# EKG Interp/scenario take 2



## tah06090 (Feb 18, 2011)

here we go 72 yr old female c/c CP ems is bls. 12 lead is done transmitted shows ST elevation II,III, avf with reciprocal changes laterally, 5 min from hospital pt has arrest cpr and defib x1 this is the 12 lead as shes being rolled in the ED


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## boingo (Feb 18, 2011)

Whats her K+?


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## tah06090 (Feb 18, 2011)

5.0 mEq/L is K, btw she is alert and oriented and in this rhythm


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## 18G (Feb 18, 2011)

An elderly female with CP and 12-lead showing inferior MI will get the standard ACS tx, cath lab alert, and if arrested standard ACLS.


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## reaper (Feb 18, 2011)

No right sided or 15 lead?


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## tah06090 (Feb 18, 2011)

no prehospital EKG pt was on continuous 12 lead she stated i dont feel right this is what the second 12 lead looked like


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## rhan101277 (Feb 18, 2011)

Vtach w/ pulses?  If stable try amiodarone 150mg over 10 mins, then maintenance infusion.

If she goes unstable then sync cardiovert.


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## socalmedic (Feb 18, 2011)

I would not call that V-tach. looks like V-fib to me. to the OP i dont understand what you are getting at. is there a question or is this just an FYI.


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## Hockey (Feb 19, 2011)

socalmedic said:


> I would not call that V-tach. looks like V-fib to me. to the OP i dont understand what you are getting at. is there a question or is this just an FYI.



This.


V-fib.  Shock, CPR and all the goodies.  Not vtach.  But does it even matter


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## MrBrown (Feb 19, 2011)

First ECG looks like some sort of wicked bundle branch block or hyperkalemia 

Second is either diagnostic mode VF or it's VT

If its VT Brown would cardiovert first and ask questions or hang amiodarone later


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## CANMAN (Feb 19, 2011)

Hockey said:


> This.
> 
> 
> V-fib.  Shock, CPR and all the goodies.  Not vtach.  But does it even matter




Ummmm the second 12 lead is clearly V-Fib, anyone who disagrees needs to repeat P-school.  As far as treatment modalities it certainly matter's if it was V-tac vs. V-fib, you could have a stable V-tac with pulses thus requiring no defib


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## Hockey (Feb 19, 2011)

CANMAN13 said:


> Ummmm the second 12 lead is clearly V-Fib, anyone who disagrees needs to repeat P-school.  As far as treatment modalities it certainly matter's if it was V-tac vs. V-fib, you could have a stable V-tac with pulses thus requiring no defib




Actually I thought I read somewhere that they went unresponsive and had no pulse.  But then again I was 4 sheets to the wind last night as well


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## CANMAN (Feb 19, 2011)

Damm 4 sheets to the wind, you treatments are still fairly on point :beerchug:


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## 18G (Feb 19, 2011)

I am confused by the whole scenerio. The first ECG posted and description given makes it sound like that ECG is post-arrest. Did u get the ECG's mixed up when u posted em?

The second one is definitly vfib. If the pt. had a pulse with vfib then she had a LVAD.


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## 8jimi8 (Feb 19, 2011)

I thought lvad doesn't have a palpable pulse??


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## reaper (Feb 19, 2011)

Most won't have a palpable pulse. But you would have to be blind, to not see an LVAD on them.


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## Aidey (Feb 19, 2011)

18G said:


> The second one is definitly vfib. If the pt. had a pulse with vfib then she had a LVAD.



Huh? That doesn't make any sense. 



8jimi8 said:


> I thought lvad doesn't have a palpable pulse??



Usually not, but there are some people with the older pulsating types that do have a "pulse".


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## 18G (Feb 20, 2011)

Aidy... ur right... that does not make ne sense... lol. I am well into a 44hr shift and spewed that out without thinking much abt it. It is def vfib but the LVAD comment is not correct. As mentioned most pts with LVAD dont have a pulse or one that is severely diminished. It is possible however, that a pt with a LVAD can have vfib and be walking and talking. I think that is where my comment evolved from.


