77 year old female: Unresponsive

This is a great case sent in my a reader who wishes to remain anonymous. We hope you find it as intriguing as we did!

After clearing up from a routine interfacility transfer, you're dispatched for a 77 year old female who is unresponsive at a local extended care facility. A BLS engine crew is enroute as well and has a few minute lead on your unit.

As you're arriving the engine crew hails you on a tac channel and relays that the patient is unresponsive, but breathing and they have put her on a NRB and are checking her blood glucose level.

You're directed to the room where the engine crew is completing their assessment of the patient. The facility staff states the patient was alert and oriented at 0600 when they did their rounds. However, when they came back at 0900 to give the patient breakfast and her morning medications they found her unresponsive.

Apparently, EMS is called frequently for this patient becoming unresponsive, although she does not know why. She hands you the patient's paperwork as the captain from the engine gives you the patient's vitals:

  • GCS: 8 (E2 M2 V4)
  • Pulse: 60, weak at the radials
  • BP: 118/56
  • RR: 16, clear bilateral lung sounds
  • SpO2: 82% on room air, 94% on a non-rebreather
  • BGL: 102 mg/dL (5.6 mmol/L)

As your partner helps the engine crew move the patient to your stretcher you read over her paperwork:

  • PMHxhypertension, osteoarthritis, renal cysts, urosepsis, advanced parkinson's disease, history of UTIs, dementia, history of plueral effusion, COPD
  • Medshydrocodone, sorbitol, ferrous sulfate, dulcolak, prednisone, albuterol, ativan, heparin, aspirin, colace, sinemet, synthroid, tylenol, furosemide, potassium chloride, aricept, multi-vitamin, claritin, lactulose
  • Allergiescipro, septra, florinef, bactrim, levaquin, zoloft, gentamicin

A quick physical exam reveals moaning to painful stimuli, pinpoint pupils, whole body tremors, a foley catheter with adequate output amber in color. The remainder of the exam is unremarkable.

In the back of the unit you place the patient on nasal capnography while your partner places the patient on the monitor:

We'll See What Shakes Out - Rhythm Strip

At this point your partner grabs the 12-Lead cable and begins placing electrodes while you acquire an IV.

We'll See What Shakes Out - 12-Lead

You're 10 minutes from a local hospital, and 15 minutes from a cardiac center.

  • What is our patient's rhythm?
  • What does the patient's 12-Lead show?
  • What are your treatment priorities?

Leave your answers below!

Looking for the conclusion? 77 year old female: Unresponsive – Discussion.

68 Comments

  • kyle lunden says:

    possibly the UTI

  • Vegasmedic says:

    Transport to the closest. Push Adenosine / cardiovert the SVT. Get post conversion 12 lead. Anything else?

  • Andy Breden says:

    Looks like afib with RVR. We could try some adenosine on our way to synchronized cardioversion. Adeno may slow rate to see underlying rhythm. If not change, synched shocked at 150-180J for our system.

  • Pete says:

    Looks like uncontrolled A-fib, but her primary issue appears to be opiate related. She is starting to show signs of CNS depression, with unresponsive and pinpoint pupils.  I would hit her with a small dose of Narcan first, then see if there are any changes to the 12 lead. If not, I would then move to treat the a-fib..

  • CTmedicstudent says:

    how about cartizem first….

  • Jeffrey J. Holbrook says:

    The presenting problem and the reason why EMS was called is an unsconscious person. Noting the v/s and the patients meds (Hydrocodone and Ativan), I would like to know what this patients pupils look like?. Lets R/O an overdose on these medications first and maybe try some Narcan. (2 Mg's IV here) Secondly and possibly the underlying problem (I am hesitant to believe that given the v/s!) is the Atrial Fibrillation with RVR and some aberrantly conducted beats. Utilizing the protocols in our region we can treat this with 5 Mg's of Lopressor in 50 Ml's of 0.9% NaCl over 10 minutes. My money is on the O.D. and that is where I would start……

  • Michael Conkling says:

    I think this patient is being suppressed with opiates. Adenosine would be key. Definitely transport to the closest facility as this is clearly an unstable patient.

  • john says:

    This is a pretty wicked 12 lead. There are some questionable points in this 12 lead. I kind of agree with pete about the Narcan, but I dont think it would change the 12 lead at all. Most opiate OD's pt's are bradycardic. I would administer Narcan, and cardiovert. If no change I would would attempt to treat the rate as well as the afib. I am a Medic student.

  • Mike Sherriff says:

    It appears to be a narrow complex rhythm, likely sinus, with a rate of just over 60, about the same as her pulse. Accompanied by a whole bunch of artifact from her Parkinsonian tremors.  
     

  • DaveOC says:

    I think Mike is right….her pulse is 60. The rhythm strip lead III shows a regular rhythm at 60 ish BPM with what looks like flutter waves in between but could be a bunch of artifact. Adenosine or cardioversion might kill this lady.  Try a little narcan and see if she comes round.

