wont have the vaso effects that morphine does. Continue to moniter pt at 3-5 minute intervals. Send any changes to hospital.

  • Jmorrison349 says:

    Slightly off topic. Why does everyone seem so concerned with IVs in the AC?

  • Troy says:

    Jmorrison,

    The reason everyone goes for the AC is because its a relatively large vein and you can put a nice large bore in it with little difficulty (usually). Plus in an emergency situation its easy to find. If you can find an 18+ in the forearm, by all means hit it. I stay away from the hands due to Cardiologist tend to get grumpy with that placement.

    Plus think about what is going to be flowing through those IV: heparin, nitropresside, integrilin, large amounts of fluid, fetanyl…..ect. I personally feel more secure with an AC than anywhere else, usually.

    As for the interp…Inferioposterior MI. V4R. IV, O2 via NC (if holds above 94), ASA, nitro, fentanyl, trending vitals and 12 leads, and copious amounts of diseal fuel.

  • Aharon says:

    Hi my friend , the next staps is to make monitoring on that ptiant and transfer to hospital with 1mg/min in drip to the vain that we do befor.

  • Aharon says:

    I forget 150mg amio IV

  • Brian H. says:

    Do not waste time with any additional leads, right sided ECG, posterior leads, leads with patient standing on their head, whatever. THIS IS A STEMI. Right sided involvement can be deduced from the ST depression laterally, but really does not need to be diagnosed in the field. See the above comment from Tom regarding “overthink” creep. Initiate STEMI protocol, +/- nitro depending on pain / BP, and initiate high flow diesel therapy.

  • Christopher says:

    Hey Tom,

    Elevation in II, III, aVF with reciprocal changes in I and aVL. Early transition in R Wave progression in V2 with depression and inverted T-Waves in V2, V3 make me lean to Inferior/Posterior. Elevation in III taller than II probably RVI as well with occlusion in the RCA. Considering everything the patient just went to, don’t have time to get V4R or Posterior leads. Two IV’s, prefer same side. ASA, Fluid Bolus, Nitro once IV’s are established and a bolus started so I don’t tank her BP. MS for pain, hopefully she got the Versed prior to the cardioversion. Talk to the MICN about any other treatment they may want at this time. Off to the Cath Lab we go

  • Sean says:

    what’s a micn?

  • Brandon K says:

    Was wondering about the AC IV issue/topic as well. WHat is the thought process about avoiding the AC? All of our local hospitals recommend at least an 18ga IN THE RIGHT AC. I think due to their access to that arm in the cath lab. I have not heard of any reaosn to not use the AC either in STEMI or any other call???

  • AW says:

    Nitro to an inferior MI +/- suspected (or if you confirmed) right sided involvement? Really, serious question, anyone still doing that? It was a caution for a few years now it’s a contraindication for us, 3+ years. Increases the size of the infarct and morbidity/mortality is the stand that our MC has chose to take based on studies (yes there are other studies that makes it look not as bad). Interesting to see the diversity in the protocols. Morphine is out too, so it’s Fentanyl or not depending on the pt. Personally I’m going to hope the sedation holds out since preload has already been messed with.

    First thing I want after that cardioversion is to assess perfusion and monitor sedation/airway. Maybe it sounds silly saying I’d go that basic but vitals and the 12 lead need to wait for the rhythm to stabilize, meanwhile I need to get hands back on the patient following the ‘clear’. Manual pulse monitoring and airway/BVM assistance if needed while her rhythm settles are first on my list of things to do.

    Then vitals and 12 lead, 150mg Amiodarone over 10 minutes and transport to closest destination or determined by your diversion matrix (if there is one) for AMI. Call ahead or transmit, whatever it is your set up to do.

  • Christopher says:

    Brandon K/et al,

    My local OR prefers forearm/hand IVs. Our cath lab will take what they can get on emergent activations. But they likely would prefer a non-positional line, and we all know AC starts can get positional.

