ST-elevation/VT/AIVR

[pamedic983]

I had a patient today that I brought into our local hospital ER and didn't take to a larger city hospital with a cath lab and caught some heat from my supervisors. I'm looking for some information. My pt had an altered mental status and wasn't much help in getting a past medical history and his wife (GCS15) wasn't much help either. Anyway, when I put him on the monitor, he was in a sinus rhythm with a rate in the low 80's with frequent PVC's. He would have runs of 3 or more unifocal PVC's that would correct themselves with no change in his condition. A couple of times he had longer runs (15+) of those PVC's that didn't seem to effect him. I did a 12-lead and didn't see anything alarming there. I captured one of the long runs on the monitor with a print out and brought them back to the station with me. One supervisor called it "a downward deflected QRS with ST-elevation" while the other said it looked like V-tach with "a tombstone" look. I told them I considered it AIVR because his underlying rhythm was sinus in the 80's with normal P, QRS, and T. I even showed them some of the single PVC's that had the same shape as the long runs and they insisted it wasn't AIVR or an accelerated junctional rhythm. Am I way off on this one? I wish I could post the strips I had. I thought V-tach would have had a much higher rate and if it were ST-elevation I would have had a relatively normal underlying rhythm.

I just want to make sure I am making the best decisions.

 

[Ridryder911]

Sure it was not "Sustained V-Tach" which has a wide and slower rate?


R/r 911

 

[VentMedic]

One supervisor called it "a downward deflected QRS with ST-elevation" while the other said it looked like V-tach with "a tombstone" look.

????

A 12-lead can appear to be normal on first appearance but hopefully the hospital can get a copy of his past EKGs.

At this point it isn't so much in a name but now the cause. Too many people get hung up with "name that rhythm" and forget to look for the many causes of the rhythms. Funny looking beats on a piece of paper can be called many different things by many different professionals. That is why the EKG is only one diagnostic tool.

This rhythm as you described can be anything from an electrolyte imbalance, med toxicity or a coronary vessel such as the LAD wanting to occlude.

 

[pamedic983]

Thanks

Thanks for the insights. I was thinking maybe dig toxicity since he was on dig or an electrolyte problem since he didn't appear very well "maintained" and had a history of diabetes.

What would be the distinguishing factors for sustained v-tach? His rate was only in the low to mid 90's when he had the sustained runs of what I call PVC's.

 

[triemal04]

Curious, did any of the PVC's cause an actual heartbeat? Did the run of 15+? During that run, what would the rate have been if it continued?

From what you're describing, you had a pt with multiple PVC's and runs of vtach. Like has been said, the cause could have been from multiple reasons, most not very good if it was progressing to that point.

I'm curious (just curious without knowing the entire story or seeing an actual strip) why you didn't find this at least mildly alarming.

 

[pamedic983]

Alarmed

Yes, I was alarmed by this and that is why I chose not to bypass the closest hospital for stabilization rather than continuing on to a larger hospital that was 30min or more away.

Had those runs of 15+ continued, his rate would have been somewhere in the 90's. They were regular and the same shape as the PVC's. When I felt his pulse upon first arriving, it felt regular and further on during transport, I would call those PVC beats perfusing beats because I could feel them at his radial artery.

 

[triemal04]

Ok. Still would (without seeing a strip) stand by my first interpretation. Was the patient actually unstable enough that you needed to divert? Not saying that anything wrong was done at all, especially without having all the details, but with that type of rhythm, there could be multiple causes, including coronary occlusion. Might have been better to get him somewhere where he could be treated for all the causes. And you do (hopefully) have the ability to treat him yourself (somewhat).

 

[pamedic983]

Treatment

Pt details: B/P hovering around 200/100 each time I took it, respirations 14, SpO2 96% on 4lpm, blood glucose 244mg/dl, lungs clear, GCS of 10. When I called in my report with my findings I asked if I should administer nitro and was told not to due to how close I was to the hospital. The pt was not alert enough to give ASA and he didn't respond appropriately when I asked if he had chest pain.

I know the pt was not transferred out of the hospital as of yet (a good sign) so I'm assuming it wasn't coronary artery occlusion since we do all of the transports out to the cath lab. I will check in and see what I can find out about him .

