This is the conclusion to 65 year old male CC: Fall with injury. You may wish to review the history and clinical presentation.
When we left off the patient was in severe heart failure with the following 12-lead ECG.
As we have mentioned before on several occasions, the most important thing when treating a patient with a tachycardia is to decide whether or not the tachycardia is causing the symptoms or the symptoms are causing the tachycardia.
In other words, you should try to rule out the possibility that it's a compensatory tachycardia. As this case clearly demonstrates, this can be very difficult!
The crew felt that the differential diagnosis for this wide complex tachycardia (from most likely to least likely) was VT, 2:1 atrial flutter with LBBB, sinus tachycardia with LBBB, or some other SVT with aberrancy.
Due to the patient's instability, the treating paramedic felt there was little to lose and much to gain by attempting synchronized cardioversion. If the rhythm was VT or 2:1 flutter the patient's condition might improve dramatically. If it turned out to be sinus tachycardia with LBBB he'd be in the exact same position.
There appeared to be no change in the heart rhythm.
A report was given to online medical control and the patient was transported emergently to the hospital.
On arrival the patient was placed on BiPAP and started on a NTG drip.
Here was the 12-lead ECG on arrival.
The patient was given lopressor 5 mg slow IV push.
The conversion rhythm shows sinus rhythm at 92 bpm with left bundle branch block.
So, we now know that the patient probably had LBBB at baseline. However, without a heart rate histogram it's difficult to say whether or not this was 2:1 flutter that converted sinus rhythm or sinus tachycardia that was slowed down with the lopressor.
This is often overlooked in the emergency setting but in the inhospital setting it's very important to document the onset or termination of an arrhythmia for this very reason.
The patient's SpO2 came up above 90% and the patient became more alert and was attempting to communicate by the time EMS was done writing their report. No further information is available.