  • Caleb D. says:

    Yeah, I forgot the Amiodarone. So add to my first post 150mg Amiodarone over 10 through one IV and straight into the rest of the treatment path. Other than that, you’re darned skippy I’ll be using nitro on a confirmed right sided MI. Nitro is a great drug, the problem with it is people forget that you can give it through an IV at a lower concentration and through the IV it doesn’t last as long. Take a look at your SL nitro, it’s .4mg standard dose, and lasts on average of 3-4 minutes via the SL route. 400mcg/4minutes = 100mcg/min (we all know that it doesn’t absorb evenly over time) so your scale looks something more along the lines of 100mcg/120mcg/80mcg/60mcg per minute over the 4 minutes. Where as with my nitro drip I can control how many mcg/min and when I shut it off if it’s too much and bottoming out the preload, I shut it off and it’s done.

  • eff dog says:

    aside from the obvious electrical therapy that should take place IMMEDIATELY, what is the concensus on anti-arrythmics? Lidociane can be given as a push, plus (annecdotally) kicks in faster. fewer(?) side effects. Amiodarone has the advantage of working on both atrial and ventricular rhythms- if there was a slight chance this was svt with abberancy (which is unlikely in this case). cons with amio- more pro.arrythmic, more likely, 10% of causing hypotension, takes TEN FULL minutes to give! That’s a tough one. hopefully the cardiovesion works so you shouldn’t need anti-arrythmics :-/
    FA

  • eff dog says:

    correction- may add anti-arrythmic to prevent arrythmia VT from returning AFTER cardiovesion. New questions/comments/concerns… doesn’t EVERY pt have ST abnormalities after electrical therapy? how do you differenciate if it is from the MI or the joules?. Also, with regards to IV location… if it is an emergency and “they” (OR, ER, Cath lab) aren’t in the back with me, what they prefer goes out the window :-)

  • Medic-Minx says:

    (+)AMS, loss of radial pulses and the presence of this rhythm is definitely unstable. While my partners were getting this patient loaded into my truck and getting pads on her and getting a line going, I’d still be drawing up 2mg Versed to pre-sedate (unless I truly had no time)… sync cardioversion 50-100 joules. If it converts follow up with 150mg Amiodarone infused over 10 min. Reevaluate getting that 12-L I’d definitely call her a STEMI-ALERT. I’d get a right-sided 12-L (always time for that, especially since nobody would take that call on their own, they’d take a rider (unless you run 3-man crews all the time). If she’s alert give ASA. If she has a positive Right-12 then I’d be cautious with the NTG but if she’s still in a significant amount of pain and has as tolerable BP I’d give it. The key is to re-assess this patient. Stat BP’s, lung sounds, pain scale, and mental status. Capnography if you have the tool, serial 12-leads and an emergent transport to a cardiac facility.

    I know someone asked it about NTG in a right-sided MI… our agency has it as a relative contraindication and to be very cautious. And remember—if her BP bottoms, turn off the NTG (if you use IV form (Tridil) and open up the saline–if she has or starts to develop congestion/pulm edema with persistent hypotension then consider Dopamine at 5mcg/kg/min. Again…reassess, reassess, reassess.

  • looks like svt with aberrancy to me. hahahah. =P

  • Robert F. (Las Vegas) says:

    Treatment: O2, ASA, Obtain Vascular Access, Pacer Pads Ready, NTG is Contraindicated in our system as well for RVI’s. Anyone have definative studies for treating RVI’s w/ NTG? I’m curious as well.

    “Although right ventricular infarction occurs in more than 30% of patients with inferior posterior left ventricular myocardial infarction, hemodynamically significant right ventricular infarction occurs in less than 10% of these patients.” Emedicine. http://emedicine.medscape.com/article/157961-differential

    12 Lead Interpretation: RVI w/ posterior wall involvement. Consider LMCA Stenosis

    Lead III exceeds the ST elevation in lead II, confirming RVI. In addition, there is “net positive” amplitude in v1, v2, v3 w/ depression signifying posterior involvement. ST elevation in lead AvR showing possible LMCA stenosis… FU***C*****!!