 

[EMT-P633]

I ran into a case similar to this when I was on my clinicals. I was at a small hosp / er, 8 beds total and 4 of those were fast track. Anyway in my case, the PT was in a sinus rythym. can not remember if it was NSR or sinus tach, but would have runs of V-tach that would only increase his heart rate by 15-20 bpm. I was able to capture the run on paper, it was a polymorphic V-tach(was not toresodes). As I remember my pt's other V/S were WNL. Treatment for this PT was amiodarone, after the initial dose, the runs stopped. would throw the occasional PVC, later PT was addmitted with an amiodarone drip hung and later released.

Couriosity strikes me. If you interpreted your strip with runs of VT that were uneffected by increased O2, and AHA algorithm says for a stable VT to treat with 150mg amiodarone over 10-15 min, why didnt ya try that?

Im not critizing ya, I dont know all the details. just one question i had after reading your post and after having a similar situation.

 

[Melbourne MICA]

A couple of times he had longer runs (15+) of those PVC's that didn't seem to effect him. One supervisor called it "a downward deflected QRS with ST-elevation" while the other said it looked like V-tach with "a tombstone" look. I told them I considered it AIVR because his underlying rhythm was sinus in the 80's with normal P, QRS, and T. I even showed them some of the single PVC's that had the same shape as the long runs and they insisted it wasn't AIVR or an accelerated junctional rhythm.
I just want to make sure I am making the best decisions.

When you had the run/s of 15+ what was the rate? Where the VEb's wide and regular? Are you sure they were the same morphology as the single VEB's? Did the sinus beats conducted after the VEB's show a full compensatory pause?

Sustained runs of regular wide complex VEB's with a rate above a hundred/min should be treated as VT. If all the complexes are the same shape then they are coming from the same pacemaker site so they cannot be "poly"morphic. (monomorphic). And if the VEB's are in fact polymorphic and have a rate less than 100/min then its not polymorphic VT either, just ectopics. Ectopy often responds well to oxygen alone. You did'nt say how the pt was treated. Amiodarone/Lidocaine?

The pts meds may have given some clues. VT is more common in the elderly.

I agree with triemal - sounds like sinus with runs of VT and monomophic VEB's.

MM

 

[TomB]

Remember the "rule of appropriate T wave discordance" with abnormal QRS complexes (including bundle branch blocks and ventricular rhythms). The T wave and the ST segment should be deflected opposite the terminal deflection of the QRS complex. So a downwardly deflected PVC will show a positively displaced ST segment and a positive T wave. That is not to be confused with the ST segment elevation of AMI. LBBB is a STE-mimic for the same reason. The complexes are negatively deflected in the right precordial leads, which also show ST segment elevation and upright T waves.

 

[FF894]

Sorry, breezed through this so I may have missed it- with runs of VT like this and the patient being symptomatic, would you be out of line to start him on lido and continue to the hospital 30 min away if thats where he needs to be? I would call medical control to discuss options. I certainly don't know all of the details, but if the hospital you went to needs to ship him out again in a 1/2 hour then maybe just do what interventions you could provide on the way to the tertiary center.

 

[MOflightmedic]

I don't think it's ever easy to say "I'd do exactly this" but here are some of my thoughts in response to your thread and the other replies.

What was causeing the runs of PVC's? Hard to say, it could be many things. Could you of treated it with any meds? In my opinion, no. You stated the rate was 80ish. Personally, I wouldn't ever start lidocaine or Amiodarone with a rate that low. I think you'd be asking for big trouble, especially if there was a heart block present that you missed--and yes, this can happen. This wasn't VT and even if it was just a long burst of salvos I still wouldn't of started lido or amiodarone unless it persisted "for some time" and was greater than 150 bpm! Stick to your ACLS guidelines and remember not to harm your patient with improper treatment. Lido or Ami are improper TX, in my clinical opinion, based on what I know about this patient. It may have even slowed his conduction far enough to cause a cardiac arrest.

Personally, I don't think medical control would of gave you any orders for lido or amiodarone if you contacted them.

So where would I take this patient? The closest hospital because of his arrhythmias or straight to definative care? This is a tough spot to be in and I think it's best to have a good idea of what your service directors prefer you do in a situation like this before you have to make this decision in the field.

You can find yourself between a rock and a hard spot very easily. Say you take the patient the extra 1/2 hour to definative care and he ends up coding 10 minutes from the definitive care center. Now you're being asked why you passed up an ER with a patient that could easily become unstable. On the other hand, if you stop at the closest "ER" (quotes placed for a purpose), you could very well be asked why you took a patient, who has an airway, to an inappropriate facility for their condition.

There's no clear cut answer to this situation, in my opinion. You have to weigh everything, make your decision, and be ready to defend your decision based on the criteria of why you did what you did. Hope this helps....