# 88 y/o female with palpitations



## zzyzx (Aug 24, 2015)

Here's a tricky ECG for you. To be honest, I was really annoyed the other night because I could not figure it out until an ED doc explained it.

88 y/o female c/o palpitations, otherwise asymptomatic. All her vital signs are stable. She says this has happened to her before and that it is "my A fib acting up."

This is what you first see on the monitor (see image): a wide-complex tachycardia, regular and with no variation of the heart rate of 155. 

(12 lead to follow later).


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## zzyzx (Aug 24, 2015)

The image is upside down. Not sure why that happened.


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## MonkeyArrow (Aug 24, 2015)

While the rate technically qualifies it as an SVT, it certainly does not look like your normal one. The strip almost looks like R-on-T phenomenon. I eagerly await more info and the 12 lead.


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## EMT11KDL (Aug 25, 2015)

I am waiting patiently for the 12 lead with monkey.  but first thing I would do seeing that is check my leads/wires/connections because that would not be what I would be expecting to see from the short description you gave.


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## Gurby (Aug 25, 2015)

Well, it's not her AFib acting up... (or is it?)

Garcia says that when you see a rate of exactly 150, consider AFlutter with 2:1 conduction.  Given history of AFib, she might be on calcium channel blockers or have AV node pathology that could maybe help cause this... Wide complex due to aberrant conduction maybe - bundle branch or hemiblock?

It would be interesting to know her relevant cardiac history/meds, see old EKG's, etc.


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## zzyzx (Aug 25, 2015)

Here is the first ECG...


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## zzyzx (Aug 25, 2015)

You will have to rotate the file after you open it. I'm not sure why it keeps getting uploaded like this.


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## Gurby (Aug 25, 2015)

I think I stand by my first guess.  The P waves look a bit sawtoothy, and the PR interval is so short at times that it feels like there could be another P wave buried in the previous QRS that is the one that actually gets through.  Or not.


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## MackTheKnife (Aug 26, 2015)

Rate is 150 and concur with aberrant conduction.


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## teedubbyaw (Aug 26, 2015)

Can't see the 12 lead but at a rate of exactly 150 you have to consider aflutter


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## zzyzx (Aug 27, 2015)

After diltiazem push....


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## teedubbyaw (Aug 27, 2015)

Damn your sideways ekg's. 

Why cardizem?


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## zzyzx (Aug 27, 2015)

You can rotate the image after you upload it. Sorry, don't know why it up loads rotated like that.


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## triemal04 (Aug 27, 2015)

teedubbyaw said:


> Can't see the 12 lead but at a rate of exactly 150 you have to consider aflutter





teedubbyaw said:


> Why cardizem?


Uh...does not compute...


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## teedubbyaw (Aug 27, 2015)

Asymptomatic. Does not compute.


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## Gurby (Aug 27, 2015)

Still standing by my previous guess of AFlutter with 2:1 conduction.  Now that you've given her a Ca channel blocker you're further messing with the AV node, causing it to flip around to 2:1 or 3:1.  

Kind of concerned about v1 and v2 though.  It could either be rate-induced ischemia, or maybe ischemia happened first and affected the AV node, causing this arrhythmia?


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## Aprz (Aug 27, 2015)

teedubbyaw said:


> Damn your sideways ekg's.
> 
> Why cardizem?





teedubbyaw said:


> Asymptomatic. Does not compute.





zzyzx said:


> 88 y/o female *c/o palpitations*, otherwise asymptomatic. All her vital signs are stable. She says this has happened to her before and that it is "my A fib acting up."


She was symptomatic. I kinda find it confusing when people say the patient is complaining of _____, otherwise asymptomatic. People usually miss the part before the asymptomatic part even when the report is verbal.