  • Johnny says:

    Ok the rhythm is most likely an a-fib, and she takes heparin so she has HX of it. Her HX also shows frequent UTI and renal cysts, and she takes lasix. Therefore it’s reasonable to conclude that she may be experiencing some stage of renal failure and is unable to metabolize the opiates that she is taking. Narcan first, for sure. If no change in the pt then start looking to treat the a-fib, since it’s not new onset a-fib I’d be on the phone with med control to get another brain looking at the situation and treatment ideas.

  • Sean V says:

    The underlying rhythm is hard to interpret, looking at Print 3 it appears to be crazy A-fib with RVR in Lead II, however if you look at Lead III there are complexes that have deep S-waves that are evenly spaced and has a rate of about 75.
    This patient has Advanced Parkinson's Disease and in the description has "whole body tremors". This ECG is full of artifact.
    I'm going to call this a Sinus Rhythm with a rate of 75.
     
    My money is on this being an accidental Hydrocodone OD with the pinpoint pupils, so I think it would be appropriate to start an IV and give this patient Narcan 0.4mg SIVP, and I would stress SIVP because of this pt's age, I do not want to slam Narcan into her, throw her into withdrawal, and then have her seize.

    However I'd be also concerned about a few other things, the Narc OD is the more obvious one, but we have a patient with some significant medical problems:
    UTI & Urosepsis, is this patient sick with this again, I know our catheter & urine looks ok, however we should do a Temp. This is lower on my list of concerns because she isn't tachy or tachypniec, and her BP isn't too bad.
    Hypo/Hyperkalemia, This patient is taking Lasix & Potassium, screw either of these meds up too much and we can have some serious issues. Tough to say by looking at the ECG, as I'm not seeing a classic Sine-wave pattern to indicate HyperK, so labs would be indicated to look at this.
     
    But anyways, Treatment priorities are our ABCs, we could look at putting an NPA to give us a more patent airway, continue with the NRB oxygen, look at putting a nasal cannula EtCO2 on as well to see where our CO2 is at, IV access, I dont' want to get too crazy with hitting her with a bunch of fluid due to the Lasix in her medication diet (is the Lasix for CHF, renal failure, liver failure…etc). Then our extremely SIVP Narcan 0.4mg, and repeat this until desired effect up to a maximum of 2mg. In my opinion, desired effect for this patient is to see a rise in our GCS and the ability to maintain O2 saturations without an NRB. As long as she's improving I'm happy, I don't need to get her to a GCS 15, because if I do, I may completely block out the opiod receptors with the Narcan, then we're now dealing with another problem, significant pain; also if I bring her up too fast, she may seize, so it's better to have to have her in a nice comfortable ED where this can be done in a controlled fasion.

  • Cody says:

    Not worried about the OD as she is still breathing at 16 bpm.  Would rather not deal with a patient who is also pissed because they just got a slug of Narcan.  Yes, she is old, but in my experience, even the elderly get pissed when you mess up their high whether it is intentional or not.  The EKG is what is concerning.  At that point, I would most likely go straight to Cardizem.  If the Cardizem didn't work, I would move to cardioversion.  This patient would go to a cardiac hospital.  Five extra minutes is not going to make enough of a difference to delay definitive treatment for the a-fib RVR when we are perfectly capable of controlling the patient's airway if the need arises.

  • Sean V says:

    I also forgot to mention that we can titrate our Narcan to our EtCO2. It's likely that this patient is breathing shallow, and her CO2 is high, so if we get CO2 back into normal ranges with the Narcan then we are winning and warding off respiratory acidosis.

  • Sean V,

    An ETCO2 reading was acquired and was initially 33 mmHg, the waveform is present on the rhythm strip. I've updated the post to make this more clear!

    Thanks for the nudge :)

  • Mike Sherriff says:

    For those thinking this is a-Fib,  you would have to call it A-Fib with WPW (which as I said above, I don't think it is).  
    You would have to call it A-Fib with WPW or accessory pathway because it is smoking fast in places (up to and over a rate of 300 at times), it is polymorphic, and it is irregularly irregular. Your AV node won't let 300 atrial fib impulses per minute through.  When you see rates that fast, you need to think accessory pathway.
     If you decide it is A-Fib with WPW, you likely only have one treatment for it: Cardioversion at (for us) 150J, or if it won't sync due to it's polymorphic pattern then defibrillation at 150J.
    Adenosine, calcium channel blockers, amiodarone, lidocaine should all be avoided with A-Fib with WPW as they can quickly lead to death.  If you have some procainamide laying around and the pt is relatively stable, then maybe you could try this.  But really, electricity is your best bet.
     

  • Matt H. says:

    The underlying rhythm appears to be a-fib with a RBBB, with maybe some PVC's thrown in. I'm raising an eyebrow at anyone suggesting adenosine. For A-Fib? Really? Nor would I even remotely consider cardioversion. She's normotensive, her RR is adequate, and due to her Hx of COPD she probably sats high 80's to low 90's anyway. She's prescribed hydrocodone, which would explain the pin-point pupils, although I don't thnk this is an overdose or cardiac related. There's an underlying cause to the arrhythmia, possibly a UTI. 
    O2, IV, fluids, transport. 

