Snapshot: 32 year old male–chest discomfort

Here's a new snapshot case straight from the UK… We have a 32 year old male, normally fit with no history whatsoever. He has had a stressful week (personal issues), and decided maybe a 4 mile run might help. It didn't. When he returned home, he developed sudden onset of chest discomfort, and decided to lie down for bit. After a couple of hours, he wasn't feeling better and called 911.

While he is alert and oriented, he is also anxious and diaphoretic. Lungs are clear bilaterally, but the RR is elevated at about 30. Pulse is too fast to count, but the BP is 126/70. He describes the chest discomfort this way: "I feel like someone is punching me in the chest!" It is substernal, non-radiating, and rated a 5/10. His only other complaint is a touch of lightheadedness.

Here is the rhythm strip and 12 lead:

Your mission, should you choose to accept it, involves coming up with a differential diagnosis for our patient, and stating which factors favor one diagnosis over another. Oh, just one more thing… How do we treat him?

We look forward to your excellent responses!

47 Comments

  • Patrick says:

    V-Tach is what i would call this ecg ( wide complex tach).  My differentials would include SVT, electorlite immablance(hyponatremia) dehydration. with the history of being stressed has he been eating ok and what has he been if anything differently than he normally does.  I would start with getting pads on him starting two large ivs and giving a some fluid also can try vagal to see if we get any changes.  I would want a blood sugar and i would possible put the pt on to end tidal co2 NC to see what we might get a reading.  with  a high respirtory rate i am thinking more towards a metobolic cause for this vs. being a "heart problem".  my treatment would include two iv's fludi bolus consider Amioderone, mag sulfate, O2, check pt's temp and if the pts starts to get worse consider cardioverting.

  • Newer EMT-I says:

    V-Tach with pulse and good pressure.  Pt is mentating alright for now.  Emergent Transport, O2, IV, Monitor, Pads on the pt and ready.  150mg Amioderone over 10 minute drip.  

  • Rick Calzone says:

    This is my "oh sh*t" 30 second diagnosis. PSVT. 1) Young guy with no structural heart disease 2) The rate is VERY fast 3) AVR is negative. The patient is symptomatic so its gonna be versed and cardioversion. Screw Adenosine and possible WPW… Im aggressive. Worse come to worse caridoversion will treat VTACH as well. 

  • Rick Calzone says:

    @patrick… this guys "metabolic" heart rate should not exceed 188bpm (give or take a few)
    220 – age
    This is a heart issue… (a serious one)

  • Petar says:

    V-tsch with unstable vitals. Sedate, sych cardioversion and possibly amiodarone bolus. Transport.

  • Terry says:

    Fast and wide is suppose to be treated as v-tach. But this is not v-tach. The axis is -40 there is no v-lead concordance v-6 is positive and the rate is usually not that fast for v-tach. AVNRT with LBBB? Could be but again the rate is usually not that fast. AVRT with WPW? That would explain the wide qrs complex and the fast rate. I am surprised that he would be 32 with no hx of cardiac issues. Treat with adenosine and cardio vert If he becomes unstable. 

  • Purujit says:

    It’s a wide complex tachycardia, looks like a v tach but given his young age and lack of co-morbidities it might just be an svt with aberrency. I think a trial of adenosine would be in order since he seems hemodynamically stable. If not then electrical cardioversion.

  • Jeff says:

    I say unspecified wide complex tach. May not be V Tach due to the axis. I’d start 2 IVs, apply pacer pads and try 6, 12, 12 of adenocard because it might work and it won’t hurt. If it’s V Tach or A fib, that won’t fix it. If it didn’t I’d admin 150 mg amiodarone slowly. Wherever the source is, I think the amiodarone would slow it down. Synchronized cardioversion if he deteriorates. Helicopter to Mission or UT. Probably valvular heart disease aggravated by stress & exercise.

