# VTach on the 3 lead, bother doing a 12?



## NYMedic828 (Aug 1, 2012)

So a crew by me at a nearby station got restricted the other day.


I don't know the story other than by word of mouth but supposedly the had a patient with cardiac complaints. They made patient contact and upon assessment applied a 3 lead and noticed v-tach. (with pulses) They proceed to complete their assessment with a 12 lead before treatment. The monitor reads acute MI, my guess is it has trouble differentiating between vtach and a STEMI because it always misreads things, but I don't know.

Anyway, right after 12 lead patient goes into arrest.

The story ends with the patient surviving. I don't know any further details.


The crew gets restricted for not treating vtach immediately upon seeing it, on the basis of the rapid potential for vtach to decay into arrest. (which coincidentally happened)

So, my question is, if in the same situation would you treat what you think to be vtach, or further your assessment to be certain prior to treatment?


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## Aidey (Aug 1, 2012)

A 12 lead would be significantly helpful in determining if it was truly v-tach or SVT with abberancy. Since the treatment is the same for both when unstable, I probably would have tried to get a 12 lead while simultaneously setting up to cardiovert, and then cardioverted immediately after the 12 stopped staying "acquiring". 

Now if it took them 5 minutes to get the 12 lead after getting the 3 lead, I can understand the crew receiving some sort of remedial training.


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## NYMedic828 (Aug 1, 2012)

Aidey said:


> A 12 lead would be significantly helpful in determining if it was truly v-tach or SVT with abberancy. Since the treatment is the same for both when unstable, I probably would have tried to get a 12 lead while simultaneously setting up to cardiovert, and then cardioverted immediately after the 12 stopped staying "acquiring".
> 
> Now if it took them 5 minutes to get the 12 lead after getting the 3 lead, I can understand the crew receiving some sort of remedial training.



Yea, like I said I don't know the story in much detail.

I figured the same to ensure it is really Vtach, in the case of a concious patient we could also start an amio drip before resorting to zapping them.


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## Anjel (Aug 1, 2012)

NYMedic828 said:


> Yea, like I said I don't know the story in much detail.
> 
> I figured the same to ensure it is really Vtach, in the case of a concious patient we could also start an amio drip before resorting to zapping them.



Conscious maybe....but not unstable. By the time you set up the drip for an unstable conscious person, they could no longer be conscious. 

Now if their BP is good and mentation is ok. Then I would explore other options before zapping


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## Veneficus (Aug 1, 2012)

I can see why they got dinged for it. 

But I think it would be presuming a lot given the lack of info to determine if it was right or wrong.


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## NYMedic828 (Aug 1, 2012)

Yea I posted a pretty vague presentation.

I don't know as to the stability of the patient on arrival or anything for that matter.

Just mostly asking if a 12 lead is always indicated in these situations, which I felt it was but wanted second opinions.


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## Doczilla (Aug 1, 2012)

I guess what it really boils down to, for me at least is this: 

Will the 12 lead change my treatment? 

Do you run medic/medic in NYC? What about the firefighters? ALS? I suppose that could have made the difference between chosing one thing or the other , or accomplishing the 12 lead while also gaining IV access or applying fast patches. 

As far as EMPIRIC therapy in wide complex tachycardia on a 3 lead goes, the only time it'll really shoot you in the foot to give amiodarone was if you somehow confused the strip with WPW/A-fib. 

And that's conservative, even. Some would argue (including MD's ) that any degree of symtoms constitutes "instability" , and advocate skipping right to cardioversion. Even if it's "I feel funny." 

I do think that there is a deliniation between "unstable", and "pulseless", and i have a feeling that I'm not the only one on this forum who feels this way. 

Man, I hate playing Monday morning quarterback. Nobody likes 'em.


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## DesertMedic66 (Aug 1, 2012)

Is no one trying the Valsalva Maneuver before cardioversion anymore?


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## Doczilla (Aug 1, 2012)

Maybe for SVT. But once you progress into (assuming this is) V-tach, its out of the vagus nerve's hands.


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## NYMedic828 (Aug 1, 2012)

firefite said:


> Is no one trying the Valsalva Maneuver before cardioversion anymore?



NYC no longer advocates the usage of valsalva techniques.

We run dual medic/dual EMT. Assuming it came in as a cardiac, they would had a CFR engine dispatched with them as well.


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## Christopher (Aug 1, 2012)

NYMedic828 said:


> I don't know the story other than by word of mouth but supposedly the had a patient with cardiac complaints. They made patient contact and upon assessment applied a 3 lead and noticed v-tach. (with pulses) They proceed to complete their assessment with a 12 lead before treatment. The monitor reads acute MI, my guess is it has trouble differentiating between vtach and a STEMI because it always misreads things, but I don't know.
> 
> Anyway, right after 12 lead patient goes into arrest.
> 
> ...



