Symptomatic Ventricular Trigeminy

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JD2012

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Apologies for the long post but want you to have all the info. This call was a while ago so the details are hazy. I don’t have a strip so you’ll have to take my word for it.

59 y/o male lying supine in bed CAOx4, feeling “weak and dizzy”, very pale, and very anxious repeating “something ain’t right”. Rapid RR. No CP or nausea u/o/a. PMHx of HTN and on statins. Father died of MI at 55.

Wife present, who called 911 40 minutes prior (they live way in the hills) after pt had sudden CP 9/10 “sharp” and then “slumped over the computer and was unconscious for 5 seconds” she states. Moved him to bed, which was close (appx 5 ft).

SpO2 was in low 90s
BP 160/90 (I think, I remember it being very high)
HR appx 100 -110 with ventricular trigeminy that was occasionally perfusing and occasionally multifocal, 12 lead showed no ST changes on sinus beats
Capnography (low, I don’t remember the exact #),

High flow O2 (NRB)
IV x 2 with blood draw
Amio drip 1 mg/min piggy backed into NS line and then we were off. Continued med adm enroute and watched him closely.

Pt skin color and sx improved enroute + ectopy dissipated to when we arrived at the hospital only occasional PVC present and his only sx was a HA stating he “felt better”.

I caught a lot of flack for it because certain senior medics feel that MONA was more appropriate and only give antiarrhythmics when I see runs of VT. I am not aware of hypoxia causing trigeminy, not to mention the NRB did nothing to help him. The literature that I have (textbooks) support use of antiarrhythmics in malignant PVCs. I understand the issues with brady rhythms and PVCs but don’t feel that was the case here. Appreciate any thoughts or advice.
 
JD2012 said:
Apologies for the long post but want you to have all the info. This call was a while ago so the details are hazy. I don’t have a strip so you’ll have to take my word for it.

59 y/o male lying supine in bed CAOx4, feeling “weak and dizzy”, very pale, and very anxious repeating “something ain’t right”. Rapid RR. No CP or nausea u/o/a. PMHx of HTN and on statins. Father died of MI at 55.

Wife present, who called 911 40 minutes prior (they live way in the hills) after pt had sudden CP 9/10 “sharp” and then “slumped over the computer and was unconscious for 5 seconds” she states. Moved him to bed, which was close (appx 5 ft).

SpO2 was in low 90s
BP 160/90 (I think, I remember it being very high)
HR appx 100 -110 with ventricular trigeminy that was occasionally perfusing and occasionally multifocal, 12 lead showed no ST changes on sinus beats
Capnography (low, I don’t remember the exact #),

High flow O2 (NRB)
IV x 2 with blood draw
Amio drip 1 mg/min piggy backed into NS line and then we were off. Continued med adm enroute and watched him closely.

Pt skin color and sx improved enroute + ectopy dissipated to when we arrived at the hospital only occasional PVC present and his only sx was a HA stating he “felt better”.

I caught a lot of flack for it because certain senior medics feel that MONA was more appropriate and only give antiarrhythmics when I see runs of VT. I am not aware of hypoxia causing trigeminy, not to mention the NRB did nothing to help him. The literature that I have (textbooks) support use of antiarrhythmics in malignant PVCs. I understand the issues with brady rhythms and PVCs but don’t feel that was the case here. Appreciate any thoughts or advice.
Click to expand...

What do you mean by "Occasionaly perfusing"? You felt a weaker pulse during the PVC? Yes, Hypoxia can cause PVCs. As far as being symptomatic it is really patient dependent but it will say that lot of people I see with vent bi/trigeminy are asymptomatic. I guess it depends on your protocols but I would think amino would be advised, why wait until they sustain V Tach to do something about it. Are they on any medications? Some labetalol may do some good
 
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I mean while feeling for a pulse and looking at the monitor a few PVCs would have a pulse and a few would not. I know weird.
 
PVC usually have a lower cardiac output due to being premature and lack of proper filling so that does make sense you may not feel some with a radial pulse.
 
That's kinda where my mind was going during the whole thing. His body was not getting the end organ perfusion it needs due to the PVCs messing with his CO overall. Wife mentioned that he'd gotten worse as they waited for us. High BP and HR told me his heart was trying to compensate for the decreased CO, which only increased the ectopy.
 
JD2012 said:
That's kinda where my mind was going during the whole thing. His body was not getting the end organ perfusion it needs due to the PVCs messing with his CO overall. Wife mentioned that he'd gotten worse as they waited for us. High BP and HR told me his heart was trying to compensate for the decreased CO, which only increased the ectopy.
Click to expand...

There is probably something else going on here, the PVCs may be signs of something not necessarily the cause. Why the syncopal episode? Possibly a run of pulseless V tach. I know you said no ST changes but what about the possibility of a spontaneously reperfused MI, you said there was a decent amount of time from the call to the time you got there.

Also I would think with that BP and HR even with the reduced cardiac output during those PVCs that his end organ perfusion was fine. Just a guess tho.
 
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Trigeminy was most likely NOT that cause of his symptoms, but possibly a result of the underlying pathology. Also, giving the amiodarone at 1mg/min with no bolus is going to be rather useless as that is the maintenance dose, which is meant to maintain blood levels after sufficient blood concentration is achieved following a loading dose. Pt. had a good pressure and his HR wasn't that high, even if the PVCs were not perfusing at all (unlikely), he would still be having 66-73 beats per minute. Treating PVCs, even in the setting of an MI, has not been advocated for years due to evidence showing no benefit for the patient (and harm in some cases). Now, there are patients with PVCs for which treatment may be considered, but this doesn't sound like one of those (rare) patients (e.g. myocarditis, pericarditis, or hypertrophic cardiomyopathy).
 
Generally PVCs are a symptom, not a pathology. The senior medics are correct, the guy probably needed MI care not ami. At my shop we would have had a friendly chat and forwarded it to the medical director.

As an aside...textbooks are still teaching treatment of "malignant" PVCs?!?
 
Thanks for the reply. Yes textbooks, the Mosby and Brady ones that I have still teach treating malignant PVCs and I got mixed messages through my precepting from different paramedics. Thanks for the input. I guess I was wrong. Not afraid to admit it. Glad I didn't hurt the patient.
 
usalsfyre said:
Generally PVCs are a symptom, not a pathology. The senior medics are correct, the guy probably needed MI care not ami. At my shop we would have had a friendly chat and forwarded it to the medical director.

As an aside...textbooks are still teaching treatment of "malignant" PVCs?!?
Click to expand...


Any input on a spontaneous reperfused MI? Would the ST elevation normalize within 40 mins? I would think so but not sure.

I'm not a paramedic btw so some of my input might be dumb
 
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