    Patients w/ LMCA Stenosis carry a 60% mortality rate if not immediately taken to the cath lab :( , and even if the patient does make it, there is a 40% mortality rate under the knife :(

  • chris m says:

    Pt unstable, biphasic cardiovert 100-200-300-360,this would be asap and versed would still in my pouch, obtain 12 lead, send off, 02 if sats below 92%,iv large bore times 2 rt arm 1 tkvo 1 saline lock,do a tnk checklist,if needed hang antiarrthymic,v/s stable no dopimine needed and fluid bolus hold off,asa,nitro precaution,morphine, then 1mg/kg enoxaparin sq up tp 100mg abdominal then TNKasa weight based if no contraidications.Hope for the best……….
    New rules in overoxygenating and fluid in AHA guidelines and we are seeing a differnce here.

  • Troy says:

    Robert,

    I saw the tombstone T’s in aVR but my J point is marked right at the isometric line. Although the pattern does fit, I believe with the elevation in the inferior leads that the STD is more likely the reciprical changes of RVI and PWMI. The fact that STE is III>II which leads towards an RCA culpit.

  • Baron says:

    In regards to the AC:

    In our radiology department, CT chest with contrast for a PE study can only be done (when through a peripheral IV versus a PICC or Power Port) in the AC or closer, with a 20g or larger.

    Given that PE is relatively high on the CP differential when considering AMI, this is one of the main reason’s that the AC is a default IV location for our chest pain patients.

  • TS says:

    My area hospital wants lines as low as possible, regardless.

  • Robert F. (Las Vegas) says:

    Troy,

    AVR looks like it has 1 1/2 boxes of st elevation from the TP Segment w/ the correct morphology, unless i’m measuring wrong! LOL

    Your right, It does look like Inferior-Posterior-R Ventricular MI… Whether or not it is the RCA is questionable, typically w/ RCA/RVI the classic triad is hypotension, jvd, and clear lung sounds which does not fit this patients criteria. In addition, i’m not seeing bradycardia/av blocks.

    Cheers!

  • Trent Adams says:

    A 15-lead EKG would be a no brainer for this pt. I also noticed that the pt has a physiologic left axis deviation. Monitoring of lead V1 (MCL-1) would have been the correct thing to do as well. A 12-lead should have been obtained prior to cardioversion to make sure the pt was truly in V-Tach as well as to check for signs of bundle branch blocks. “LEAD II HAS NO CLUE!” As Bob Page would’ve probably said.

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EMS 12-Lead

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Comments
Stephen Smith
Conclusion: “And then I gave her a NTG…”
There is also no data I'm aware of that shows that, in the reperfusion era, nitroglycerine helps patients with STEMI who do not have elevated BP or pulmonary edema. Data is lacking in all regards.
2014-10-24 16:14:36
Kevin
44 year old male CC: Palpitations
Why on earth would you risk VF, by giving Adenosine to rule out rhythms.. This is dangerous, and foolish. There might be a slight chance that this is WPW.. You might as well just give him Cardizem, they are both AV nodal blockers... I don't know why the AHA even added this stupid idea..
2014-10-22 13:31:06
Vince DiGiulio
The 360 Degree Heart – Part II
It is standard practice in electrocardiography to label the first 90 degrees counter-clockwise from "zero" that way. When you see a patient with "left axis deviation" you'll see that their measured QRS axis is somewhere between -30 and -90 degrees. Imagine if you saw someone with a mean QRS axis at 5 degrees. Now imagine…
2014-10-21 14:00:37
Bryan
The 360 Degree Heart – Part II
I don't understand why (-)III and aVL are be labeled -60 and -30 degrees instead of 300 and 330 degrees?
2014-10-21 13:43:29
The 360 Degree Heart – Part II | EMS 12 Lead
The 360 Degree Heart – Part I
[…] first post in our “360 Degree Heart” series attempted to visualize how the different frontal plane […]
2014-10-21 12:50:56

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