I agree with what others have said about it being atrial flutter. It looks like 2:1 atrial flutter prior to cardizem administration and 4:1 atrial flutter post cardizem administration. The rate of 150 prior to cardizem and 75 with visible flutter waves in the inferior leads II, III, and aVF supports this. Fibrillation can look like p-waves or flutter waves, but I measured atrial activity / flutter waves rate to be 300 supporting atrial flutter. Atrial fibrillation can look regular at a high rate, but this is obviously regular even at a slow rate. Atrial fibrillation can become regular and slow with digoxin.


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## zzyzx (Aug 27, 2015)

Yup, A flutter with 2:1 conduction. Nice job guys! For a long while after the CCB, she bounced around between AF, AF 2:1, and AF 4:1, until settling down to AF at a normal rate. She was given PO diltiazem as well.


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## teedubbyaw (Aug 27, 2015)

Are palpitations a reasonable symptom to push cardizem w/ a rate of 150? Meh. Is a rate of 150 high for an 88 y/o? Meh. Does she have a prescription for a CCB? Probably. Let a cardiologist dig deeper.


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## zzyzx (Aug 27, 2015)

Sorry but I have to strongly disagree with you on not providing treatment


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## zzyzx (Aug 27, 2015)

.


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## zzyzx (Aug 27, 2015)

edit


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## teedubbyaw (Aug 27, 2015)

Hey, you're the one describing her as asymptomatic. If you felt she was asymptomatic, again, why cardizem? I'm not knocking treatment, but I'm asking why.


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## Aprz (Aug 27, 2015)

teedubbyaw said:


> Are palpitations a reasonable symptom to push cardizem w/ a rate of 150? Meh. Is a rate of 150 high for an 88 y/o?


I have no idea. I would like to learn more about diltiazem (cardizem).

I believe it can also be given to treat atrial fibrillation with rapid ventricular response and fascicular ventricular tachycardia. It seems reasonable to me to administer it to treat a symptom caused one of those cardiac arrhythmias. I guess we should be thankful it is not in my scope, haha. Hopefully I knew more about it if it was in my scope of practice.

What's your threshold for diltiazem administration. Seems like that's something you'd administer to somebody symptomatic (eg palpation), but stable versus somebody who is hemodynamically unstable or at risk of rapidly deteriorating (eg rate of 300 with 1:1 atrial flutter).

I believe it comes packaged as 125 mg in 125 mL. I think you give it as 5 mg/hr and decrease/increase it in 2.5-5 mg/hr increments. I have no idea how to bolus it.

@teedubbyaw I don't think it was him who gave the cardizem. I thought it was the physician at the ER?

@zzyzx On the EKG Club on Facebook, we remove the name *and date* of the EKG. If it is not removed, they delete it. Although this isn't the EKG Club, I think it would be good to get into the habit of that. They do it in case there is anybody who is super old that would narrow down who it is with the help of the date I think.


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## triemal04 (Aug 28, 2015)

teedubbyaw said:


> Asymptomatic. Does not compute.


Meh...I suppose that depends on how you feel about the fact that she has palpitations or how long she'll sustain a fast rate with minimal atrial kick (could be a long time, or it might not be)  Or if you prefer to treat the problem or let others take care of it for you; honestly a very acceptable decision in some circumstances.  This lady though...barring a non-cardiac cause for her tachycardia...she get's treated.


Gurby said:


> Still standing by my previous guess of AFlutter with 2:1 conduction.  Now that you've given her a Ca channel blocker you're further messing with the AV node, causing it to flip around to 2:1 or 3:1.
> 
> Kind of concerned about v1 and v2 though.  It could either be rate-induced ischemia, or maybe ischemia happened first and affected the AV node, causing this arrhythmia?


And?  Why is this concerning to you?  Both the change in conduction, which would be expected with the use of a calcium channel or beta-blocker, and the clear left ventricular hypertrophy?


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## triemal04 (Aug 28, 2015)

Aprz said:


> I have no idea. I would like to learn more about diltiazem (cardizem).
> 
> I believe it can also be given to treat atrial fibrillation with rapid ventricular response and fascicular ventricular tachycardia. It seems reasonable to me to administer it to treat a symptom caused one of those cardiac arrhythmias. I guess we should be thankful it is not in my scope, haha. Hopefully I knew more about it if it was in my scope of practice.
> 
> ...


