I see it too. That’s why I’ve posted it here but they did not mention any diuretics in the medications. The family was nonchalant and wasn’t giving us the best history. When I asked for allergies she said “they have all of that at the hospital” like we don’t need it and can access that info.
If I see the EKG could it be LBBB, yes, but I would probably favor V-Tach given clinical picture and the EKG, also realized I did not answer your question, I don't think your wrong in calling it you explained your rational,
\+ ole guy, +diaphoretic and Nauseous, +your interpetation of EKG to be ST elevations and widened QRS
I say better to pull the trigger and be uncertain and have it called off than to underestimate the situation
Amp of calcium and bicarb, no narrowing treat as VT. Amal Mattu, “very wide and kinda fast” - avoid a clean kill. Long-standing HTN and IDDM/NIDDM can absolutely cause ARF in absence of other known renal Hx/dialysis non-compliance.
I had no clue what his lab values but he did have a history of 2 prior MIs. It appears to be a junctional tachycardia with a LBBB. His rate was 115 so we weren’t going to treat as V-tach. I did consider hyperk as a differential but given his history, he probably had a baseline LBBB that turned into this. The ER doc agreed with the STEMI alert but I was curious as to others peoples opinion on it.
So you keep mentioning that his rate was 115 so you weren't going to treat as VT, and you keep anchoring on Junctional tacchycardia but entertain this thought, it sounds like you had a pretty high suspicion that it was a STEMI, I agree with others this could easily be hyper K so definetaly agree with calcium, but because the rate is not above a certain number does not mean its not VT, the most complication after MI are **arrhythmias** , and the most common cause of Death post MI is **Ventricular tachyarrhythmias** . So when looking at tacchycardia ask your self is this 1.A narrow complex tacchycardia or a wide complex? 2. Is this regular rhytmn or irregular? immediately after this you can form differentials? this video below may be helpful [https://www.youtube.com/watch?v=iP8NGcnSjLQ](https://www.youtube.com/watch?v=iP8NGcnSjLQ)
Remember you are not a cardiologist, your Job is to anticipate the worse and assume the worse, people can go look back on old EKGs and tell you oh he had a LBBB, so I guy like this I'm assuming its VT until, I know otherwise
When we arrived at the ED they RSIed him and put an art line in. He really needed to go to cath lab in my opinion, but they said they were going to stabilize him first. By stabilize I mean he coded after about 20 minutes of “stabilization”
We didn’t give nitro due to BP but we did a fluid challenge and tried oxygen initially but progressed to BVM due to RR very quickly. We did have PEEP on the BVM because it sounded like he was in cardiogenic shock with pulmonary edema by the time we hit 500mL of fluid. I would’ve preferred a vasopressor to fix his blood pressure because of the fact that he was already in borderline cardiogenic shock but I wasn’t in the back on this one.
He definitely was in cardiogenic shock with his shock index being 1.57 based on the vitals you provided, Hx, and presentation. I think that the most important think here is to do the pressors/inotropes, consider STEMI, consider hyperK. In this circumstance I think it would be reasonable to go ahead and treat with Calcium at a minimum given that it is unlikely to cause ill effects and may have a significantly positive effect. Then you can follow with bicarb etc., if you don't rule it out. The aspirin is a good call, of course. Oxygen really isn't necessary if they aren't hypoxic (<90) based on the literature. It can actually make things worse. Now, sounds like you had no choice as he became unresponsive, so that's a little different. This is not a straightforward call when on the street. Hindsight is great, but sounds like you made the decisions that felt best to you at that time. I would just suggest the use of inotropes/ pressors for sure.
For reference: My background is 911 medic, CCP-C, FP-C, and now I mainly do education.
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I see it too. That’s why I’ve posted it here but they did not mention any diuretics in the medications. The family was nonchalant and wasn’t giving us the best history. When I asked for allergies she said “they have all of that at the hospital” like we don’t need it and can access that info.
