So here is the final decision for you to make and the real reason why I started this tale. This is a short post so have a quick read and let me know your thoughts.
The crew have arrived on scene to back me up. With this case, since I have been involved from the start and had medicated Jim, I thought it only right and proper to accompany him to the hospital, so one of the crew from the vehicle drove my car and I attended and travelled in the back of the ambulance with Jim up to the hospital.
I had Jim lying on the stretcher and had him attached to the monitor again. Just as I had attached the leads, Jim suddenly said
“Oooh Mark, I really dont feel very well”
As I look at him, I quickly throw a glance at the monitor which now shows this :
Click to Enlarge
He remains conscious for now, but becomes pallid and diaphoretic within seconds.
Now, quick.. How do you treat this patient?
You need to open the ECG in full screen so you can see the full length of the strip to really see what is going on.
Medic999 
OK, I'll take a stab at it: torsades de pointes? Patient is obviously unstable so I would ensure the pads are still securely in place, call for sedation orders (we're required to, it's a state thing…not getting into that) and get ready to “whack'em”. Last time it was a great learning experience for me so I am hoping to learn even more this time.
By: PGSIlva on February 4, 2010
at 11:36 am
Patient flat, defib pads on, blue lights on and foot down, prepare for cardiac arrest, pre-alert into hospital. Explain to the patient that his heart has gone into an abnormal rhythm and we're going to go to hospital quickly.Whilst Torsades is a shockable rhythm, he's still conscious and we can't sedate in the UK. An indication for atropine is “paroxysmal ventricular arrythmias requiring suppression”, so you could consider another 500mcg of atropine?
By: KH on February 4, 2010
at 12:16 pm
Hey mark, keep these bad boys coming! This really is great learning for me.
By: PGSIlva on February 4, 2010
at 12:45 pm
This is certainly beyond what I think I can do. So I can see tachycardia…but the amplitude of the complexes are varying sinusoidally – is this polymorphic VT?
By: aledt on February 4, 2010
at 12:54 pm
Could be torsades, judging by his consciousness, I'd lean away from V-fib for the moment, but keep an eye on it for sure. Working with torsades will be tricky. No time for sedation, if the pads are in place, and I hope they are I'm going to see if my monitor can find sync points, if so I cardiovert. If not, I'm ready to defibrillate him. My mag orders are 2-4mg slow IV infusion over 10 minutes in an underfill bag on IV piggyback which will take a minute or two to set up.Wish you had cardioversion now Mark? If, that is, the monitor can find the points?
By: the Happy Medic on February 4, 2010
at 1:47 pm
Mag him, for sure. Do you have magnesium? I guess you don't have cardioversion? If you don't have either of those, and you are within a few minutes of the hospital, I might consider holding off on the defib (pucker factor though it might be).Looks like it might be an R on T etiology (kinda hard to tell).What did you do?
By: Matt on February 4, 2010
at 2:22 pm
Also, is that a fusion beat toward the end of the strip?
By: Matt on February 4, 2010
at 2:23 pm
Looks like torsades de pointes. Again, not alot I could do about it within my protocols. Very cool case though. I've enjoyed this.
By: LouisaS on February 4, 2010
at 2:31 pm
Diesel bolus, O2 15L/NRB, put the AED patches on him, and radio report. I'm assuming I have ALS, he's got the monitor. What's a 12 lead look like for that?James Rosse, EMT-B
By: jamesrosse on February 4, 2010
at 3:06 pm
JamesLike a bunch of squigly lines on funny looking paper! Sorry dude I'm just kidding…I'm fried and needed to be a wee bit goofy.
