# 86 y/o SOB



## rhan101277 (Jun 27, 2011)

You arrive at a psych facility for a 83 y/o male with SOB.  You arrive to find him breathing at 24BPM, clear lung sounds, pulse ox 93% on monitor.  Monitor shows afib w/ occasional non-perfusing PVC's rate 110, BP 130/85.  A hx is gathered and you find pt has CAD, CHF, no allergies, stents placed.  Pt has altered mental status but it is not new onset, staff reports he has been getting more and more confused lately.

Pt SOB started two hours ago and staff states he has been having some heart rhythm issues.  You stick him on 12L NRB and his pox goes up to 99%.  In route you notice occasional PVC's but patient is still stable has good B/P and other vitals are good.  You see nice longs runs of afib followed by several runs of the strip below.  How would you proceed with treating these changes?..


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## abckidsmom (Jun 27, 2011)

I would continue to monitor, back off on the oxygen if I could, get IV access and transport.

I would get the pads out, but not put them on.  I've found much efficacy in waving defib pads in the air in front of patients:  wards off evil spirits.  I've never, ever used defib pads on someone when I got them out to ward off evil spirits.


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## Anjel (Jun 27, 2011)

Just from a basic POV. 

I probably would of did 2-4lpm via NC. And transported.

Keep an eye on the mental status changes and the other vitals. Adjusted the o2 as needed. 

I think the pt needs als to take the them if they can get there sooner than I can get to the hospital. Because of the monitor changes and A-fib.


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## medicsb (Jun 27, 2011)

2lpm O2 via NC.  BGL.  12 lead ECG just to better assess the rhythm, but it appears to be AF w/ paced beats (thx lifepak pacer arrows).  Saline lock.  Stare at the patient because there is nothing else to do. (Perfect world: pt. would be turfed to BLS.)


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## EMSrush (Jun 27, 2011)

abckidsmom said:


> i've never, ever used defib pads on someone when i got them out to ward off evil spirits.



lol!


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## Akulahawk (Jun 27, 2011)

medicsb said:


> 2lpm O2 via NC.  BGL.  12 lead ECG just to better assess the rhythm, but it appears to be AF w/ paced beats (thx lifepak pacer arrows).  Saline lock.  Stare at the patient because there is nothing else to do. (Perfect world: pt. would be turfed to BLS.)


Sure those are pacer arrows? I'd be expecting that they'd be very, very regular... unless it's now failing, allowing the underlying afib rhythm to show through.


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## medicsb (Jun 27, 2011)

Akulahawk said:


> Sure those are pacer arrows? I'd be expecting that they'd be very, very regular... unless it's now failing, allowing the underlying afib rhythm to show through.



The underlying AF is definitely showing through, which isn't uncommon in my experience.  It does look like there may have been some noncapture with the first 2 beats, probably because the pacer was firing at the same time as ventricles were depolarizing.  After the 1st 2 obvious paced beats (wide complexes), it appears that there are some fusion beats.  A longer strip would be useful as would a 12 lead.  You'd probably see the actual pacer spikes in some of the precordial leads (most likely v1, v2 ish).


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## usalsfyre (Jun 27, 2011)

Akulahawk said:


> Sure those are pacer arrows? I'd be expecting that they'd be very, very regular... unless it's now failing, allowing the underlying afib rhythm to show through.



Afib, my guess is a demand pacer. I'm not sure their's not some failure-to-capture though. 

Treatment wise? Probably just VOMIT, minus the O.


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## Akulahawk (Jun 27, 2011)

usalsfyre said:


> Afib, my guess is a demand pacer. I'm not sure their's not some failure-to-capture though.
> 
> Treatment wise? Probably just VOMIT, minus the O.


Makes sense. TX: VoMIT... (little o...)  The 12LPM is a bit overkill... I'd wonder if a resp rate of 24 is normal for him though. If it is, No O.


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## Anjel (Jun 27, 2011)

Ok...

What is VOMIT? Lol o is apparently oxygen.


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## Akulahawk (Jun 28, 2011)

Anjel1030 said:


> Ok...
> 
> What is VOMIT? Lol o is apparently oxygen.