  • Rich says:

    The new ACLS is saying Adenosine first so I would try that, Lots of o2, Of course have the pads out but not opened yet. I feel no need to waste pads if there is only a chance that you would use them. Then go with Lidocaine cause my protocol gives me the choice and I am old school that way. And of course if 2 rounds doesn’t work, I would go ahead and sedate for cardioversion at 100j. People can sustain VTACH for a long time, so you have time to try things, but move as fast as you can without freaking the patient out.

  • Jes says:

    Agree it is a wide complex tach – poss SVT. Treatment would involve ECG (transmit to ED en route), defib pads in place, IV and may try vagal, analgesia if required. Transport ASAP.

  • Tom says:

    Stable VTach. Start transporting cold to my closest Level 1. 2L O2, IV access, fluids TKO, 150mg Amio over 10min. Young guy….should be able to sustain this for a while so no “pads just in case”. (I prefer to not practice “just in case medicine”). Repeat Amio if needed. Consider moving to Procainamide if no conversion with Amio. 2nd IV access if time allows. Closely monitor BP and mental status. Fun call.

  • Nick A. says:

    SVT with aberrancy. Wide complex tachycardia which is regular and no discernable PW’s. Axis is Pathological LAD. Morphology of V1 is not indicative of VT with a negative complex in that lead, no concordance and V6 is positive. I do not see delta waves, so WPW is not suspected. I would have him try vagal maneuvers by trying to blow out the plunger of a 10 mL syringe while an IV is established. PADS are on. Adenosine @ 6mg rapid IVP. If that doesn’t work, 12 mg. Amiodarone @ 150mg over 10 minutes. Finally, if nothing works, 100mg of Fentanyl and 2mg of Versed IVP, then cardioversion @ 100J……that should do it……hopefully.

  • Lee says:

    This is V-tach with a pulse, wide complex. This is unstable being the pt is anxious, diaphoretic, respirs @ 30 x min, pulse over 150 (262) and he is lightheaded stating it feels like someone is punching him in the chest. Place pads, consider sedating pt being he has a good BP. Cardiovert @ 100 J. Also would be thinking about an amiodarone drip infused over 10 min.
    Be thinking about a possible electrolyte imbalance.

  • Simon M says:

    A wide complex tach should ofc always be treated as a V-tach until proven otherwise. However this rate is pretty fast for a V-tach. It's regular, but because of the rate one may suspect an accessory pathway. My guess would be antidromic re-entry tach with WPW, or maybe even ortodromic tach with aberrancy, although it's tough to recognize any RBBB-pattern.
    Maybe try with some IV adenosine or DC conversion.

  • karen says:

    Vtach with a pulse. Add in diaphoretic and anxious pt is a candidate for sync cardioversion…..if the pt did not have perfusion compromise then ludocaine 1.5 Mg/kg inital if that didnt convert you could give another two .75Mg/kg does and hang a maintenance drip.

  • Josh says:

    Since the patient is symptomatic, however not currently unstable, I'd go ahead and do O2, large bore IV and get the pads on his chest…
    I'm not convinced this is V-TACH, so I'd start with vagal maneuvers first, and if unsuccessful I'd follow with 6mg adenosine (and 12mg if needed) to treat/rule out SVTwith aberrancy or A-Flutter with 1:1 conduction. If unable to correct or identify the above two rhythms with treatment so far, I'd probably give 150mg amiodarone drip over 10 minutes with rapid transport, and be ready to sedate and rapid cardioversion if patient deteriorates.  

  • Medic7 says:

    Due to tachy morphology-would be difficult to determine the pathophysiology of this EKG strip. Need to slow it

    down and reassesss. Complexes most likely buried within the QRS complex.No meds,illicit drugs, energy drinks,etc. mentioned.Recent Hx not avail. LVH, LAD, ventritcular strain pattern present. Consider pericarditis,delevopment spontaneous pnuemothorax,hyperkalemia,hypercalcemia,magnesium

    imbalance,dehydration,acidosis,pulmonary embolism, costalchondritis,tamponade,R/O CVA(yes, EKG changes can occur with a CVA!). Tx agressively due to pt being symptomatic and alter differential Dx as needed: monitor, IV access x2-initially tko then consider bolus of lactated ringers when stable, right and/or posterior EKG as avail, oxygen, glucometry, capnography, aspirin, vagal manuevers, nitroglycerine, adenoside, morphine, sedation-Fentanyl, versed, cardiovert-wide complex @100j, amiodarone/lidocaine drip, bicarb, mag sulfate, Albuterol neb for possible K+ correction. VS q5mins. Be prepared with pads, dopamine and ET kit. This guy needs labwork and CXR done!