By: PGSIlva on February 4, 2010
at 3:13 pm
Well this is a good time to discuss prolonged QT intervals class. They can be congenital Jervell and Lange-Nielsen syndrome, Romano-Ward syndrome or acquired; Bradyarrythmias, complete AV block, MI, hypokalemia, hypomagnesemia, hypocalcemia, Quinidine and many other drugs of different classes. A prolonged QT can lead to this poor fellow’s problem Torsade de Pointes. I don’t think the atropine caused it. It happens due to the whole Na Ca ion flux thing that happens during prolonged repolarization that I can’t for the life of me ever remember. Torsades can lead to V-Fib but can be self limiting. He however has serious S&S and I know this will sound wrong but unsynchronized cardioversion is in order, the pattern of Torsades is too irregular for the monitor to synchronize. So the next step of treatment of Torsades is to shorten the QT interval, pacing will do this and Isoproterenol infusion also would do this by increasing the heart rate which is what you were attempting to do in the first place. Also Magnesium 1-2mg IV may be of some benefit in treating Torsades. The other priority is removing the drugs that may have caused the bradycardia or treating for them (beta blocker, Ca channel blocker OD) and correcting for electrolyte imbalances. I’m sorry but it did not look like you had many options available to you for this poor guy. Now that he is hypotensive EPI is starting to look real good and may get his heart rate up but like I said you don’t seem to have many options at this point. In my years of practice as a medic I have occasionally said to myself while doing drug out dates in the bag “ why do we still carry x, y, or z”. Then something like this walks along and you thank god you had that one seldom used med, and Isoproterenol and Mag come to mind… This was a good one for us that is, crappy for you.
By: dcimedic on February 4, 2010
at 3:20 pm
I think the rhythm is torsades de pointes however I don't know how to treat it, unless you can cardiovert? So put on the pads and hope for the best en route.Fantastic set of posts Mark! Great to learn from.
By: Squeezey on February 4, 2010
at 4:18 pm
torsades…..high flow O2, diesel therapy, and, from my protocols: for “stable” TdP Contact Med Command (CMC) for orders for amniodarone or magnesium. for unstable – cardiovert immediately, consider sedation but do not delay cardioversion for sedation.per protocol notes:1. Many patients who present with wide complex tachycardia have evidence of cardiovascular dysfunction (low blood pressure, chest pain, congestive heart failure, altered level of consciousness). Some of these patients are unstable (such as shock, pulmonary edema, decreased level of consciousness) and require immediate synchronized cardioversion. The rest who have mild hypotension, mild shortness of breath/scattered rales, chest discomfort and a GCS >13 may be treated with medications. If the patient develops unstable signs/symptoms at any time during treatment, proceed immediately to the cardioversion column. The following chart illustrates the continuum from borderline to critically unstable.Borderline / UnstableLow BP / ShockSOB, Scattered Rales / Pulmonary EdemaMild chest discomfort / Severe chest discomfortAlert & oriented / Decreased level of consciousnessGCS 14-15 / GCS < 13per case study pt appears to be temporarily on the stable side of borderline, but pt can (and most likely will) deteriorate rapidly….~be prepared for pt to code, and treat per protocol if so.
By: PrincessAnika on February 4, 2010
at 4:24 pm
OH forgot to add…..CHECK MONITOR LEAD/PLACEMENT and ensure its not artifact….then proceed w/ protocol.
By: PrincessAnika on February 4, 2010
at 4:26 pm
Wow dcimedic – I bow to your knowledge. You have given me alot to read up on. Thanks!I will wrap everything up in the next post – the conclusion, but as you can see, I have very little options open to me as compared to you.
By: Medic999 on February 4, 2010
at 4:41 pm
Great question KH :”An indication for atropine is “paroxysmal ventricular arrythmias requiring suppression”, so you could consider another 500mcg of atropine?”And one that I am hoping someone more intelligent than me can answer? You have really made me think about it though.Thanks
By: Medic999 on February 4, 2010
at 4:42 pm
I will try, PG, but cases like these dont come along that often!
By: Medic999 on February 4, 2010
at 4:42 pm
Cardioversion?You know I want it anyway, but wait till you read my conclusion in two days time to see if you would have still use it when you see what happens next.
