EMS is called to the residence of a 90 year old female who awoke to an “uncontrolled bowel movement” that corresponded with sudden onset abdominal pain.
On EMS arrival, the patient is alert and oriented to person, place, time, and event. She has a grimace on her face and appears acutely ill.
When asked the exact location of her pain she points to the epigastric area.
Past medical history: “Cardiac problems”
Medications: Numerous (but list unavailable)
Vital signs are assessed.
- RR: 18 shallow
- HR: Too rapid to count
- NIBP: 118/60
- SpO2: 96% onÂ room air
The cardiac monitor is attached.
The patient is immediately loaded on the gurney and relocated to the back of the ambulance where she is placed on oxygen, an IV is established, and the combo-pads are placed.
Breath sounds are clear bilaterally.
A pacemaker is noted in the upper-left chest.
A 12-lead ECG is captured.
Wide and fast rhythms should be considered VT until proven otherwise. Regardless, in this case the morphology strongly favors VT over SVT with aberrancy.
See also: 60-Second Soapbox: Wide Complex Tachycardia at Academic Life in Emergency Medicine.
At this point the patient’s skin appears grayish, pasty, and moist. Her level of consciousness is diminished and she stops responding to verbal stimuli.
Synchronized cardioversion is performed at 100 J.
Another 12-lead ECG is obtained on arrival at the hospital.
Sinus rhythm with demand pacing at a rate of 70.
The patient was given amiodarone and admitted to the ICU.
Wellens HJ, Bar FW, Lie KI. The value of the electrocardiogram in the differential diagnosis of a tachycardia with a widened QRS complex. Am J Med 1978;64:27-33.