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## tah06090 (Feb 20, 2011)

Ok to clear things up the first ECG is post arrest but the patient woke up aftter first defib and the second ECG is when she arrested again. This was just a interesting case i was sharing considering the patient kept waking up i have 2 more ECGs from this case to post, so patient was defib again and woke up heres what the 3rd ECG looks like pt was also given TNK at this point


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## Hockey (Feb 20, 2011)

tah06090 said:


> Ok to clear things up the first ECG is post arrest but the patient woke up aftter first defib and the second ECG is when she arrested again. This was just a interesting case i was sharing considering the patient kept waking up i have 2 more ECGs from this case to post, so patient was defib again and woke up heres what the 3rd ECG looks like pt was also given TNK at this point




And that is Vtach.


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## Hockey (Feb 20, 2011)

18G said:


> Aidy... ur right... that does not make ne sense... lol. I am well into a 44hr shift and spewed that out without thinking much abt it. It is def vfib but the LVAD comment is not correct. As mentioned most pts with LVAD dont have a pulse or one that is severely diminished. It is possible however, that a pt with a LVAD can have vfib and be walking and talking. I think that is where my comment evolved from.




Just wondering, if they have a LVAD and are in vfib, walking and talking, what is the proper treatment then?  Or are they going to be symptomatic? 

I've never ran into anyone with LVAD that I am aware of and never into a critical call.


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## socalmedic (Feb 20, 2011)

will a patinet with a LVAD in vfib will most likely not have very good coronary perfusion due to the insertion of the LVAD higher in the aorta regardless of systemic perfusion. I would treat as "unstable" v-fib.


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## Hockey (Feb 20, 2011)

socalmedic said:


> will a patinet with a LVAD in vfib will most likely not have very good coronary perfusion due to the insertion of the LVAD higher in the aorta regardless of systemic perfusion. I would treat as "unstable" v-fib.



Stupid question and I'll blame this on the excessive studying stress of having to retake it but...with unstable v-fib, that would be the same treatment as unstable vtach?  I mean v-fib is usually pulseless apneic patients that I have ran into


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## Shishkabob (Feb 20, 2011)

Vfib will ALWAYS be considered unstable, pulseless and apneac.  It's a non-perfusing rhythm.    Same algorhythm and essential treatment as pulseless vtach:  Shock fast.


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## socalmedic (Feb 20, 2011)

thats why i put "unstable" in quotations. the question was if the person IS perfusing but in v-fib, how do you treat.


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## Shishkabob (Feb 20, 2011)

Are they perfusing adequately?  


If so, I say that warrants a call to a doc.


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## tah06090 (Feb 20, 2011)

Alright time for a new EKG that last scenario pt eventually stabilzed and was flown to a PCI facility

let me know what you guys think of this


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## jjesusfreak01 (Feb 20, 2011)

Hmm, clear bigeminy with good P-waves prior to the PVCs (they appear to be from the same focus). Almost makes me want to say WPW or something else with secondary conduction pathways.

The only problem with this is that the beginning of the QRS complexes aren't slurred like I would expect. I would try to brady the patient down just to see what happens, but i'll stick with my original guess for now.

PS: Lack of ST change or Q waves makes me think that the v-fib and v-tach are results of a rhythm disturbance, not an infarction.


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## Aidey (Feb 20, 2011)

18G said:


> Aidy... ur right... that does not make ne sense... lol. I am well into a 44hr shift and spewed that out without thinking much abt it. It is def vfib but the LVAD comment is not correct. As mentioned most pts with LVAD dont have a pulse or one that is severely diminished. It is possible however, that a pt with a LVAD can have vfib and be walking and talking. I think that is where my comment evolved from.





Hockey said:


> Just wondering, if they have a LVAD and are in vfib, walking and talking, what is the proper treatment then?  Or are they going to be symptomatic?
> 
> I've never ran into anyone with LVAD that I am aware of and never into a critical call.




A LVAD is not a pacemaker, the patient must still have a perfusing rhythm to be alive. The LVAD only takes over for the left ventricle, so if the right ventricle isn't beating properly the whole system collapses. Someone with a LVAD may have slightly more blood circulating than someone without one, but not enough to support adequate perfusion. 

If you have someone with v-fib who is still walking and talking I suggest checking your monitor to make sure it is working properly 

If you had run into someone with a LVAD you would remember, people with them don't exactly travel lightly.


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## systemet (Feb 22, 2011)

Sinus tachycardia with bigeminal PVCs, possible lateral ischemia.

P waves @ 120/min

Every second complex is wide, occurs with a shorter PR than the previous normally-conducted complex, with a rightward axis.  Noncompensatory.  These are PVCs, probably originating somewhere in the LV.