By: Medic999 on February 4, 2010
at 4:44 pm
No Magnesium Matt.As for the R on T, it certainly starts at the point where the T wave should be, but as I remember it, there were no PVC`s throughout the time he was monitored. Thats not to say that he didnt have one at that particular time.
By: Medic999 on February 4, 2010
at 4:46 pm
Hi Louisa.Im glad you have enjoyed it. Im learning alot from everyones comments too. Make sure you come back in two days for the final part.
By: Medic999 on February 4, 2010
at 5:07 pm
Didnt catch a 12 lead whilst his rhythm was like this. luckily though I have another 12 lead on a patient with the same rhythm. May well post that one soon.
By: Medic999 on February 4, 2010
at 5:08 pm
Ho Ho ho ho!!!
By: Medic999 on February 4, 2010
at 5:08 pm
Glad you have been enjoying them Squeezy. I try to do some 'What would you do?' posts whenever something interesting enough comes up.
By: Medic999 on February 4, 2010
at 5:09 pm
I really do wish I had the options that you have! But alas, not for me!
By: Medic999 on February 4, 2010
at 5:09 pm
Thx for the refresh on qt dcimedic! it appears tdp, check ld placement to ensure it isn't artifact, but given the change in pt status. see if your monitor can synch the rhythm. our protocols don't call for unsynch'd cardioversion for tdp unless it's pulseless (it then falls under pulseless VT.) I was taught to only consider sedation, but the problem is that our sedation meds reduce the HR even further. I would give 1gm mag IV, or possibly dopamine drip per local protocals. we've already established BLS, and a second line is recommended. i agree with dcimedic that pacing may help as well to get his rate controlled. if his rx included a CA+ blocker, half amp CaCl could be considered.
By: halfbreedmedic on February 4, 2010
at 8:03 pm
I honestly don't think this is Torsades de Pointes for two reasons. First, the underlying rhythm did not appear to have a prolonged QTc. Second, the cyclic rate is too fast. Typically Torsades will be < 300 BPM. Using the small block method we can place the ventricular rate between 375 and 500 (probably averaging around 425). I would suggest that anyone given this rhythm strip without the clinical details would say in no uncertain terms that we're looking at VF. It meets all of the criteria (other than a pulseless patient). Regardless, it's an extremely fast polymorphic VT that looks exactly like VF. dcimedic's point is well taken that it requires an unsynchronized shock. One the rhythm converts, I would capture a 12-lead and get a computer measurement of the QTc of the underlying rhythm (which I suspect is well under 500 ms). I have no experience with isoproterenol but remember that lidocaine is one of the few antiarrhythmics that shortens the QT interval if necessary. You can also try overdrive TCP to increase the ventricular rate. You also aren't going to hurt anyone with 2 g of MgSO4. But again, I have serious doubts as to whether or not this is actually Torsades, and I would be more inclined to give amiodarone after verifying the QTc is < 500 ms. Interesting one, Mark!
By: tbouthillet on February 4, 2010
at 8:23 pm
It should also go without saying that I'd check the red electrode (since leads II, III, and aVF share the same positive electrode) and make sure this isn't artifactual.
By: tbouthillet on February 4, 2010
at 8:27 pm
Pre-cordial whack on the chest.
By: sflrvlvr on February 4, 2010
at 8:27 pm
I wouldnt have given him atropine in the first place lol. Sync him, I feel like he will decomensate fairly quickly, so electricity might be the best option. Or if you choose 2 mg of mag. since he appears to be torsades. But since I cant see enough of the strip, if its just V-tach I would give him 150 mg of amiodarone. Watch for airway comprimise, anticipate the need for pacing, and possibly CPR. Glad you have 2 in back lol.