Getting the 12-Lead is the right thing to do, especially if they have a pulse. (Not because I think we need to play the "can I give calcium channel blocker's" game with wide and fast)

Takes 90 seconds top. After the fact if they light him up or push an antiarrhythmic there will be something to look at in the ED other than a long Lead II.

If your patient is peri-arrest VT, then no light them up before the 12-Lead.

If they have palpable radials, get the 12-Lead.

I submit that if they're going to crump while you spent the time getting your 12-Lead, they were going to crump while you fiddle-farted with an IV too.


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## Christopher (Aug 1, 2012)

Doczilla said:


> Maybe for SVT. But once you progress into (assuming this is) V-tach, its out of the vagus nerve's hands.



I'd get them to try it, maybe even push adenosine if I wasn't sold on VT. Otherwise it's procainamide/lidocaine (or amiodarone/lidocaine, depending on the service) for me.


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## Doczilla (Aug 1, 2012)

Christopher said:


> Getting the 12-Lead is the right thing to do, especially if they have a pulse. (Not because I think we need to play the "can I give calcium channel blocker's" game with wide and fast)
> 
> Takes 90 seconds top. After the fact if they light him up or push an antiarrhythmic there will be something to look at in the ED other than a long Lead II.
> 
> ...



Just curious , have you encountered someone who legit wanted to give CCB's for wide complex? 

That's the dangerous thing about ACLS: if you don't understand the physiology of antiarrythmics , you might mix your algorithyms up


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## Christopher (Aug 1, 2012)

Doczilla said:


> Just curious , have you encountered someone who legit wanted to give CCB's for wide complex?
> 
> That's the dangerous thing about ACLS: if you don't understand the physiology of antiarrythmics , you might mix your algorithyms up



A number of people who have taken classes and think they can use a 12-Lead to determine SVT from VT reliably. I usually hear, "it's too fast for VT," or "VT can't have that axis," or "there wasn't concordance," or any number of other ridiculous statements.

In general the most egregious usages of CCB's are in patients where AF w/ WPW could be a possibility (i.e. R-R <260ms). Once while I was waiting on a bed for my patient I watched as another patient who received 40mg of diltiazem enroute to the hospital, was cardioverted into asystole, and thankfully resuscitated. AF w/ WPW believed to be "AF w/ a preexisting aberrancy".


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## Doczilla (Aug 1, 2012)

LOL. 

Something about seeing "cardioverted into asystole" tickles me. 

For those of you who may be wondering why I poked into this, its because many providers do not understand the cardiac action potential, and how it relates to antiarrythmics. The atrium depolarizes with calcium. The ventricles depolarize with sodium. 

This is why class I is uses for ventricular arrythmias, and class IV for atrial arrythmias.


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## Dwindlin (Aug 1, 2012)

Stable, yes get the 12-lead.  Unstable, no.  Would treat first then get a 12-lead if/when stabilized.


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## TomB (Aug 1, 2012)

It sounds like a crock to me. In every ED I've ever worked in (or delivered patients to) a conscious patient will get a 12-lead of their arrhythmia prior to treatment.



Veneficus said:


> I can see why they got dinged for it.
> 
> But I think it would be presuming a lot given the lack of info to determine if it was right or wrong.


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## Veneficus (Aug 1, 2012)

TomB said:


> It sounds like a crock to me. In every ED I've ever worked in (or delivered patients to) a conscious patient will get a 12-lead of their arrhythmia prior to treatment.



Agreed, but it doesn't mean they got dinged by a medical professional or an ED. A cookbook field sup is more than capable of doing damage.

I would guess they would argue that 70% of SCA is caused by arrhythmia secondary to MI. 

They would go one further and state that the ACLS algorythm for unstable VT is cardioversion.

I am not advocating it was wrong to do the 12 lead. Only that I can see why they did what they did.


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## VFlutter (Aug 1, 2012)

I think it would be prudent to get the 12 lead if the patient is stable enough. A lot of rhythms look like V tach in lead II, a 12 lead will provide more information. However it sounds like there is more to this story, or who ever dinged them is being overly critical. The amount of time it takes to grab a 12 lead probably would not have made any real impact of stopped them from coding.


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## the_negro_puppy (Aug 1, 2012)

I have had one patient with conscious / pulsatile VT.

We can't give anti-arrhythmics or cardiovert only ICPs here can.

Once the 3 lead 3 showed VT we worked on aspirin, obtaining IV access and extricating the pt to the vehicle. We were setting up for a 12 lead as the ICP arrived.