Axis for the normally conducted beats is normal, around + 60, give or take a bit.

ST segments are isoelectric. Physiologic q wave in V1, possibly a small physiologic q in aVL (second normally-conducted complex, difficult to see).

T waves are mostly upright, with the exception of aVR (normal), aVL (clear inversion), possibly inverted / biphasic in I (but difficult to see, as the T waves are very small here).

Treatment depends on clinical condition.


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## jjesusfreak01 (Feb 22, 2011)

@systemet

Do you think the wide complex beats are really PVCs? That would be an easy guess if they weren't correlated with the p-waves, which is why I was considering trying a vagal maneuver to rule that out.


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## Handsome Robb (Feb 22, 2011)

I was leaning towards bigeminal PVCs as well seeing as all the intervals seem to be WNL, from what I can tell,but I was under the influence that a PVC covered the P wave...I haven't studied 12 leads very extensively though so take my opinion with a grain of salt.


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## systemet (Feb 23, 2011)

jjesusfreak01 said:


> @systemet
> 
> Do you think the wide complex beats are really PVCs? That would be an easy guess if they weren't correlated with the p-waves, which is why I was considering trying a vagal maneuver to rule that out.



I think they're PVCs.

(1) The SA node doesn't appear to be reset.  If they were PACs or PJCs, I'd expect the P-P interval around the ectopic to be lengthened. This would be a noncompensatory pause (I used the term incorrectly in my previous post --- where I should have said "compensatory").  The P wave morphology also appears identical.

(2) The PR interval for the ectopic is shorter than the PR interval for the previous normally conducting beat.  So if this is an aberrantly conducted beat originating in the atria, for some reason AV conduction is improved, at the same time that conduction through the bundle branches is reduced.

(3) The complex only comes a few ms early.  While it's possible to have rate-dependent BBB, and it's possible that every second beat could be conducted aberrantly, I don't think this is too likely.

I'm sure someone could take a look at the Brugada criteria for VT versus aberrancy and compare the morphology of the PVCs.  I could even be that somebody -- but I'm not sure I want to go and look that stuff up.  I just don't keep it in the back of my head


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## jjesusfreak01 (Feb 23, 2011)

systemet said:


> 2) The PR interval for the ectopic is shorter than the PR interval for the previous normally conducting beat.  So if this is an aberrantly conducted beat originating in the atria, for some reason AV conduction is improved, at the same time that conduction through the bundle branches is reduced.
> 
> (3) The complex only comes a few ms early.  While it's possible to have rate-dependent BBB, and it's possible that every second beat could be conducted aberrantly, I don't think this is too likely.



Right, I wasn't suggesting rate dependent BBB, I was thinking LGL or WPW with possibly a slowly repolarizing AV node or bundle branches (allowing for every other beat to be conducted normally). If it was the AV node that was slow, then it could be either of these, but if it was a bundle branch with slow repolarization it would need to be WPW, because LGL conduction pathways don't bypass the bundle branches. Although I agree this would be unlikely, it explains your #2 bullet point almost completely. I think that PVCs in rhythm with the normal beats and P waves is equally unlikely.


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## systemet (Feb 24, 2011)

jjesusfreak01 said:


> Right, I wasn't suggesting rate dependent BBB, I was thinking LGL or WPW with possibly a slowly repolarizing AV node or bundle branches (allowing for every other beat to be conducted normally). If it was the AV node that was slow, then it could be either of these, but if it was a bundle branch with slow repolarization it would need to be WPW, because LGL conduction pathways don't bypass the bundle branches.



So, you're suggesting it could be either:

- WPW, where one atrial depolarisation passes through the accessory pathway, and one atrial depolarisation passes through the AV node, due to variable conduction in either the accessory pathway or the AV node

OR

- LGN, with every second excitation passing through a BBB system with delayed conduction?

I hope I represented what you were saying accurately.  WPW is possible -- but the abnormal complexes have inverted T waves.  I'm not sure how many cases of WPW present with altered ventricular repolarisation (I really don't know).  With LGN, typically the QRS is narrow, as I'm sure you're aware, but if there's aberrant conduction through the bundle branches, it could become wider.

Both possibilities rely on one atrial depolarisation passing through the AV node, and a subsequent depolarisation passing through an accessory pathway.  Again, I'm not sure how frequently this happens.



> Although I agree this would be unlikely, it explains your #2 bullet point almost completely. I think that PVCs in rhythm with the normal beats and P waves is equally unlikely.