Serious question:  are you really a paramedic?


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## Aprz (Aug 28, 2015)

My education is paramedic. I work as an EMT. My paramedic certification is pending.


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## zzyzx (Aug 28, 2015)

@Aprz....thanks for your reply. To answer your question, diltiazem is the go-to drug for AF and A flutter, but the best way to answer your question in more detail is to simply direct you to Google the drug. Wikipedia is actually a fairly good resource, but you should research it further. Allnurses.com is a good resource as well as the nurses on that site have hands-on experience of using the medication.

I'll have to check out that Facebook ECG page.


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## Tigger (Aug 28, 2015)

triemal04 said:


> Serious question:  are you really a paramedic?


More than a phew places out there that don't carry diltiazem, if they carry a calcium channel blocker at all...


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## Aprz (Aug 28, 2015)

No calcium channel blockers here or in adjacent areas.


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## Gurby (Aug 28, 2015)

triemal04 said:


> And?  Why is this concerning to you?  Both the change in conduction, which would be expected with the use of a calcium channel or beta-blocker, and the clear left ventricular hypertrophy?



I was concerned about the ST elevation in v1 and v2, but you're right, this is a perfect textbook case of LVH with strain - I'm angry that I missed that!  She meets the v1or2 + v5or6 > 35mm criteria, and if not for the flutter wave buried in the T waves in the lateral leads the morphology would be textbook.



zzyzx said:


> Sorry but I have to strongly disagree with you on not providing treatment



Regarding treatment, I don't think there's any question that she should be treated - the question is whether we as EMT's should be doing it in the field with a 10min/30min/1hr transport time  (by the EKG's you posted, it looks like here she was .  My protocols say I can give diltiazem if heartrate is greater than 150, patient is symptomatic but stable.  So she does meet the criteria, but I'd like to know more of her medical history and medications before making that call.

If she is prescribed diltiazem or a similar drug I probably push it happily.  If her symptoms are chest pain, SOB, etc, rather than "palpitations, this happens sometimes it's just my AFib acting up", I'm a lot more eager to push it.

I'm definitely going to keep a close eye on her, but with a transport time under 15 minutes or so and patient as described, I probably just start a line, saline KVO (careful of fluid overload), repeat 12-lead en route, make sure I know about it right away if her symptoms change.  If we're 20+ minutes out from the hospital, I think I lean more towards treating.  How long this has been going on factors in, too - if it started 12 hours ago I'm less concerned than I would be if she just felt it start 15 minutes ago and called 911.

Do you agree/disagree with that reasoning?


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## triemal04 (Aug 28, 2015)

Tigger said:


> More than a phew places out there that don't carry diltiazem, if they carry a calcium channel blocker at all...





Aprz said:


> My education is paramedic. I work as an EMT. My paramedic certification is pending.


Not really implying anything, just curious is all.  Cardizem/diltiazem is a very basic, common medication.  It's so common in fact that it is, and has been for some time, part of ACLS.  I know there are places that don't use it; I just find it curious that someone who should have taken ACLS, is a paramedic, and has a high interest in EKG's doesn't know the basics about a standard drug that is used to treat cardiac arrhythmia's.


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## Carlos Danger (Aug 28, 2015)

150 is very fast for an 88 y/o. 

I would treat that even if asymptomatic.


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## triemal04 (Aug 28, 2015)

Gurby said:


> I was concerned about the ST elevation in v1 and v2, but you're right, this is a perfect textbook case of LVH with strain - I'm angry that I missed that!  She meets the v1or2 + v5or6 > 35mm criteria, and if not for the flutter wave buried in the T waves in the lateral leads the morphology would be textbook.