Because we can't actively treat pulsatile VT by itself, my priority is getting appropriate assistance and preparing for the patient to crash/initiating early transport


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## Doczilla (Aug 1, 2012)

As impressive as your stringent paramedic requirements are, it must suck to have your hands tied like that


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## the_negro_puppy (Aug 1, 2012)

Doczilla said:


> As impressive as your stringent paramedic requirements are, it must suck to have your hands tied like that



Indeed but then again actually sick patients are a rarity. Even if they gave us more drugs and cardioversion/pacing we wouldn't use them enough to justify IMO. 

Some people are crying out for ET tubes at our medic level, however considering I've put in 2 LMA's in the last year, there's no way we would eve get enough to be proficient. Did I mention that although our medic training is 2.5 years and now moving to a 3 year BS degree, we do 0 hours of hospital placements?


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## NYMedic828 (Aug 1, 2012)

the_negro_puppy said:


> Indeed but then again actually sick patients are a rarity. Even if they gave us more drugs and cardioversion/pacing we wouldn't use them enough to justify IMO.
> 
> Some people are crying out for ET tubes at our medic level, however considering I've put in 2 LMA's in the last year, there's no way we would eve get enough to be proficient. Did I mention that although our medic training is 2.5 years and now moving to a 3 year BS degree, we do 0 hours of hospital placements?



What do you do for 3 years??? :unsure:

Your educational standards are what ours should be but then you can't do anything with it? I don't get it.


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## KellyBracket (Aug 2, 2012)

Yeah, I want 12-leads from the field. Lots of them. 

An initial ECG, a second one after starting treatment, a third as you pull up to the ED, and additional shots anytime something changes. More ECGs the better. Also makes for *great posts on this forum!
*
There can be some critical data there, and if the patient has a pulse, as several folks have pointed out, you have 30 seconds to grab a 12-lead.


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## the_negro_puppy (Aug 2, 2012)

NYMedic828 said:


> What do you do for 3 years??? :unsure:
> 
> Your educational standards are what ours should be but then you can't do anything with it? I don't get it.



the 3 year university degree is spent covering subjects like A&P, pharmacology etc with clinical placements "prac" ride times on an ambulance.

To be fair, we can pretty much do everything your medics can do except for anti-arrthymics, IO and ET tubes.

The Inetnsive care paramedics who can do the above have an extra 18 months training and are moving to a Masters level qualification, plus a requirement of 2 years minimum on road as a normal medic


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## CANMAN (Aug 3, 2012)

Not to thread jack, and I am all about higher education but that's ridiculous in my opinion. Moving to a Masters to give IO's and tube....I will go get my Masters and practice anesthesia here in the states.


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## OzAmbo (Aug 4, 2012)

NYMedic828 said:


> What do you do for 3 years??? :unsure:
> 
> Your educational standards are what ours should be but then you can't do anything with it? I don't get it.



Its not about toys and skills bro.

The education requirement is set by the services and they also set the skill sets that their own paramedics work with, and what they cant work with is 3000+ paramedics all trying to stay competent at some gnarly toys that they will hardly ever use


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## OzAmbo (Aug 4, 2012)

the_negro_puppy said:


> Some people are crying out for ET tubes at our medic level, however considering I've put in 2 LMA's in the last year, there's no way we would eve get enough to be proficient.


m sure theres some remote enough places up there where this could be beneficial though?

Are they talking about cold tubes or IFS/RSI?


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## BigBad (Aug 4, 2012)

who here has ever cardioverted a unstable vtach into something other than dead or really dead?


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## Christopher (Aug 4, 2012)

BigBad said:


> who here has ever cardioverted a unstable vtach into something other than dead or really dead?



Mine have gone to a paced or sinus rhythm (that often speeds to around sinus tach).


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## the_negro_puppy (Aug 6, 2012)

OzAmbo said:


> m sure theres some remote enough places up there where this could be beneficial though?
> 
> Are they talking about cold tubes or IFS/RSI?



Cold tube. Our Intensive Care Medics can't even RSI. Though we have a few Emergency Doctors with fly cars in metro areas that can RSI, given packed red blood cells etc


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## jwk (Aug 6, 2012)

the_negro_puppy said:


> Cold tube. Our Intensive Care Medics can't even RSI. Though we have a few Emergency Doctors with fly cars in metro areas that can RSI, given packed red blood cells etc



They carry blood in their vehicle?


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## the_negro_puppy (Aug 6, 2012)

jwk said:


> They carry blood in their vehicle?



Essentially yes. They drive small AWD fly cars and also carry equipment such as FAST ultrasounds, chest tubes etc


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