Yeah. I really don't know.  I'd have to do some reading to have a more informed opinion about that.  I would have thought that bigeminal PVCs would be much more likely, but I may be wrong.

BTW, this is an awesome site.


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## jjesusfreak01 (Feb 24, 2011)

systemet said:


> Yeah. I really don't know.  I'd have to do some reading to have a more informed opinion about that.  I would have thought that bigeminal PVCs would be much more likely, but I may be wrong.



I agree bigeminal PVCs would be more likely, which is why I would try a vagal maneuver to see if the PVCs separate from the P-waves.


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## systemet (Feb 25, 2011)

jjesusfreak01 said:


> I agree bigeminal PVCs would be more likely, which is why I would try a vagal maneuver to see if the PVCs separate from the P-waves.



I get the idea behind this -- and the idea is good.  I'm just not sure doing vagal maneuvers here is going to be safe.  If the ventricles are already irritable, and you suppress the sinus node / AV conduction, an ectopic could become some VT.  

Just a thought.

If the patient's asymptomatic (granted we have no clinical info here), we're not going to treat anyway, beyond perhaps a nasal cannula.


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## systemet (Feb 25, 2011)

systemet said:


> I get the idea behind this -- and the idea is good.  I'm just not sure doing vagal maneuvers here is going to be safe.  If the ventricles are already irritable, and you suppress the sinus node / AV conduction, an ectopic could become some VT.
> 
> Just a thought.
> 
> If the patient's asymptomatic (granted we have no clinical info here), we're not going to treat anyway, beyond perhaps a nasal cannula.



Sorry, I just realised that the way I wrote that sounds a little condescending.  I didn't mean it to come across that way.


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## socalmedic (Feb 25, 2011)

@ systemet, good interpretation you have been studying lately and i like that. however i have one question, maby i missed it, but how are you explaining the the P-waves in front of your "PVC". I think in this case leaving it as Bundle conduction delay would be more appropriate than trying to truly define it. what we have is a wide complex rhythm which came after V-FIB and V-TACH yea the 12 lead is not going to be normal after that... wait 30min to an hour and see what it is then i guarantee it will be different.

here if you have a ventricular rhythm with ROSC you go to the cath lab, and i believe we have found occlusions in 100% of our patients meeting these requirements.

please i am not being a smart ***, but after an arrest there is going to be ischemic, and altered conduction. you have to take the 12 lead at face value and treat you patient. 

notice: please disregard any spelling or grammatical errors i dont feel like editing right not


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## systemet (Feb 25, 2011)

socalmedic said:


> @ systemet, good interpretation you have been studying lately and i like that.



Sort of.  I've been out of the field for a couple of years, going to school.  Now I'm thinking about going back to working as a paramedic in a year.  It seemed like a good idea to start reviewing things before that! 



> however i have one question, maby i missed it, but how are you explaining the the P-waves in front of your "PVC".



P waves arise (probably in the ventricles), transmit to the AV node, and undergo AV delay.  Around the same time, an ectopic focus in the ventricles fires, creating a PVC.  The SA-initiated depolarisation never passes the AV node, the impulse that originates in the ventricles depolarises them, but is blocked from (retrogradely) propagating into the atria by the AV node.

So we see the P wave, as the atria depolarise, but the wide complex that follows originates from an ectopic ventricular focus.  



> I think in this case leaving it as Bundle conduction delay would be more appropriate than trying to truly define it.



It might be.  It's a possibility.  Distinguishing ventricular complexes / rhythms from aberrantly conducted sinus/atrial/junctional rhythms is difficult.



> what we have is a wide complex rhythm which came after V-FIB and V-TACH yea the 12 lead is not going to be normal after that... wait 30min to an hour and see what it is then i guarantee it will be different.



I thought this was a new patient?  Is this the same patient from the previous ECGs?

This is still a sinus rhythm.

If this is a post-arrest ECG, I agree, there's a good chance it will look different in a while.  Treating arrhythmias in the post-arrest period can often cause more problems than it fixes.  Without knowing the clinical state of the patient, it's impossible to decide on treatment.



> here if you have a ventricular rhythm with ROSC you go to the cath lab, and i believe we have found occlusions in 100% of our patients meeting these requirements.



Really?  

Perhaps I'm misunderstanding what you've written -- but it sounds like you're saying all of your patients with post-arrest VT have had coronary occlusions on angiography?  Is this published anywhere? How many patients is 100%?




