86 y/o SOB

[rhan101277]

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?..

 

[abckidsmom]

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.

 

[Anjel]

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.

 

[medicsb]

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.)

 

[EMSrush]

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

lol!

 

[Akulahawk]

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.

 

[medicsb]

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).

 

[usalsfyre]

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.

 

[Akulahawk]

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.

 

[Anjel]

Ok...

What is VOMIT? Lol o is apparently oxygen.

 

[Akulahawk]

Ok...

What is VOMIT? Lol o is apparently oxygen.

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

 

[Anjel]

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

Oh ok. Gotcha thanks

 

[rhan101277]

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

 

[thinkABC]

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

 

[rhan101277]

Is is possible this guy was having runs of vtach

 

[thinkABC]

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

 

[MrBrown]

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.

 

[usalsfyre]

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.

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?

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.

 

[rhan101277]

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

 

[rhan101277]

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