  • Brevyn says:

    Our internist wher I work showed me something I’d never considered before…for the life of me I cannot remember the name of the slurred wave associated with the beginning of the QRS in a WPW pt, but when the re-entry pathways are being used and there’s an extreme tachycardia, those waves can be found in the peak of the QRS, making it look like a “church”. That’s what this looks like to me. This pt should receive oxygen to keep SPo2 above 95%, at least one large IV, and should be prepared for cardioversion. Adenosine in a WPW is dangerous and can cause asystole because of its ability to shut down accessory pathways, and I believe a standard dose of amiodarone, 150mg over 15 mins is appropriate while preparing synchronized cardioversion. Because the pt has chest pain, he is considered unstable, and electricity is indicated, but I think amiodarone would be effective as well.

  • Ian Smith says:

    SVT/ broad complex with stable BP. Treatment = Oxygen therapy, establish IV access TKO and consider carotid sinus massage with continous 12 lead monitoring. Pain score is 5/10 with raised RR symptomatic of SVT, metabolic imbalance and anxiety reaction, consider pain relief and swift transport if CSM does not regulate the heart rate. This appears to be a long lasting SVT problem that requires further and more definitive investigation.Although the history given did not suggest it, I would consider possible WPW. People with tachydysrythmias may have an underlying WPW syndrome and delta waves will not be noted at this rate. Unfortunately UK guidelines do not allow the use of amiodarone other than for VF or pulseless VTach refractory to defibrillation

  • Dan says:

    Hmm.. tough to say, although I am leaning towards SVT w/ abberancy due to the axis, lack of fusion beats, and the fact that clinically the patient is a healthy, fairly young person. O2 at 15LPM, 18G AC, 6mg Adenosine IVP. If Adenosine does not convert the rhythm, then I would start an Amiodarone drip 150 mg over 10 minutes. Without resolution, this patient is getting some midazolam and fentanyl.. electricity time.

  • doobis says:

    It looks to me to be A Fib RVR to me; however, it will probably end up being something crazy like variable conduction A Flutter when the conclusion is published on here.  I remember working with someone that had worked in cardiac telemetry for 30+ yrs telling me that when they get above the 200-250 bpm rate it is typically an A Flutter situation.
    At any rate he is most likely going to need to be cardioverted either in the field or in the hospital. Most likely I'd cardiovert him in the field; however, if the hospital is around the corner I may elect to delay since he is normotensive and has compensated for several hours.  Rather have him cardioverted in a hospital with 10x as many hands availible should the cardioversion go south.

  • Jason says:

    WCT’s should be considered vtach til proven otherwise. However, the age, rate, axis, initial negative deflection in AVR and a relative short QRS (130ms) point to SVT. The Pt has chest pain so I would treat with ASA, titrate O2, nitro and fentanyl. Pt’s pressure and mental status do not warrant immediate cardioversion but I would have the pads on in case pt deteriorates. Being wide complex, I would suspect wpw with a- fib, a-flutter and would avoid giving AV nodal blocking drugs such as Adenosine or Amiodarone as the AV node is what is saving him from VF.

  • Colten says:

    It definitely looks wide, but the rate seems too fast for Vtach. Even tho the book states if your faced with a wide complex tachycardia, treat as Vtach, I feel this is more of an Afib with abberency. It is slightly irregular. Adenosine will definitely slow it down but if it doesn't convert it, then I'm definitely leaning at the point more towards the Afib with abberency. At that point I would go with my first dose of Diltiazem. Worst case scenario, patient declines then cardio version it is. Amio would be another though for me since it can work both on ventricles as well as the atrias. All in all, a good strip for critical thinking. Thanks for showing.

