You hear the red phone ring as you are about to take a bite out of your sandwich in CCT. The notification is for a patient being brought in for “VT.” You ask the dispatcher if EMS is performing CPR, and they tell you that the patient is awake and talking.
You hang up the phone and say to yourself skeptically: “Ok, let’s see what is really coming in”.
The patient is a 50-year-old male with a past medical history of hypertension and anxiety who has been complaining of intermittent dyspnea for three weeks. He went to his primary physician on the day of presentation with palpitations and chest tightness. His PMD called EMS because the patient appeared uncomfortable and was found to be tachycardic in the clinic. The EMS rhythm strip showed regular, wide complex tachycardia. The patient was given 150 mg IV amiodarone, placed on 15 L oxygen via a non-rebreather mask and brought to the ED.
The patient denies any cardiac history, drug use, or cigarette smoking. He drinks alcohol socially. He takes hydrochlorothiazide for hypertension and was started on hydroxyzine for anxiety by an urgent care clinic two weeks ago.
The patient is awake, alert and talking to you. His lungs are clear to auscultation. His skin is warm and well perfused. The ECG is handed to you, and you see this:
How are you going to manage this patient? Please explain your decision-making.
jriggins21
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2 Comments
Roberto López Mata · June 25, 2020 at 3:27 pm
QRS seems wide, more than 200 mseg in some places. Right side of EKG is a bit artifact.
If the patient if stable, i would recommend a bolus of Magnesium Sulfate or Bicarb. He has anxiety, we have to look other medications besides hydroxizine.
Molly Kentarou Yamazaki · June 28, 2020 at 6:35 pm
I’ve had rhythms similar to this and the ER always tried Amioderone or Procanimide and they usually worked so id suggest giving 10mg/kg of Procanimide over 20 minutes and if the rhythm converts do another 12 lead and if it doesn’t go straight to sedative and cardioversion (I have an ICD so thats why they wait to put the pads on me)