  • Jonathan says:

    Due to the fact that she is in a NH and was fine at 0600 and no meds have been given today I’d say an od is unlikely but still possible and the pinpoint and CNS depression due support the OD possibility. Let’s start at the basics here, she has an airway and is breathing , the NRB is helping the SpO2 for now so let’s move on to circulation, weak radial pulses show poor circulation which could also be why the SpO2 is so low and the rate of 256 is definitely a great indicator this is a perfussion issue. So is it rapid a-fib or SVT? For me, a HR of 256 is not going to be easy to decipher between the two and I wouldn’t spend anytime arguing it. I’m definitely going to throw the phone book at this problem first adenosine and cardizem are great meds to start with here although some would argue and with good reason the her signs and symptoms would warrant immediate cardio version. For me though I’d give the meds first. If I was unsuccessful with these three interventions then I would explore the OD possibility, and with most NH pt’s a nasty UTI is always a good possibility so sepsis is always a concern. So in short I would try to fix the rate to find the true rythm first. No need to reinvent the wheel on this one. ABC’s first….thats just my humble opinion anyways but then again I’m just an ” ambulance driver” LOL

  • JVH says:

    Considering the pt's hx of Parkinson's and physical exam showing body tremors, I'm going to be very skeptical that Lead II is showing an accurate rhythm as opposed to interference due to the pt's tremor. With that in mind, looking at Lead III (keeping in mind the pt's pulse as obtained by the BLS truck), I'm thinking Sinus Rhythm.
    With the 12-lead, I again have the same skepticism that it is showing much of anything diagnostically significant as opposed to interference due to body tremors.
    I actually have several concerns here. Per the story, pt has yet to receive morning medications–does that include her (assumed PRN) hydrocodone? I'm skeptical of the opiate overdose route if that's the case, assuming that the nurse did in fact see the pt A&O three hours earlier and the pt has not received any medication since the evening prior. Another concern is the blood pressure. This patient has a hx of hypertension and has not received morning medications. Is this her normal blood pressure for the morning? Also, the "weak at the radials" concerns me. Is that pulse one that was obtained at the wrist, or is it Carotid? Pulse ox is saying pulse is 107, and calculated rate from lead III is approx 90. I'm making an assumption that "remainder of the exam is unremarkable" means that the pt's skin temp is normal? I would very much like a temperature at this point. Also, what is "adequate output" from the foley? How long has it been since the foley was last emptied? If we say there was X mL in the foley bag, it makes a significant difference if the foley was emptied three hours ago during rounds versus some time last night when the night shift got to it.
    As far as "diagnosis" and treatment goes, I'd throw possible opiate overdose in there just to cover all bases and give 0.4 mg Naloxone IVP q2 min per our protocol. I would probably also give some fluids (not necessarily WO, but at a moderate rate) with high suspicion of sepsis. I'm not concerned with SVT or A-Fib (there is always the possibility this is a new onset thereof, but again, I think it's much more likely the "fast" rate on the ECG is due to pt tremors).

  • Dominick says:

    Just out of curiosity, those who are calling this a sinus rhythm at 60-75…. are you even looking at the other 11 leads of the 12 lead? Sure, it looks that way in Lead III, but not in every single other lead available.
    Heart rate appears to be around 300-ish, pulse of 60-ish. That means that the rest of the QRS complexes are not producing a pulse or sufficient mechanical response. What's curious is the different axis and QRS morpholoy. My suspicion is more towards Atrial Fibrillation with an accessory pathway. It appears that the 60-75 are the "normal" impulses passed through the AV-Junction (a controlled Atrial Fibrillation). Or potentially some sort of AVNRT with the same pathophysiology. I would be concerned about blocking conduction through the normal pathways with Adenosine.
    This patient's pupils are constricted, but it would be hard to make the determination whether she is therapeutic or an overdose. It seems the facility hands out the meds, so I would be slightly less inclined to believe it was an overdose. Still, it would be in my differential. Someone else made a good point about her renal issuesand potentially the inability to  excrete the opiate and it's metabolites. However, that would strike me as a chronic problem and less likely to result in an acute altered mental status.
    This patient does meet the technical definition of an unstable tachycardia via the altered mental status. If she's an overdose, then she's already conveniently pre-sedated for the proceedure. And given that I'm suspecting accesory pathway anyways, I'd get a 12-lead and go ahead and cardiovert.
    Given a difference of only 5 minutes, the cardiac center would be the appropriate facility for this patient. Unless you have crew change or food waiting at your fire hall, then some may opt for closest facility for that reason. Not that I agree.

  • Samuel Finch says:

    First, I would hold the patients hands or legs still since the shaking from her advanced Parkinson’s is probably what’s causing the artifact with frequent QRS complexes and obtain a clear 12 lead. Then, I would make my decision based on the findings. In addition, place the patient on Capnography to see what her ETCO2 is.

  • Samuel Finch says:

    Also, I agree with those who say to administer Narcan due to the pin point pupils and home medications since that sounds like an opiate overdose. You can give the Narcan without any side effects and if the pt improves, great! But, again obtain a better 12 lead.