  • Colten says:

    And what I meant as abberency, I ment as WPW.

  • Colten says:

    Sorry I contradicted myself, on this patient I would stay away from the Diltiazem due to the accessory pathway and go straight to Amio.

  • Simon says:

    All very fancy, but as a newly qualified EMT, what would your advice be if I came across this on the road? 

  • Newer EMT-I says:

    Well Simon…that's a tough one.  You wouldn't see anything as you would not have a monitor on him…however, based off his presentation…I would be treating as if this was an MI…O2, IV, ASA. Drive fast and get ALS involved asap.

  • Christopher says:

    @Simon,
    Well as an EMT the patient is presenting to you in moderate distress (as evidenced by their respiratory rate versus their blood pressure) with a pulse so rapid you can't count it. This is one of the rare patients who requires more than BLS care. Thus you begin transport to more definitive care (likely emergent). Either requesting an ALS intercept or taking the patient to the closest appropriate facility depending on how time consuming each option is.
    A sustained tachycardia at that rate is not compatible with maintaining hemodynamics, so the individual will likely pass out or lose palpable pulses at some point. You can prepare for this thru close monitoring and the application of an AED if they become unresponsive.

  • Aaron @ 52 Crew says:

    I am going to call it AVNRT (SVT) with aberrancy.  I think that the 12 lead is regular so I am not worried about WPW with A fib.  I believe it is not V tach because of the fast rate, progression through the precordial leads, no fusion beats, and the -40 axis.  With that said I will go with O2, IV (18G or larger).  I will instruct the pt to do vagal maneuvers as I draw up 6mg Adenosine.  If 6mg does not convert then I will go with 12mg Adenosine.  Last resort will be sedate with 0.05mg/kg (max 4mg) Ativan and cardiovert 100J.

  • Ken says:

    This is certainly wide and clearly >120 which, to me, puts this in WCT/VT territory. Although it MAY be SVT w abberancy, or MAY be WCT with WPW, or MAY be VT, I would choose to cardiovert at  least 200 for the following reasons. 1. Admittedly, I'm just not sure.  2. I could make a bad day worse with cardizem or amio and their contraindications to specific rhythms. 3. This guy is unstable with chest pain and RR ~30, which for me,  =  bypassing adenosine, instead going straight to cardioversion.  3. In none of the above rhythms is cardioversion CONTRAINDICATED at some point in treatment. 4. Not being expert in the intracacies of this rhythm, there is less chance for harm with cardioversion as opposed to making a wrong drug choice. I would hate to over-read this and see something that isn't there or miss something that is. So he gets narcs and juice.

  • nossen says:

    WPW with 1:1 conduction of atrial flutter is my guess.. the rate is too fast for re-entry rhythms of the AV-node. VT is a possibility, but not my guess, but still treat as VT – cardiovert.

  • Pam Allen says:

    More than likely antidromic tachycardia because of age and negative cardiac history.  12 Lead shows negative avR making VT unlikely.  Adenosin trial could be done since he is hemodynamically stable or any vagal manuever.  Following conversion WPW pattern may be observed.  If not, it could be concealed.  A workup to determine the presence of an accessory pathway may be indicated

  • Bradlee says:

    As this pt is a young and fit person and that his bp is holding steady, I would lean toward this being a possible SVT.  New protocols state give him Adenosine fast with a fluid bolus to boot because of possible dehydration after running.  If that did not fix it, have pads ready, give sedation and sync. cardiovert starting at 100j.  I would also begin transport to the hospital, transmit the EKG,  and contact medical command to discuss possibly more options for treatment.  The pt now has a heart hx, bummer;(

  • Arnel C says:

    Young patient with stable tachycardia. ? wide considering close inspection of the QRS is only about 100 ms. So to argue against VT – clinical- young/no (known)cardiac hx / ecg features – No AV dissociation, no concordance (+/-), RS interval in V4 in about 60ms, LBBB morphology in V1 but S nadir is only about 40 ms and R in V6. So this must be pre-excitation. Tx – procainamide (stable).