By: emtpncv on February 4, 2010
at 9:20 pm
from what i understand….LifeTeam EMS in Harrisburg PA is hiring….. 😉
By: PrincessAnika on February 4, 2010
at 9:57 pm
For whatever it's worth (i.e. not much), this I got a QTc of .563 seconds.My method: I used the second strip (the regular wide complex strip). I measured a QTI of ~.68 seconds and a RR of 1.46 seconds. There are a few QTc formulas, but I only know this one, which I'm told over-corrects at fast rates: QTc=QT/square root(RR).A quick trip to google reveals that the square root of 1.46 is 1.2083….68/1.2083=.563…As Mark indicated, there were no premature complexes during the entire monitoring, but a prolonged QTc and a polymorphic ventricular-somethingfast does lend some degree of credence to it being torsades
By: Matt on February 4, 2010
at 10:20 pm
Thanks for the reply, Matt. For that strip I measured a QT interval of 520 ms (13 small blocks) with a heart rate of about 40 (1500 / 38 = 40). Using the QTc calculator at MedCalc (QT = 520; RR = 38 small blocks) I got a QTc of 422 ms.
By: tbouthillet on February 4, 2010
at 10:36 pm
Matt I agree with your math I also killed a few brain cells with your formula but I got 468 ms, I believe that a QTc of .44 is considered a long QT. I know that this patient does not fit perfectly into the textbook TDP but I smell a zebra not a horse. But this is just my opinion and I'v been wrong before.
By: dcimedic on February 4, 2010
at 10:49 pm
Thanks for the reply, dcimedic. 440 ms is borderline for men and 460 ms is borderline for women. To be clinically significant usually requires a QTc of 500 ms. Regardless, I'm not sure how you're measuring an uncorrected QT interval of 680 ms for the rhythm strip in question. I'm only seeing 13 small blocks which is 520 ms. There could very well be a zebra, although Mark does say, “The patient remains conscious for now….” indicating LOC could be imminent. The patient is already lying supine, so perhaps he remained conscious for several seconds after the onset of VF. It takes a few minutes for aortic pressure and central venous pressure to merge together after the onset of VF. In other words, there is some forward blood flow.
By: tbouthillet on February 4, 2010
at 11:05 pm
Okay, since I apparently don't have anything else to do tonight, feel free to check out my MS Paint version of a .64 second measurement at <img src=”http://i757.photobucket.com/albums/xx219/QTcnitpicker/QTcfromMarkscall.png” border=”0″ alt=”Photobucket”>
By: Matt on February 4, 2010
at 11:33 pm
LOL! Thanks for the graphic, Matt. I would respectfully suggest using all three leads and include the narrow QRS cardiac cycle as well as the wide QRS cardiac cycles. I found them to be in agreement. See attached graphic (I have no idea if this is going to work). <img src=”http://i12.photobucket.com/albums/a234/firemedictb/EMS%2012%20Lead/QT_interval_999_medic.jpg” border=”0″ alt=”Photobucket”>
By: tbouthillet on February 5, 2010
at 12:13 am
well assuming it's not articfact it looks like torsade to me and the techniocal maths is waaay over my head so if it was me dealing that's what I'd be goping with. My procedures at my level allow me to synchronised cardiovert but I don't get any drugs to play with so it's going to have to be pretty simple. Lots of O2, get a line in if not already and fluids for the shock and get ready for the arrest-but what about trying a valsalva manouever?Call for back up and travel under lights.