  • Justin Davis says:

    If you look back up at the original vitals, her pulse was 60 at the radial and weak. Her BP was in an normal range. So just based off that we know that the pt is profusing. The 3 lead in lead 2 looks like a-fib but in lead 3 it’s a sinus rhythm with lots of artifact. We are always taught to go by the pt and not the monitor. With the pt having advanced Parkinson’s your going to have a lot of artifact. The 12 lead shows a-fib with rvr also wpw is noted. Since I’m thinking that its artifact I’m going to rule out the 12-lead. To me it sounds like an opiate overdose so I would treat it with narcan to titrate to get the pt’s respiratory drive up and going again.

  • James W Hooper says:

    Aricept can also cause an altered mental status and pinpoint pupils.  I also think some people are treating the monitor and not the patient.  What is the pulse rate on the opposite radial and at the carotids?  I think there may be artifact on the 12 lead due to movement. I would try to get a cleaner 12 lead and treat accordingly.  I agree with using some low dose Narcan.  What are her mucus membranes like?  I think IV fluids are also a good call here, though I would titrate them based on her history.  What is her abdomen like?  We need to ask the NH staff what her stools have been like.  She could have a GI bleed.  I would hesitate to use electricity unless there are negative changes in the patient's condition that warrant it.  Regardless, I think a cardiac hospital might be better for her overall, in case that 12 lead actually is a correct one.  

  • Brian says:

    Not gonna cover what everyone else did but a thought.  Manual Pulse of 60 / weak, RR 16, SP02 82 RA.  I am willing to bet that this pt IS bradycardic and bradyipnic compaired to her baseline (normal).  that with low SPO2 and pinpoint pupils, Im going with an OD

  • Travis says:

    I would probably make sure the airway was nice and open (maybe an oral airway) . The patients breathing is self maintained. Aside from the weak radial pulses the vitals are okay. I would be hesitant to do a cardioversion for fear of the patient throwing a clot if the rhythm is afiv with rvr. I would also hate to cardiovert if the underlying rhythm is only 60 bpm with the tremor artifact mimicking afib with rvr. I’m also skeptical of the OD as I would expect the patient to be retaining co2 and have a decrease in respirations. The co2 was only 33 and RR was 16.

    My treatment would be mainly supportive. I would consult with medical control for advice and transport to the cardiac center where there would be further resources to make a more accurate diagnosis and treatment plan.

  • Dennis says:

    Narcan is a good idea, but I thought a little out of the box. The pt has Hypoxia with normocarbia. She's not retaining CO2, which is inconsistent with an OD. Treating the A Fib is also a good idea. But, which came first? Did the disease cause the uncontrolled A Fib or did the uncontrolled A Fib cause the symptoms. Thinking outside of the box, if you look at the capnography waveform, its shark fin shaped, indicating bronchospasm. If the A Fib was exacerbated by something, hypoxia is the most likely cause. Which makes sense that she is then shunting from the periphery (Weak Pulse) to obtain more oxygen to the core. I'd recheck lung sounds.  I'm going with a final diagnosis of COPD exacerbation and treat appropriately.

  • Nathan says:

    I tend to be very conservative in my treatments, especially with short transport times. Her palpated pulse is 60 which corresponds to the prominent complexes in lead three. I would also attempt to hold her hand still and take another reading to see if that changes the morphology. Her vitals are adequate, but how does she look (aside from altered)? Now that her sats are up to 94%, how are her skin signs? Has there been any improvement in her response? Being a long time narcotics user, I would be reluctant to narcan her. My goal with narcan is to make sure their breathing is adequate, and in this case it appears to be (with the supplemental O2).
    I would get a line and get my kit together just in case and initiate transport. If she appears stable and non-shocky I would continue O2 admin and that's it. Transport decision would depend on additional assessment and a better look at ongoing monitor readings. If it *does* appear to be RVR with non-transmitted pulses she would go to the cardiac facility. Otherwise, she would go to closest.

  • David says:

    Their are to many holes that need to be filled in in her report. If this was written as her full report that is sad. It’s to difficult to guess what is going on.

  • Christopher says:

    David,
    This is intended to be a discussion and as such many details are left out to facilitate learning. Making educated guesses is an important part of learning!
    Thanks!

  • Jim Bianga says:

    The strip is an aid for care for this pt. assess the pt not the strip! I would do vitals, take a pulse!!!! and go from there. If the pt is possible O.D. I would establish IV access draw some Narcan for the possability of respiratory arrest, transport to the closest facility. I wouldn't over think this, just treat according to the vitals and pt.

  • Robert Sedaker says:

    Does this case study have a follow up? (or do any of them?)  It would be nice to comare our discussion with the ED's assessment

  • Robert Sedaker,

    Yes this case has follow-up and a conclusion, however, it will not be presented just yet. Most of our cases have a discussion/conclusion posted within a few days, or if we are slacking or waiting on more information at least within a week.

    I hope this helps!

  • Shana R says:

    manual check on pulse to see if it reflects monitor. With Parkinsons patient is not able to be still and give you a clear EKG, which means artifact….Pinpoint eyes, look at meds. Make sure you have a patent airway. Put on O2, Get IV, start bolus 200 and give Narcan. Continue to monitor VS.   Proceed to hospital.