Beware of imitators!  The big bad imitators!    Also, while you absolutely should not use the computer's interpretation as gospel and base your plan off of it (IF, and that's a big IF, if you are competant at interpreting 12-leads that is) I don't see anything wrong with using it as a second opinion if you are working alone; just don't let it sway you if it doesn't make sense.  In the same vein, it's worth trying to figure out why it comes up with the conclusions it does; could be that you missed something, or could be due to an error, but worth thinking about.  In this case, bet that would have been the nudge to remember that LVH can cause benign elevation.



> Regarding treatment, I don't think there's any question that she should be treated - the question is whether we as EMT's should be doing it in the field with a 10min/30min/1hr transport time  (by the EKG's you posted, it looks like here she was .  My protocols say I can give diltiazem if heartrate is greater than 150, patient is symptomatic but stable.  So she does meet the criteria, but I'd like to know more of her medical history and medications before making that call.
> 
> If she is prescribed diltiazem or a similar drug I probably push it happily.  If her symptoms are chest pain, SOB, etc, rather than "palpitations, this happens sometimes it's just my AFib acting up", I'm a lot more eager to push it.
> 
> ...


Like I said, this lady, barring a non-cardiac cause for her tachycardia, should get treated.  Are you WRONG to not do so?  No, not really, but I wouldn't say that it is the best option.  She's mildly symptomatic; if she were truly asymptomatic, you wouldn't be there, and her rate is higher than it should be.  High enough to cause problems on it's own?  Depends on the specific person but maybe not, at least not in the short-term; medium term or long-term is a different story.  But, she also has lost her atrial kick due to the fib/flutter, which, coupled with less ventricular filling time due to the tachycardia could cause her to have problems quicker than if she was in a sustained sinus tachycardia for one reason or another.  A slower ventricular rate would be beneficial in this instance.  It's also worth taking into account how long you think she'll maintain herself, AND how long it'll take for the ER to start their treatement.

For me, she get's treated.

For someone who doesn't and has GOOD reasons not to...maybe not wrong, but not really right either.


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## teedubbyaw (Aug 28, 2015)

triemal04 said:


> Beware of imitators!  The big bad imitators!    Also, while you absolutely should not use the computer's interpretation as gospel and base your plan off of it (IF, and that's a big IF, if you are competant at interpreting 12-leads that is) I don't see anything wrong with using it as a second opinion if you are working alone; just don't let it sway you if it doesn't make sense.  In the same vein, it's worth trying to figure out why it comes up with the conclusions it does; could be that you missed something, or could be due to an error, but worth thinking about.  In this case, bet that would have been the nudge to remember that LVH can cause benign elevation.
> 
> 
> Like I said, this lady, barring a non-cardiac cause for her tachycardia, should get treated.  Are you WRONG to not do so?  No, not really, but I wouldn't say that it is the best option.  She's mildly symptomatic; if she were truly asymptomatic, you wouldn't be there, and her rate is higher than it should be.  High enough to cause problems on it's own?  Depends on the specific person but maybe not, at least not in the short-term; medium term or long-term is a different story.  But, she also has lost her atrial kick due to the fib/flutter, which, coupled with less ventricular filling time due to the tachycardia could cause her to have problems quicker than if she was in a sustained sinus tachycardia for one reason or another.  A slower ventricular rate would be beneficial in this instance.  It's also worth taking into account how long you think she'll maintain herself, AND how long it'll take for the ER to start their treatement.
> ...



So, she's in a period of afib/aflutter again. Are you seeing any clinical signs of her diminished atrial kick? Will you in an hour from now? And again, is 150 'really' high for an 88yo?

When I worked in a cardiac monitoring facility tracing ekg's of at home pt's, this was one of the most common things to see, and very rarely would a pt become symptomatic. Missed medication dosages were a big cause. Rhythm would reset and the pt would go back to watching TV. I don't like seeing rates that high in an 88yo, but it's not a red flag in this particular pt as far as I can gather.

5 minute transport time, I'll get the best history I can for the doc and not push cardizem. When I'm an hour from the hospital, she'll get drugs pushed.