By: J1 on February 5, 2010
at 2:07 am
Well alot of you said it's Torsades de pointes.. Actually it looks like it ( twisting of the point ).. But am still thinking about an accesory pathway ..Have a look to the PR interval with the presence of delta wave .. It looks like WPW which aggravate the VF ..If the patient is stable i would start the treatment with procainamide .Many thanks
By: Hillis on February 5, 2010
at 2:56 am
You've missed an important part of this, the indication is JRCALC is “Symptomatic bradycardia in the presence of…paroxysmal ventricular arrhythmias requiring suppression” be careful quoting halves of indications :PAnyway yes, atropine has been shown in a widely published case report from 1998 to be beneficial in Torsades. Heart 1998;79:99-100 is the reference. However, it's not ideal so I'd probably hold off on the atropine in favour of more widely accepted therapy unless in extremis. I guess though in extremis would be the patient arresting, and we have ALS to tell us what to do for that…
By: hljhb1 on February 5, 2010
at 4:17 am
A little off topic, but this reminded my of a lovely old lady I took in to hospital for investigations for her AF. She had been having dizzy spells for months, but appeared well and met me at the door laughing and joking and even refused to let me carry her bag.Just as we were approaching hospital, I recorded an ECG…just as I went for the print button, this happened….http://picasaweb.google.co.uk/lh/photo/3-rh_dNq…A full six second sinus pause! She felt quite dizzy and unwell too, although she spontaneously resolved and was no where near as sick as your chap. The admission unit was heaving though and I was rather pleased that we got to take her straight to CCU.
By: Angor Animi on February 5, 2010
at 4:23 am
Hi, can I just ask why amiodarone? A side effect of the drug is torsades and it is contraindicated in patients with 2nd/3rd degree blocks without pacing. Also, my understanding is that amiodarone prolongs the QT interval which is one of the characteristics of torsades. Surely you would be worsening the arrhythmia? A class IB antiarrhythmic might be indicated however.Mind you, for UK paramedics amiodarone is only indicated in cardiac arrest with VF/pulseless VT refactory to defibrillation, so this is all a bit academic this side of the pond!p.s. If of course it is Torsades we are looking at, I'm not 100% convinced… If it's something else, with a shorter QTc, I'm with you on the amiodarone.
By: hljhb1 on February 5, 2010
at 4:31 am
not for all uk paramedics! we use amiodarone for symptomatic pulsed vt under a pgd.
By: ak on February 5, 2010
at 4:52 am
Apologies ak. I shouldn't take JRCALC as quite so Gospel!
By: hljhb1 on February 5, 2010
at 7:29 am
Angor Animi – Yikes! If memory serves a 3-second asystolic pause warrants a pacemaker in the absence of drug overdose or electrolyte derangement. It was a happy coincidence that you captured this event! Thanks for sharing.
By: tbouthillet on February 5, 2010
at 12:13 pm
i agree treat the patient not rely on machines
By: jscott791 on February 5, 2010
at 6:11 pm
having been out of ems for a couple of years (long story – illness) i copied/pasted from State protocols – wide complex tach in adult. stable or unstable – if unstable cardiovert (consider sedation) then contact MC for orders, if stable is it reg (vtach w/pulses etc) or irregular? if irreg CMC. on contact, possible orders include amiodarone (150mg IV infusion over 10 mins, if available) or if torsades: magnesium 2mg IV. if unstable (repeat) synch. cardioversion after antidysrhythmic.so yeah, i didn't type it right the first time – sorry for the confusion.PA State ALS protocols:http://www.dsf.health.state.pa.us/health/lib/he…
By: PrincessAnika on February 5, 2010
at 11:24 pm
having been out of ems for a couple of years (long story – illness) i copied/pasted from State protocols – wide complex tach in adult. stable or unstable – if unstable cardiovert (consider sedation) then contact MC for orders, if stable is it reg (vtach w/pulses etc) or irregular? if irreg CMC. on contact, possible orders include amiodarone (150mg IV infusion over 10 mins, if available) or if torsades: magnesium 2mg IV. if unstable (repeat) synch. cardioversion after antidysrhythmic.so yeah, i didn't type it right the first time – sorry for the confusion.PA State ALS protocols:http://www.dsf.health.state.pa.us/health/lib/he…
By: PrincessAnika on February 6, 2010
at 4:24 am
[…] @UKMedic999: New blog post: Part 3. What would you do…ECG Geek 6 http://999medic.com/2010/02/04/part-3-what-would-you-do-ecg-geek-6/ […]
By: Twitter Weekly Updates for 2010-02-07 | Life Under the Lights on February 7, 2010
at 1:39 pm