  • Tracy Grohs says:

    I have been a medic for 17 yrs, many of our newer medics seem to be treating the monitor and not the patient. I very much agree with Justin Davis and Dennis. You have to think outside the box at all times and be prepared for any outcome. My diagnosis’ are COPD Exacerbation and Urosepsis. Please do let us all know what the diagnosis was though.

  • doobis says:

    Double check all vitals and insure the rate is accurate.  Assuming it is . . .
    This is an unstable PT with a HR around 300 BPM, poor oxygenation, and likely poor perfusion.  Either the BLS company did not give accurate vitals or things changed from their vitals to EMS' evaluation.  It appears A Fib RVR to me and I'd go with that ACLS treatment protocol.  The rate alone would cause severe stress on her heart.  Being that it is unstable I'd go for immediate sync. cardioversion (125 j, 200, 300, 360) or if needed, unsync.  
    There is no way I'd play around with giving medication cardioversion for a PT like this.  Joules are more reliable, quicker, and indicated for unstable PTs.
    Go to the cardiac hospital, it is a cardiac event.  Part of EMS' job is to triage and transport to appropriate facilities.

  • doobis says:

    Oh as to the ETCO2, these things are squirly at times and don't register clear patters when people are not breathing normally.  Assuming the lungs were clear as stated, I'd leave that alone, beyond the O2, until the rate is controlled and reassess later.
    The same goes for possible narcotic OD.  She likely always has pinpoint pupils given her med hx.  After the heart is stabilized, I'd reassess for narcotic OD.  (Besides, given I'd cardiovert this PT, the narcotics in her system will likely reduce the painful nature of the shock.)

  • Gene Ilten says:

    Does this patient have a history of elevated ammonia levels? Lactulose is usually prescribed for this and could account for her many episodes.  I would agree that she is stable enough for transpoprt with miimal treatment.  Possibly consider Narcan, but sometimes doing nothing can be the best thing for the patient if we are not sure what is going on.

  • Amanda says:

    With the patient having full body tremors, I wouldn’t be comfortable saying treat for afib or flutter, that could just be artifact. Aside from being unresponsive the vitals are not alarming. I’d say hypoxia would be my biggest concern. And in this case the montra of IV O2 monitor would be acceptable. I’d get ready for her vitals to drop and watch the RR and consider narcan if it dropped. But not knowing how long she’s been in afib I would not go straight to cardio version, I was always taught you don’t shock afib unless you absolutely have to. I’d get 150mg in 100ml of amio ready in case whether it’s a flutter or afib that would treat the rate if it went up.

  • Stacy says:

    I think I would provide O2 start a line and head to the hospital. No quick fast or dirty treatment at all.. Maybe a fluid bolus to see what shakes out… Vitals are fine and she is stable other than the unresponsiveness… Fix what you see is wrong and let the rest ride until you get more answers. Could be: lots of things from OD to Brainstem infarct or her roomate may have somothered her with a pillow for snoring. This is not a case where I would break out any big guns. 10-15 minute transport is not that far.

  • Brian L says:

    With such a disparity between leads, I would want to know what rate is noted when listening to heart sounds. I would be willing to bet that it would match lead III. I  would consider narcotic OD vs. sepsis. ETCO2 waveform is troubling also. I would administer Narcan slow and if no change, give a fluid bolus. Transport to closest facility.

  • Bill says:

    Assuming that the patients rate is 247 and thats not artifact I would start with either Adenosine or move straight to cardiovert this patient. I do not think the rate is from hypoxia due to the sa02 being up to 94%, it has been my experience with very tachy rates from hypoxia corrects its self in seconds after sa02 comes up. I would work on slowing the rate!!

  • Bill says:

    if the rate is mostly artifact I would start with Narcan..

  • Eric F says:

    Sorry, not a medic yet but I will take every chance to learn I can get, so here is my two cents…First, we're going to manually check those vitals, either way we're headed to the cardiac center. Better safe than sorry. Second, obtain a better 12 lead if possible(definite artifacts there). She has a line in and adequate respirations with O2 sat (ETCO2 questionable) on NRB for now, but is there an increase in GCS yet? I don't fully believe the OD but I do believe in the end there is a good case of polypharmacy going on. I would be monitoring this patient closely(less a better read in that 12 lead), and be prepped should her condition deteriorate. There are a lot of factors here: Alert and oriented 3 hours prior with "acute onset" but repeatedly called for same "unconscious" pt.(polypharmacy?); What meds and dosages are/were given and when?; Any clue as to her most recent BM and/or vitals taken by the staff?; Why is her GCS 8 with a V4? Is/was she talking with some sense at some point? I would be hesitant to push meds(at this point) after some good arguments and with regards to her HX and current meds, again I'm no medic, the deterioration of the patient's condition would dictate that. 