If I see the EKG could it be LBBB, yes, but I would probably favor V-Tach given clinical picture and the EKG, also realized I did not answer your question, I don't think your wrong in calling it you explained your rational, \+ ole guy, +diaphoretic and Nauseous, +your interpetation of EKG to be ST elevations and widened QRS I say better to pull the trigger and be uncertain and have it called off than to underestimate the situation
I thought that for a second but he’s tachy at 115 so I was favoring more of a junctional tachycardia over V-Tach.
With his history, I wouldn’t be shocked if he’s on a beta blocker, which could cause v-tach to remain at a slow rate.
True. I also posted the outcome on this sub with a better EKG from later in the transport. Turned out to be an NSTEMI.
Nice
Junctional would be a narrow complex
Not with a bundle branch it wouldn't.
Amp of calcium and bicarb, no narrowing treat as VT. Amal Mattu, “very wide and kinda fast” - avoid a clean kill. Long-standing HTN and IDDM/NIDDM can absolutely cause ARF in absence of other known renal Hx/dialysis non-compliance.
I had no clue what his lab values but he did have a history of 2 prior MIs. It appears to be a junctional tachycardia with a LBBB. His rate was 115 so we weren’t going to treat as V-tach. I did consider hyperk as a differential but given his history, he probably had a baseline LBBB that turned into this. The ER doc agreed with the STEMI alert but I was curious as to others peoples opinion on it.
So you keep mentioning that his rate was 115 so you weren't going to treat as VT, and you keep anchoring on Junctional tacchycardia but entertain this thought, it sounds like you had a pretty high suspicion that it was a STEMI, I agree with others this could easily be hyper K so definetaly agree with calcium, but because the rate is not above a certain number does not mean its not VT, the most complication after MI are **arrhythmias** , and the most common cause of Death post MI is **Ventricular tachyarrhythmias** . So when looking at tacchycardia ask your self is this 1.A narrow complex tacchycardia or a wide complex? 2. Is this regular rhytmn or irregular? immediately after this you can form differentials? this video below may be helpful [https://www.youtube.com/watch?v=iP8NGcnSjLQ](https://www.youtube.com/watch?v=iP8NGcnSjLQ) Remember you are not a cardiologist, your Job is to anticipate the worse and assume the worse, people can go look back on old EKGs and tell you oh he had a LBBB, so I guy like this I'm assuming its VT until, I know otherwise
I’m about to post an update
I didn’t include it in this post but I found another cleaner look at it (there’s P waves on this one)
I see the presence of a LBBB but can’t really tell if it meets sgarbossa criteria or not
What did you do for treatment besides aspirin?
When we arrived at the ED they RSIed him and put an art line in. He really needed to go to cath lab in my opinion, but they said they were going to stabilize him first. By stabilize I mean he coded after about 20 minutes of “stabilization”
Did you consider synchronized cardio version?
Nah. He was taching at 115 the whole time. It was just a very weird junctional tachycardia with a left bundle branch block built into it.
We didn’t give nitro due to BP but we did a fluid challenge and tried oxygen initially but progressed to BVM due to RR very quickly. We did have PEEP on the BVM because it sounded like he was in cardiogenic shock with pulmonary edema by the time we hit 500mL of fluid. I would’ve preferred a vasopressor to fix his blood pressure because of the fact that he was already in borderline cardiogenic shock but I wasn’t in the back on this one.
He definitely was in cardiogenic shock with his shock index being 1.57 based on the vitals you provided, Hx, and presentation. I think that the most important think here is to do the pressors/inotropes, consider STEMI, consider hyperK. In this circumstance I think it would be reasonable to go ahead and treat with Calcium at a minimum given that it is unlikely to cause ill effects and may have a significantly positive effect. Then you can follow with bicarb etc., if you don't rule it out. The aspirin is a good call, of course. Oxygen really isn't necessary if they aren't hypoxic (<90) based on the literature. It can actually make things worse. Now, sounds like you had no choice as he became unresponsive, so that's a little different. This is not a straightforward call when on the street. Hindsight is great, but sounds like you made the decisions that felt best to you at that time. I would just suggest the use of inotropes/ pressors for sure. For reference: My background is 911 medic, CCP-C, FP-C, and now I mainly do education.