Vitals, Oxygen, Monitor, IV, Transport...


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## Anjel (Jun 28, 2011)

Akulahawk said:


> Vitals, Oxygen, Monitor, IV, Transport...



Oh ok. Gotcha thanks


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## rhan101277 (Jun 28, 2011)

Akulahawk said:


> Vitals, Oxygen, Monitor, IV, Transport...



This...

Those are PVC's not a pacer, although the patient has a pacer it is a demand pacer and should not be firing.  Even the new pacers should show very small spikes when they are active and these do not.  I couldn't most other strips but there were some multifocal PVC's as well.  That and the rate of the rhythm led me to choose PVC's.  He had long runs of afib in between these long runs of PVC's


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## thinkABC (Jun 28, 2011)

The QRS's in the bizarre beats look to me to be right around .12.  Can they be PVCs?


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## rhan101277 (Jun 28, 2011)

Is is possible this guy was having runs of vtach


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## thinkABC (Jun 28, 2011)

If they are PVCs, then those are runs of VTach, right?


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## MrBrown (Jun 28, 2011)

thinkABC said:


> If they are PVCs, then those are runs of VTach, right?



No, six or more continuous PVCs is considered a burst of VT

Brown would keep him on the lowest litre flow to achieve an SpO2 of >96% and drive to the hospital.


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## usalsfyre (Jun 28, 2011)

rhan101277 said:


> Those are PVC's not a pacer, although the patient has a pacer it is a demand pacer and should not be firing.


Be careful making this assumption unless you know the pacers settings. Demand pacers generally sense R to R intervals. Too long without a beat and it will throw it's own beat in. Meaning afib will have lots of paced beats. They do not calculate overall heart rate as a rule. 



rhan101277 said:


> Even the new pacers should show very small spikes when they are active and these do not.


I bet I haven't seen a pacer spike in three years or so. Physio's software does a VERY good job of filtering them out, hence the arrows. Where did you get taught you have to see some sort of "spike" to be a paced rhythm?



rhan101277 said:


> I couldn't most other strips but there were some multifocal PVC's as well.  That and the rate of the rhythm led me to choose PVC's.  He had long runs of afib in between these long runs of PVC's


If there were multifocal PVCs, the multifocal beats were probably PVCs. But what you've posted is too "pretty" and lines up too well with the pacer arrows for me to think anything other than a demand pacer.


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## rhan101277 (Jun 28, 2011)

You can't always think that just because the monitor is showing arrows means it is the holy grail of pacemaker detection.  Furthermore if it is set to a specific R R interval; it is the same as pacing at a specific heart rate and the heart rate should be constant regardless of how often the pacer has to pace.  This is further indication that these are PVC's.  

I have seen the monitor show arrows in patients who had no pacemaker and it was simple artifact.

Here are some pacemaker strips, yes not all will show pacemaker spikes on the monitor, but most do.

http://library.med.utah.edu/kw/ecg/image_index/index.html

Scroll down to (9) artificial pacemaker strips


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## rhan101277 (Jun 28, 2011)

If it was a pacer it was not causing mechanical capture.  No beats were felt.


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## usalsfyre (Jun 28, 2011)

rhan101277 said:


> You can't always think that just because the monitor is showing arrows means it is the holy grail of pacemaker detection.


However, if your not willing to trust you equipment you'll end up hanging ami on a paced rhythm one day. I've seen it happen. For all of the "treat the patient" BS that exist out their, modern cardiac monitors are pretty dang good. The distrust that exist, and continues to be taught, is often misplaced blame from a bygone era. There are times you absolutely WILL NOT see a spike through the filtering software. As pacers get better, you'll see it less and less. 




rhan101277 said:


> Furthermore if it is set to a specific R R interval; it is the same as pacing at a specific heart rate and the heart rate should be constant regardless of how often the pacer has to pace.  This is further indication that these are PVC's.


What I gave was an incredibly oversimplified explanation. Someone once gave me a much more detailed rundown on the ins and outs of modern pacers....and I've forgotten most of it in the ensuing years. 



rhan101277 said:


> I have seen the monitor show arrows in patients who had no pacemaker and it was simple artifact.