  • Lon says:

    Follow your coma cocktail.  D50 is not warranted due to the normal glucose level.  However she is exhibiting ONE of the signs of narcotic OD.  Treat with a slow iv push of narcan until her mental status improves.  If the mental status does not improve I would continue with a Priority 1 transport to the cardiac center.  Even though the pulse of 60 looks correct by looking at lead three.  This does not appear to be cardiac in nature she appears to need a high level of acute care.  I see a regular rhythm in lead three.  There is a lot of artifact.  Treat the PATIENT not the MONITOR.  Anyway she needs a hot run to the cardiac center if treatment does not change her mental status.

  • James D says:

    PUT YOUR HANDS ON THE PATIENT
    Airway: Pt responds to pain by moaning, so airway is open and Pt has control.
    Breathing: Listen to lung sounds, evaluate rise/fall of the chest due to COPD and treat accordingly. Remember the Pt SPO2 was 82% on room air which is low, even for a COPD Pt.
    Circulation: Listen to heart tones for rate/rhythm, then reassess/treat accordingly. Check for carotid and radial pulses bilaterally to confirm "weak". Raise the Pts feet and reassess pulses.
    Continue Oxygen therapy, IV access with 250ml bolus then TKO, .4mg Narcan to assess for changes, reassess.
    A full HANDS ON assessment is required for this Pt.  With the exception of GCS, this Pt is stable on oxygen. Early notification to ER would be a good idea. I might even check with medical control.  I don't mind asking for help. 
    If the transport time is under 10 minutes, I wouldn't keep screwing with the monitor for a "good strip" on a Pt with "body tremors." I would treat the patient. After all, by the time you get a "good strip," you could be at the hospital.  

  • Jay M says:

    Out of curiosity, does this patient have any advanced directives? I would be extremely surprised if she didn’t, given the Hx I’m getting.

    I’d be interested to know more about her baseline mental status, too. It’s hard to say if this patient is unstable, or perfusing as per normal.

    I agree that a thorough hands-on exam is the most important step to come next, with the next step being getting as much Hx as I can possibly get from the nursing staff.

    The ECG feels like a distraction to me in this specific incidence. It’s covered in artifact and quite possibly unreliable anyways without more information.

    Another question I have is, was this pt truly unresponsive before? If the nurse that found her (who’s probably assessed one or two unresponsive people before…well, maybe) was accurate, than a GCS of 8 is a significant improvement over a short span of time. I’d keep that in mind while weighing my decisions.

    When it gets down to it though, her vitals are reasonable, her mechanical pulse-rate is exceptional despite the expensive monitor’s reading, and she’s showing good urine output, so there’s at least some indication that she’s perfusing normally.

    So while considering what I do know against what Im unsure of, I’d say this patient can afford to be in my care for the extra 5 minutes that’ll itll take to bring the patient to the cardiac center, on the chance that this is an acute (or even reversable) cardiac event. I’d run O2, start a line TKVO, repeat 12-leads, place the pads on her, and continue to reassess airway and vitals.

    Or, well, assuming she doesn’t have some legal documents saying that I shouldn’t.

  • Wiggy says:

    Going to agree with the Opiate OD/ controlled A-fib crowd.

    Need to stay hands on with the Pt and treat appropriately.

  • Jason says:

    Of all 48 previous comments, my personal observations and views fall most in line with Mike Sheriff's who brings up an undeniable truth.  Ask any electrophysiologist this question and they will confirm that it is physiological impossible for the A-V node to transmit electrical impulses to the ventricles at a frenetic rate of 350+ beats per minute without the benefit of an accessory pathway.  This is especially true in a 77-year-old female.  The most telling evidence that is merely artifact and nothing more are the statements of:  (1.)  "Advanced Parkinson's Disease" and (2.)  "whole body tremors".  FYI: The eponym Parkinson (as in Dr. James Parkinson) should be capitalized.  Parkinsonism can cause one of the more convincing forms of artifact next to the so-called "toothbrush tachycardia".  I know from having been a cardiac monitor (telemetry) technician for 12 years and cardiographic tech for 4+ years, that both of these forms of artifact can superficially mimic SVT, ventricular tachycardia (including Torsades de Pointes), atrial fibrillation, and/or atrial flutter.  The QRS complexes are best seen marching out regularly in lead III on the 12-lead ECG and match the radial pulse given above.  I'm going to make liberal use of the words "probable", "possible", and "questionable" here in my interpretations.

    Rhythm:  Probable supraventricular rhythm (questionable sinus rhythm) at a rate of about 65/min with possible right bundle-branch block (RBBB).

    12-lead ECG:  Probable supraventricular rhythm (? sinus rhythm) at a rate of about 77/min with possible right bundle-branch block (RBBB).

    Regarding the 12-lead ECG:  I don't believe that the real, intrinsic QRS complexes are narrow, but rather they appear to be wide.  I can barely make out what I believe are tell-tale signs of an rSR' in lead V1 and a qRS in lead I with a tall, dominant R-wave followed by a wide, terminal S-wave.  If an additional ECG could be obtained minus the noisy signal, then I think this would solve the debate over the true nature of the patient's cardiac rhythm.  To achieve this result, I would relocate the limb elecrodes from a "standard" position and move them closer in towards the torso in a "Mason-Likar" configuration.  This would, at least, get the electrodes and cables off of the shaking extremities.