> please i am not being a smart ***, but after an arrest there is going to be ischemic, and altered conduction. you have to take the 12 lead at face value and treat you patient.



Absolutely.  I'm not trying to be a d**k either.  I agree post-arrest 12-leads may show ischemic changes.  I also get that changes on the ECG need to be evaluated on the basis of the patient's clinical condition.  

I realise I'm a little rusty, but I do have a little experience.  This isn't my first walk in the park 



> notice: please disregard any spelling or grammatical errors i dont feel like editing right not



No problem. Please do the same!


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## socalmedic (Feb 25, 2011)

systemet said:


> Really?
> 
> Perhaps I'm misunderstanding what you've written -- but it sounds like you're saying all of your patients with post-arrest VT have had coronary occlusions on angiography?  Is this published anywhere? How many patients is 100%?



no what I am saying is that if the initial rhythm is VF/VT and we get pulese back they go to the cath lab (by protocol). it is a small couldn't so there aren't any published studys, yet. we had 25 saves of 78 arrests with initial rhythm VF/VT, all 25 had stints placed in the cath lab.


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## Rykielz (Mar 3, 2011)

Those are clearly PVC's. I wouldn't even waste my time trying to vagal them down with a HR of 120 (not that you would even want to), which I'm assuming the PVC's are perfusing ones. I'd immediately get an IV and hang a bag of 150 mg of Amiodarone over 10 min and get them going to a hospital.


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## TomB (Mar 6, 2011)

socalmedic said:


> no what I am saying is that if the initial rhythm is VF/VT and we get pulese back they go to the cath lab (by protocol). it is a small couldn't so there aren't any published studys, yet. we had 25 saves of 78 arrests with initial rhythm VF/VT, all 25 had stints placed in the cath lab.



AHA Policy Statement: Regional Systems of Care for Out-of-Hospital Cardiac Arrest

"Up to 71% of patients with cardiac arrest have coronary artery disease, and nearly half have an acute coronary occlusion.48–50 There is a high incidence (97%) of coronary artery disease in patients resuscitated from OOHCA who undergo immediate angiography and a 50% incidence of acute coronary occlusion.48 However, the absence of ST elevation on a surface 12-lead electrocardiogram after resuscitation of circulation from cardiac arrest is not strongly predictive of the absence of coronary occlusion on acute angiography.48 A case series of patients with unsuccessful field resuscitation suggested that in such patients, VF is more likely to be due to coronary disease than is asystole or pulseless electric activity.51 [...] these studies suggest that patients who are resuscitated from out-of-hospital VF have a high likelihood of having an acute coronary occlusion."


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## socalmedic (Mar 7, 2011)

thanks tom


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## tah06090 (Mar 7, 2011)

time for a new one 

83 yr  old male AMS


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## Firemanfred55 (Mar 7, 2011)

tah06090 said:


> here we go 72 yr old female c/c CP ems is bls. 12 lead is done transmitted shows ST elevation II,III, avf with reciprocal changes laterally, 5 min from hospital pt has arrest cpr and defib x1 this is the 12 lead as shes being rolled in the ED


First EKG V-tach with ST elevations. Solution ACLS
Second EKG V-fib. Solution CPR, call coroner.


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## Firemanfred55 (Mar 7, 2011)

MrBrown said:


> First ECG looks like some sort of wicked bundle branch block or hyperkalemia
> 
> Second is either diagnostic mode VF or it's VT
> 
> If its VT Brown would cardiovert first and ask questions or hang amiodarone later


LOL
Brown why can't I get your stains out of my boxer.
lol all in good fun.


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## Merck (Mar 8, 2011)

There's something you shouldn't see - a 12 lead of VF.


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## socalmedic (Mar 8, 2011)

maby the 12 lead was already on when he went into v-tach. i would not have taken the time to do more than the std 4 lead in a symptomatic VT. he would have been riding the lightning, edison medicine, aka synchronized cardioversion. then prophylactic lidocaine or amio.


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## sihi (Mar 21, 2011)

45.

It is most likely supraventricular rhytm + LBBBB. Maybe hyperkalemia, maybe MI. 

If he has chest pain/stenocardia, you should treat him like MI.
Of sublinqual Nitro doesnt stop pain:
-Nitroglycerin IV
-Morphine
-Ac.sal. acid
-Metoprolol or Amiodarone


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