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## triemal04 (Aug 30, 2015)

teedubbyaw said:


> So, she's in a period of afib/aflutter again. Are you seeing any clinical signs of her diminished atrial kick? Will you in an hour from now? And again, is 150 'really' high for an 88yo?
> I know what I think; it's why I would treat this lady.  What do YOU think, and WHY?
> 
> When I worked in a cardiac monitoring facility tracing ekg's of at home pt's, this was one of the most common things to see, and very rarely would a pt become symptomatic. Missed medication dosages were a big cause. Rhythm would reset and the pt would go back to watching TV. I don't like seeing rates that high in an 88yo, but it's not a red flag in this particular pt as far as I can gather.
> ...


Replies in red.  

Everyone reading this gets to make the decision about what type of paramedic they want to be.  There certainly are times when it is more appropriate to NOT treat someone in the field even though you technically can...and there are certainly times when it IS appropriate, even if that means you need to dig a little further.  The choice falls to the individual.


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## Gurby (Aug 30, 2015)

triemal04 said:


> How long do you think it'll be once she reaches the ER before she get's the appropriate med?



This is something I should consider more often - sometimes it takes the doctor a while to come see the patient, and even longer for the nurses to come treat.


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## teedubbyaw (Aug 30, 2015)

triemal04 said:


> Replies in red.
> 
> Everyone reading this gets to make the decision about what type of paramedic they want to be.  There certainly are times when it is more appropriate to NOT treat someone in the field even though you technically can...and there are certainly times when it IS appropriate, even if that means you need to dig a little further.  The choice falls to the individual.



I like how you turn a constructive discussion into putting words into my mouth. Yes, benign and let someone else deal with it is how I roll. 

tootles.


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## triemal04 (Aug 31, 2015)

teedubbyaw said:


> I like how you turn a constructive discussion into putting words into my mouth. Yes, benign and let someone else deal with it is how I roll.
> 
> tootles.


I'm not putting words into your mouth, and if this isn't what you think by all means please explain what you do; in fact I even asked if you would do that in the last post.

So far you've said that the lady is asymptomatic, not having any type of red-flags, and that you wouldn't treat her.  If you DON'T think that this is a benign problem, could you elaborate more on what you think it is and WHY you wouldn't treat her?  All I can come up with so far from what you've said is because you've seen some people spontaneously convert.  And as you've said so that you wouldn't do it with a short transport time...apologies, but that does certainly sound like you are dumping the work onto someone else.

If you've got a different reason I'd love to hear it.


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## triemal04 (Aug 31, 2015)

Gurby said:


> This is something I should consider more often - sometimes it takes the doctor a while to come see the patient, and even longer for the nurses to come treat.


It's worth keeping in mind; even at the best ER's there will be a lag from when you arrive to when the patient actually starts being treated.  While it'll vary from place to place and will depend on what is going on/what needs to be done there will always be a gap.


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## teedubbyaw (Aug 31, 2015)

I asked you questions and you answered with questions. So, I'm not going to play that game with you. You don't want to back up what you're saying, then don't, but don't turn it into an attack on me. I already gave my stance.


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## triemal04 (Sep 1, 2015)

I've explained why I'd go with treating this, and with a basis beyond "The hospitals close and I've seen patients stop on their own."  I'm perfectly happy to do so again, or in more detail if that wasn't clear earlier.

Of course I asked you questions; I just don't understand your thought process.  At all.  Or you could say that I don't agree with what I can see of your thought process.  At all.  So I asked more questions so that it would be clearer.

If you don't want people questioning what you do...well...can't help you there.


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## teedubbyaw (Sep 1, 2015)

teedubbyaw said:


> you're the one describing her as asymptomatic. (OP)





teedubbyaw said:


> So, she's in a period of afib/aflutter again. Are you seeing any clinical signs of her diminished atrial kick? Will you in an hour from now? And again, is 150 'really' high for an 88yo?
> 
> 5 minute transport time, I'll get the best history I can for the doc and not push cardizem. When I'm an hour from the hospital, she'll get drugs pushed.