  • Roy says:

    Thyroid storm

  • David Wate says:

    I have been out of the game a while (back injury in 08) so I'm a bit rusty. But what I saw there was A-fib with a ton of artifact. The key tomy treatment is the fact the palpated HR was 60. Toys can be fooled. I agree with the diagnosis of many of the people who posted before, I think this is an unintentional opiate OD so I would start my treatment with Narcan, and maintain the O2 since her sats aren't great, I would also consider droppin a tube on her. But I was always really agressive with airway and the docs around here let me get away with it.

  • Matthew Haskett says:

    ECG shows motion artifact from tremors.  She's got Parkinsons and is noted to be having tremors.  The ECG is worthless in this case.  The radial pulse is 60 which doesn't correspond to any type of tachyarryhtmia which confirms motion artifact on the ECG.  She has ALOC and hypoxia with clear lungs sounds and pinpoint pupils which to me is suspicious for opiate overdose.  maintain open airway, continue O2 with SpO2 monitoring, start a saline lock, transport. 

  • VinceD says:

    I'm in the same camp as Mike Sheriff and Jason Roediger, and I think that's pretty good company to be in. Nice case!

  • Quentin says:

    I think the answer is in front of us? GCS of 8….. Eyes (to pain) 2…….. Verbal (confused) 4…………Motor (decerebrate) 2… Im looking at another cause for pin point pupils… ? Stroke (previous history of altered LOC -?TIA) or intra cerebral bleed (in the pons) causing the pin point pupils. Just a different option…
    With a perfusing heart rate of 60 with artifacts i would stay away from cardioversion (electrically of chemically) as well as no amiodarone.
    The narcan probably would not do any harm if it was not an opiate OD. But her EtCO2 , resp rate and SpO2 dont really indicate too much going on there after the the O2 admin

  • Brent D says:

    How about a constipated parkinsonian woman with a decent tremor and vagal ACS from being so bound up from her opiate sledgehammer. She appaers to be laxative positve so depite the slow k she might be the proud owner of an electrolyte imbalance.
    I can't get over the keenness to chuck antiarythmics and every other part of the cardiac cycle drugs at this lady.

  • EEW says:

    Too much artifact to really get a good sense of cardiac function. Pinpoint pupils and decreased LOC suggest opiate OD, but respiratory effort isn't impaired. Hx of COPD explains O2 sat. ETCO2 is almost shark finned like an asthma attack, but lungs sound clear.  The way the urine output is described seems a little dark, but that can happen with kidney diseases. That could also mean that an eletrolyte imbalance is causing a cardiac event. 

    Support respirations. Saline lock. Monitor vitals including lung sounds. Transport to the local hospital for stabilizing treatment. We may be going back to transfer her to the cardiac center later.

  • Cindi N says:

    I agree with everyone so far.  Artifact makes the EKG useless, but pinpoint pupils, frequent unresponsiveness and now again following 0600 meds screams medication issue.  Narcan and transport.  Support her respirations with the NRB for a few and give the narcan time to work.  Reassess as needed. 

  • dan says:

    Afib with RVR. her 02 saturation is good with the nrb and she does not have any respiratory depression. My first thought is cardioversion but im very hesitant on cardioverting a-fib… Depending on your peotocols i would do one of two things. She has renal disease so half dosing of cardizem IVD 0.125mg/kg or 5mg lopressor slow ivp. I would not give adenosine because this is rapid a-fib its not going to work. As far as the opioid OD is concerned granted she is on opioids she has also not gotten her morning meds yet but pushing narcan isnt going to hurt I would just do it after taking care of her heart.

  • GR says:

    Lead III obviously has a lot of artifact, where were the leads placed?  "Whole body tremors" sounds a little severe to be causing that much artifact…maybe more so in the left arm which would effect lead III more than lead II?  Lead II looks like a pretty clear tracing, never seen "artifact" produce that clear of QRS complexes consistently, which also matches up with the rate of QRS complexes in most of the leads on the 12 lead.  She has a-fib RVR with aberrancy.  With a rate of +200 and aberrancy, I'm not surprised that she only has 60 palpable beats/minute.  She is still perfusing so her problem doesn't seem to be a "Rate Problem."
     
    Also, she has deteriorated sometime in 3 hours without her medications being administered.  Although she does have pinpoint pupils, her RR does not indicate opiate overdose.  The GCS reported seems odd – how many patients are decerebrate posturing with whole body tremors but still responding confused?  Was it supposed to be reported as E2 V2 M4 and instead she is withdrawing from pain and moaning, like how it is usually reported? (Not E.M.V. like above).  I am thinking CVA, pontine hemorrhage would cause miosis and altered level of consciousness.  Is there a concomitant electrolyte abnormality that caused her RVR A-fib and altered LOC?  Has she been in the a-fib for awhile unnoticed and threw a clot (is she currently on the heparin or was that still on her record from 2 years ago for DVT prevention?  Her med list does not indicate she is on any anti-arrhythmics so I am assuming this a-fib is new.  Lastly…Sepsis, Sepsis, Sepsis…after all she is in a nursing home with a history of UTI, amber colored urine in her Foley, decreased loc, tachycardia…almost seems picture perfect.  Or pneumonia with 82% RA sat although lungs were "Clear," which is a weird finding in a patient with a baseline history of COPD, but it doesn't take a bilateral lung infiltrate to make a little old lady septic from it.
     