  • TBev says:

    Those look like Delta Waves to me in Lead II. I'm thinking AVNRT and WPW. O2, IV, ASA, Versed, Sync Cardioversion, then start heading towards the hospital. Since we don't have Procainamide available in our protocols, I'd call for orders for an Amiodorone Drip. The QRS width varies a bit…especially in V1-V3 where they start to get a little narrow. That and the Delta waves make me shy away from V-Tach. So with my suspicions of a reentrant tachycardia I wouldn't give any AV Nodal blockers. The recent history of stress coupled with the sudden physical exertion probably pushed his heart down this path…

  • TBev says:

    Oh and at least a 1L fluid bolus…

  • Jeff says:

    This is supra ventricular tachycardia.  Axis of -40 confirmed by interpretation of leads I-III leading to a electrical impulse orgion above the ventricles.  Also confirming this is AVR negative meaning the electrical impulse heading from the right shoulder to the left leg.  V1 is negative and V6 is positive with fairly normal R wave progression leading to SVT.  Treatment would vary whether you consider stable or unstable.  There is a possibilty of Afib with an unknown onset time causing concern for throwing a clot if cardioversion is performed with conversion to a sinus rhythm.  Trial of Adenisine would be my initial treatment, if found to be afib I would treat with Diltiazem to control rate and transport to nearest appriopriate facility.   He is currently compensating and I feel as though he would be stable enough to withhold cardioversion for fear of throwing a clot. 

  • Scott says:

    Broad complex tachycardia – probably not VT but my tx for undifferentiated broad complex tachycardia over 150 bpm would be the same. IV access, pads ready, and 300mg amiodarone IV over 30 minutes would be my first action – otherwise cardioversion with low dose midazolam prior if I judged him to be significantly compromised.

  • Simon says:

    @Newer EMT-I  – interesting you mention the monitor, where I work EMTs are obliged to use our lifepaks for full pt monitoring.  Trained to put on 12 leads (just no obligation to translate them).  At my level of practice…12 lead, pads (as a precaution), O2, aspirin back-up and call ahead to the hospital. 

  • Zeeeeeel says:

    First of all, with a rate that fast WPW has to be on the list. Looks a little irregular so must consider a-fib. Of course VT however the axis is physiologic left axis which makes VT unlikely. Could also be psvt with abberency. 

  • Mark S says:

    PSVT in my opinion.  What other medical history do they have?  Are they taking any cancer drugs which can present these symptoms.  Dinfinite vitals, O2 and transport.

  • Rick S says:

    WPW. Note the Delta Waves in V5 and V6. I would be very careful in my choice of drugs as adenosine could worsen this condition. Elective cardioversion is the optimal choice.

  • Mario says:

    My first GUT was SVT can not prove it. 

  • Colten says:

    Any follow ups on this yet?

  • David Baumrind says:

    @Colten: it will be posted tomorrow morning.

  • Ken, flight RN says:

    With the history of stress and anxiety, streneous physical activity and symptoms lasting two hours at rest V-tach is less likely to be the case.  This is SVT.  You can see the QRS is narrow in the inferior leads.  The close ST segment makes it look like wide QRS.  His vitals are stable, but symptomatic with chest pain, diaphoresis and tachypnea.  I would apply O2 2-4L/MIn, large bore IV NS in the A/C, and rapid infusion of Adenison 6mg then 12mg if no response to first dose.  If no change then sedate and syncronize cardioversion at 100J.  If monitor unable to synch with T waves, then defiib at 200J.

  • satya says:

    it's an antidromic avrt mechanism,.. we should try to give some vagal pressure on this man, to see wether it will respon or not, and maybe try some adenosine IV

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