54yo female just discharged

[Brandon O]

Nah, looks like bigeminy; R-R's are long-short-long-short-long-short.

So are you not buying those P waves?

 

[Christopher]

So are you not buying those P waves?

Perhaps PACs? I dunno, can't be simple 1:1 with the R-R's. 3:2 is the only option, but I can't march that scenario out.

 

[KellyBracket]

Truly asking here - why isn't this an example of "STEMI-seen-in-PVC?" The ST elevation in the PVCs in lead II exceeds 25% of the preceding S wave.

E.g. http://hqmeded-ecg.blogspot.com/2009/11/stemi-best-seen-in-pvc.html

EDIT: Never mind, I just figured out how to Google image search. Dr Smith's explanation: http://hqmeded-ecg.blogspot.com/2013/10/polymorphic-ventricular-tachycardia.html

 

[Rialaigh]

This ECG looked so much like a Dr. Smith ECG I googled it just to see. I guess you guys use the same machines

(btw Google says this is "RBBB" when you search by image)



Nah, looks like bigeminy; R-R's are long-short-long-short-long-short.

This ECG was not the actual ECG, just basically exactly like it, I had trouble getting a quality scan so I just searched for something that would get the gist across.

 

[Rialaigh]

This was an actual patient I had on Sunday. I transported to the community hospital she was discharged from, our transport time was around 15 minutes and I did not drill her en route. Her BP's hung out around 90/50 with no trouble breathing (beyond what was normal for her) on 4L on a nasal canula. As far as I know her chest Xray just showed chronic disease with no acute disease. I am curious about the highly diminished breath sounds on the left. Not sure on her lab work but when she called for EMS she had not been home from the hospital for more then 3 hours. I am wondering if this patient had some renal and electrolyte imbalances either associated with infection or separate and just happened stance. Or if the infection was causing a decrease in heart efficiency which was causing some acute CHF with and cardiogenic shock.

I'm curious if you have this patient in your care in excess of an hour are we hanging a pressor if non responsive to fluid therapy? Do any hospitals near you use Adenosine as a reset for this type of rhythm with hemodynamic changes? would anyone contemplate elective cardioversion with some ketamine or the like for comfort? Does anyone have experience pacing over PVC's if the heart rate drops low enough with hemo instability?

Do we have a high enough suspicion that antiobiotics and fluid are going to fix this underlying rhythm before it deteriorates or her BP drops to low or is this something that needs to be dealt with outside of fixing the possible sepsis?

 

[Christopher]

This ECG was not the actual ECG, just basically exactly like it, I had trouble getting a quality scan so I just searched for something that would get the gist across.

It's ok. I have an uncanny knack for remembering tracings...

 

[KellyBracket]

\...
Do any hospitals near you use Adenosine as a reset for this type of rhythm with hemodynamic changes? would anyone contemplate elective cardioversion with some ketamine or the like for comfort? Does anyone have experience pacing over PVC's if the heart rate drops low enough with hemo instability?

Do we have a high enough suspicion that antiobiotics and fluid are going to fix this underlying rhythm before it deteriorates or her BP drops to low or is this something that needs to be dealt with outside of fixing the possible sepsis?

If it's sepsis, it's fluids, antibiotics, pressors, intubation, and source control (e.g., if it's an infected gallbladder it gets yanked or drained, if a PICC looks like the source, it gets pulled...).

If this ECG is a fair representation of what you saw, then no specific therapy is indicated. Bigeminal PVCs are a stable rhythm, and it takes a fair stretch of the imagination to picture them causing a problem. So, no to adenosine/cardioversion/pacing/amio/what have you.

The apparently stable and chronic severe hypoxemia makes me wonder if the patient has pulmonary fibrosis of some sort. (Not cystic fibrosis, different.) I wonder, however, if the preliminary diagnosis of pyelo is correct. The presentation may have evolved, even over 3 hours.

 

[BlogAuthor]

You stole this from my blog without attribution

This case is stolen from Dr Smith's ECG Blog:
From my case of polymorphic VT. I would post the link but this site will not let me.

EDIT: This ECG is from a case on Dr. Smith's ECG Blog. See the case here

 

[Brandon O]

Truly asking here - why isn't this an example of "STEMI-seen-in-PVC?" The ST elevation in the PVCs in lead II exceeds 25% of the preceding S wave.