    I would try to get a cleaner EKG to rule out any of this "artifact," R.S.Ekg right?  Just kidding. :)  Even with her presentation of altered LOC and pinpoint pupils, she still has an adequate RR and her O2 sats came up to 94%, which should reverse any altered LOC due to decreased ventilatory drive/hypoxia from an opiate OD…plus she hasn't been given her meds this morning (but who can trust that information at a nursing home really?)  Pretty confident 1mg of Narcan won't do anything, but why not try before you choose to intubate.  If she is currently being anti-coagulated, electrical cardioversion is my next step to terminate the arrhythmia because a normal perfusing rhythm will not hurt her.  If not, I would be hesitant for the fear of throwing a clot if she has been in a-fib for a prolonged amount of time.  IV's and cautious with fluids.  If cardioversion did not improve her condition I would RSI (not with sux for potential hyperkalemia with possible worsening renal failure and inadequate medication control, plus sorbitol can exacerbate hyperK) and protect her airway since she is already obtunded and is presumably not going to improve in the near future, pending labs and CT.
     
    Great case!

  • sara says:

    atrial flutter with 3;1 block.. with af intermittent af … should have thrown some emboli into d brain stem…  if she doesnt look like hypoventilating  will wait for intubation, maintain d oxygenation with 02 as she s holding with non rebreathing mask, will take an ABG ..it s not wrong in intubating  fr protecting her airway…. echo  to r/o  any thrombus and ct brain to look for hemmorrhage / embolus.. as her vitals are stable i wont cardiovert and at d same time her gcs is very low need to be evaluated .. CT BRAIN and ABG  / echo might helpful to narrow down ur differential diagnosis.. 

  • KP says:

    I agree whole heartedly with GR. Afib RVR is clear even with the artifact. Lead II on your first strip is fairly argumentative. Though she has an altered mental status at this time, I agree with withholding agressive treatment for her afib since her other vitals are stable. This patient needs to have the cause identified at the ED prior to antiarythmics or cardioversion unless she decompensates. Otherwise I fear the afib will be refractory.
    The septic picture is important to keep in mind with this kind of history and alteration in oxygenation status. Though she is maintaining her BP on her own at this time, I wouldn't hesitate to start fluid resuscitation en route. The ED will most likely bolus her prior to her labs resulting. Without access to an ABG, systemic oxygenation is very concerning since it's possible she has been hypoxic for upto 3 hours. 
    Though there is a long list of priorities to rule out (very well listed above I might add) my gut says that this pt is probably having episodes paroxysmal afib rvr, possibly from altered fluid and electrolyte status, possibly underlying tachy-brady syndrome, possibly altered thyroid levels, infections, etc. She is very much in danger of embolic complications. I'd say that she's bought herself a stay on a monitored unit at the very least. ICU admission is certainly possible depending on the clinical course.
    Side note: If available the ECF needs to provide code status and medical directive papers. Code status at the very least. I would want to know of the pt had directives against intubation.
     

  • kyle says:

    all these upright complexes,  wide qrs…. am I alone in saying I would treat this as vtach for fear of being wrong and pushing my pt. into vfib?  Lots of people are not believing the rate because of the heart rate someone told them, I'd certainly be aquiring my own check on the pulse.   There is no way I'd give a calcium channel blocker.   

  • Jason says:

    I’m amazed there are so many diagnoses of this ecg. Poor tracing, non-diagnostic quality. None of us should attempt to base any treatment off this.

  • Kp says:

    For those who arnt relying on the EKG, you could always assess for a pulse deficit, compare your apical rate while you palpate your radial pulse. An extreme perfusion deficit or lack there off may clarify this discussion, especially in light of artifact which we may not be able to get rid of in this pt without sedation

  • arnel says:

    In telemetry i've noted lead III is more "stable" vs artifacts.
    Rhyhtm is SR at 60's
    12L has a lot of background noise and I believe still SR
    Watch out for seizure enroute and differentiate tremors from clincal seizure and partial siezure with generalization (and/or epileptia partialis contnua)

  • Jane Casares says:

    This pt is in atrial fib, probably caused by hypoxia, due to opiates and possible hypokalemia due to furosimide use. Her vitals are now stable with the O2 use. I would continue to monitor her spO2 , push the narcan. and monitor her loc. Since I am unable to check her potassium level in the field. I would transport and continue to monitor. If her vital signs become unstable I would cardiovert.

  • Roger says:

    Resting tremor frequency for Parkinsonism 4 to 5.5 cycles per second, 260 to 330 per min.

  • Mike says:

    I think airway support is where I’d start; GCS of 8 and an SpO2 of 82%. Looking through her meds and noting pinpoint pupils, try a round or two or Narcan; lead III shows a heart rate consistent w/a palpable pulse; treat the pt not the monitor. She is septic on top of the possible opiate OD.

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