Me too, BUT...the times I've seen this have been randomly and oddly spaced, never correlating with "PVCs" (by your argument there's a bit of artifact at the same point before every PVC that the machine is sensing as a pacer spike? Unlikely). Furthermore the morphology of the ventricular beats appears similar to most of the paced beats I've seen lately. Deep S wave, slight elevation above the baseline of the ST segment, no it's not something I can say is an absolute, but pacer beats, at least in my very anecdotal experience all appear "similar".



rhan101277 said:


> Here are some pacemaker strips, yes not all will show pacemaker spikes on the monitor, but most do.
> 
> http://library.med.utah.edu/kw/ecg/image_index/index.html
> 
> Scroll down to (9) artificial pacemaker strips


All of these are 15 years old. Pacemaker technology and monitor technology has come a LONG, LONG way in 15 years. Back then you were looking at LP10s, very few prehospital 12 leads, non-sensing pacers being commonly, no atrial pacing, ect. It's like comparing a 1997 car to a 2011 car. Not really easy to do.

That said, I could be wrong, cardiology is not a particular area of special interest to me.


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## medicsb (Jun 28, 2011)

rhan101277 said:


> This...
> 
> Those are PVC's not a pacer, although the patient has a pacer it is a demand pacer and should not be firing.  Even the new pacers should show very small spikes when they are active and these do not.  I couldn't most other strips but there were some multifocal PVC's as well.  That and the rate of the rhythm led me to choose PVC's.  He had long runs of afib in between these long runs of PVC's



Did you do a 12 lead?  

Many pacemakers now barely show pacer spikes in limb leads, sometimes not at all.  

I'm very very confident in saying that what you posted showed paced beats and not PVCs.  Though, it did look like the 10th beat may have been a PVC.

Even if they were "PVCs", they are no longer PVCs when there are 3 or more in a row.  At that point it becomes a ventricular rhythm of some sorts (IVR, VT, etc.).  

Anyhow, I think another poster has said anything else I might have had to say.


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## rhan101277 (Jun 28, 2011)

Has anyone ever seen someone who had a pacemaker but the pacing action was not causing any mechanical action?

That is what this patient was having if they are indeed pacemaker.


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## firetender (Jun 28, 2011)

rhan101277 said:


> Has anyone ever seen someone who had a pacemaker but the pacing action was not causing any mechanical action?


 
Sure, but they were all dead. When heart cells are dead, there is no mechanical response. On the monitor you'll see a pacer spike, but no more. If you stick a pacer into a cow's heart from the grocery store (they sell them in your neighborhood, don't they?), it won't beat.

But maybe I'm misreading your question. A pacer can malfunction by continuing to discharge steady beats while the heart is beating on its own. In other words, the pacer ignores the activity of the heart which is ignoring the activity of the pacer. In that case, you get the heart's rhythm on the monitor as well as the pacer spikes.


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## usalsfyre (Jun 28, 2011)

rhan101277 said:


> Has anyone ever seen someone who had a pacemaker but the pacing action was not causing any mechanical action?
> 
> That is what this patient was having if they are indeed pacemaker.



I've seen failure to capture in external pacing.

I've also seen providers who failed to pick up on a change in the nature of a beat when palpating a pulse.


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## usalsfyre (Jun 28, 2011)

Just so we're clear, I wasn't there, and am simply armchair quarterbacking this thing from hundreds (a thousand?) miles away. I'm simply telling you what I see based off a kinda rough picture of a monitoring strip and common mistakes I've made/seen others make.

A 12 lead would really help this process.


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## rhan101277 (Jun 28, 2011)

I have the 12 lead, I will post momentarily.  Also I have only been doing this for 7 months so I am still learning as well.


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## rhan101277 (Jun 28, 2011)

12 lead tracing


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## rhan101277 (Jul 2, 2011)

12 lead has been posted for several days, still no thoughts?


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## usalsfyre (Jul 2, 2011)

rhan101277 said:


> 12 lead has been posted for several days, still no thoughts?



12 lead is of better quality and apparently shows a different time period. I agree, what's shown on the 12 lead are PVCs.


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## emt for life (Jul 4, 2011)

it depends on the medic and what they would do in that situation


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