My doubt is because the STE in some leads seems to be an artifact -- those aren't the actual J points. If you measure off the QRS via the narrowest leads and use that to look at the rest, there's little ST change if any -- the bizarre T waves seem to be a result of what looks, to me, like buried P waves.

Also, as Dr. Smith notes, the alternating narrow beats lack matching ST/T changes (or in some leads even appear to be deflected opposite). So it's a bit hard to draw a pattern here.

This ECG was not the actual ECG, just basically exactly like it, I had trouble getting a quality scan so I just searched for something that would get the gist across.

I understand the tendency to cut corners when it comes to educational purposes -- probably everybody has thrown an image into a PowerPoint that they found on Google -- but please try to understand that for situations like this, there are people who make their livelihood and/or have dedicated hundreds of hours of their lives to producing free online medical content. Most of the time they don't mind its reuse, especially if they don't make money on it, but I think using it without attribution is always upsetting... for the same reason as when someone plagiarizes an essay -- they're passing off your work as their own, even if unintentionally. Just attribute your sources, even when using things for mere illustration, and that usually does the trick.

This was an actual patient I had on Sunday.

I'm curious if you have this patient in your care in excess of an hour are we hanging a pressor if non responsive to fluid therapy? Do any hospitals near you use Adenosine as a reset for this type of rhythm with hemodynamic changes? would anyone contemplate elective cardioversion with some ketamine or the like for comfort? Does anyone have experience pacing over PVC's if the heart rate drops low enough with hemo instability?

In general I would say that a rhythm like this should never be cardioverted, whether chemically or electrically. It would not be indicated. There's no reentrant pathway to interrupt, and it's organized so if you "reboot" there's little reason to think you'll end up with anything different. Transcutaneous pacing wouldn't be appropriate either as it's not a bradycardia.

I could be wrong but I doubt the hypotension and lethargy are due to the rhythm. (They could be due to a shared underlying cause such as MI.) It is at least regular and at a decent rate.

Question: what was the sat while in your care?

 

[Rialaigh]

I would like to apologize for my use of the EKG image with permission or attributing the work to the author. The rest of the scenario information was mine from a call ran very recently. I was looking for a EKG that represented what I saw and just grabbed the first one that looked good. I again would like to say I am sorry and will use this as a learning opportunity.


During the patient contact time her O2 sat never came above 62% for me, good waveform with minimal trouble breathing. I kept her on a nasal canula at 4L, Really her only complaint during transport was her flank pain and generalized weakness.

 

[BlogAuthor]

Thanks for the apology. Totally accepted!!
Steve Smith

 

[NomadicMedic]

Dr Smith, I know I speak for all of us (including the moderators) when I say we'd love to have you post more and share cases with us.

 

[Brandon O]

During the patient contact time her O2 sat never came above 62% for me, good waveform with minimal trouble breathing. I kept her on a nasal canula at 4L, Really her only complaint during transport was her flank pain and generalized weakness.

If accurate, this would be absolutely the lowest sat I've ever heard of in a patient with no respiratory complaints. Not sure the literature on this but it's certainly impressive...

 

[Rialaigh]

If accurate, this would be absolutely the lowest sat I've ever heard of in a patient with no respiratory complaints. Not sure the literature on this but it's certainly impressive...

Yeah, we have picked this lady up multiple times and she is just a ticking time bomb. The irony (if you can call it that) is that she never calls for a respiratory complaint. It's always weakness, falls, stroke symptoms, abd pain, back pain...etc...etc..etc..

Everytime out there have had trouble getting anything over 62-65% tops. Hospital gets the same sats and she always comes back with a midly elevated CO2 on her ABG but nothing to call home about.

 

[Brandon O]

Everytime out there have had trouble getting anything over 62-65% tops. Hospital gets the same sats and she always comes back with a midly elevated CO2 on her ABG but nothing to call home about.

Normal pO2 on the ABG or no?

 

[Rialaigh]

Normal pO2 on the ABG or no?

high 70's if I recall correctly, nothing ever was real crazy...Its just weird though, perfect wave form on the SPO2, good radial pulses, warm hands...same thing over and over