Yawn.


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## triemal04 (Sep 1, 2015)

Ok.  I think I do get it now.  As I said previously, you think that the lady is asymptomatic, not having any type of red-flags, and you won't treat her because you're close to the hospital.  And have no better reasoning than that apparently.

For anyone else reading this who might learn something:  apparently what is happening here is that it is recognized that there is a treatable problem, and it is recognized that the patient does in fact need treatment for that problem.  It is further recognized that this treatment can be delivered (safely) in the prehospital setting.  But the provider is not going to do it soley because they are close to the hospital, but would if they were further away.  There are times when it is certainly appropriate to take this line of thinking and do this; but there should be a good reason behind it.  If the decision to withhold treatment is only based on distance to the hospital, and not on the impact on the patient...you're doing it wrong.


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## teedubbyaw (Sep 1, 2015)

You're good at concluding complete and utter ********, aren't you? 

If your treatment is based on whether or not the patient will have a 'wait time' at the hospital, then you're doing it wrong.


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## zzyzx (Sep 2, 2015)

Teedubbyaw, if you had a 22 y/o who went into SVT five minutes before arriving at the ER, and who was totally stable, would you bring her into the ER in SVT?


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## teedubbyaw (Sep 2, 2015)

That's a blanket question. 

If I didn't have a 12 lead, IV access, and a good Hx, then chances are by the time I get that, we'll be at the hospital. A 'totally stable' 22yo can sustain tachycardia very well.


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## teedubbyaw (Sep 2, 2015)

P.S I have no idea what a blanket question is. lol


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## triemal04 (Sep 2, 2015)

I was going to say something else...but I don't see any reason to waste my time.  I'll just reiterate for anyone else reading this; everyone get's to make the decision on what kind of paramedic they want to be.  You can treat your patients in an appropriate manner, or you can dump your patients off on someone else and let them deal with it.  The choice is yours.

And with that, I'm out.


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## teedubbyaw (Sep 2, 2015)

Avoid questions with personal attacks. You're a real hero. Delay definitive care because you want to disperse your priorities poorly.


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## RocketMedic (Dec 27, 2015)

I'd treat it. Tachydysrhythmias become lethal quite quickly if left alone.


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## k9Dog (Dec 27, 2015)

Looks like stable v-tach, our treatment is amiodarone 150mg drip over 10 minutes. Put on defib patches in case it deteriorates


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## Doczilla (Dec 28, 2015)

Aprz said:


> I have no idea. I would like to learn more about diltiazem (cardizem).
> 
> I believe it can also be given to treat atrial fibrillation with rapid ventricular response and fascicular ventricular tachycardia. It seems reasonable to me to administer it to treat a symptom caused one of those cardiac arrhythmias. I guess we should be thankful it is not in my scope, haha. Hopefully I knew more about it if it was in my scope of practice.
> 
> ...



As with any drug, try to look at the underlying physiology you're working on. Drugs do either one or two things:

A) Block some type of physio, or 

B) Stimulate some type of physio

This is relevant because, (and this is really interesting to me) the atrium is the ONLY membrane in the entire body that uses calcium to depolarize. That immediately draws a line between the usage of sodium channel blockers and calcium channel blockers, because inversely,  the ventricles use sodium to depolarize. Atrial arrythmia? Block calcium. 

On a quick sidebar, students ask me all the time why paralytics don't kill patients due to arrythmia. Well, there's your answer there: the heart doesn't use AcH to depolarize like skeletal muscle does. 

You could almost draw a line right through the atrium and ventricles, and pick which antiarrythmic to use. The only work you've gotta do after that is interperet where the problem Is from the ECG! 

One last thing, we prefer cardizem to other CCB's, (nicardipine, amlodipine, etc), because of their selectivity. The amount of nicardipine needed to control an atrial arrythmia would tank their pressure into oblivion. 

Hope that helps!


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