Wide QRS Complex Tachycardia

[Paramedic22]

Hello all!

The other day I had this interesting call. A 61 yr old man clammy, cool, diaphoretic with chest pain (4 out of 10). Pt was mentating fine A&O X3 and had no difficulty breathing. Vitals= Resp 18, Pulse 130, B/P- inaudible, and I couldn't palpate a radial pulse. Soooo I put him on my monitor and sure enough he was in a v-tachy like rhythm, a wide complex tachycardia @ 130ish. I hung a bag and gave him a fluid bolus 250 N.S., ASA 325mg, and sync cardioversion @ 100J. Whether I wanted to cardiovert him or not, I had to because his blood pressue (even after the fluid bolus) was about 90/nothing. Now at the hospital he was still in this rhythm and they gave him 150mg of amiodarone and it broke. The call went fine, and I was satisfied knowing I did what I could do.

My Question.....

If a wide complex tachycardia can be cardioverted at 130 (as in my case) or 180 as in v-tach; can it be cardioverted at a rate of 80, or 90 or 100bpm? Let's say the pt was perfusing well enough to be mentating well (but didn't have a b/p to support pharmacological methods of cardioversion). I mean you wouldn't want to pace an IVR (unless it was super slow), so why couldn't you cardiovert? I am a cardiologist by no means, and I understand defibrilation as an outside current trying to 'reorganize' a chaotic or simply a non-perfusing electrical activity or rhythm.

I hope this makes some sense... and thank you for the responses before hand... Stay Safe!

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[TerraMedicX]

I'll give this a shot, although I'm not a cardiologist either so this is PURELY my own guess work.

The chances that a person with a rate less than 130 would be hypotensive FROM their rate alone, are almost nothing. Any normal person can get their heart rate up to 110-120 without really trying too hard, and our hearts are good a functioning at this rate. Even people with predisposing heart failure can generally maintain adequate perfusion with a rate in that range. So if they have a rate under 130-150, and are hypotensive, I would be looking to other reasons (hypovolemia, sepsis, MI -> heart failure). Additionally, cardioversion is not exactly easy on the body! We're sending a rather strong electrical current into the heart to basically reset any electrical activity, and if we're not careful about it, we can do more harm than good! Even necessary cardioversion/defibrillation causes tissue damage in the heart!

Just my 2 cents and really more of an educated guess.

Nate.

 

[bradt9881]

Think outside of the box on this one. If the rate is under 100, its not a ventricular tachycardia. Its liable to be an accelerated supraventricular rhythm or an acclerated idioventricular rhythm. I would be EXTREMELY cautious at shocking anything at a rate of 80.

http://www.emedicine.com/med/TOPIC12.HTM

 

[deleted92121]

Wow interesting discussion.

I'd bet that it was an MI with BBB. The only reason I say this is b/c i've seen something similar. V-tach like rhythm but too slow to be considered. Turned out it was an arrhythmia (A-fib with wide complex and BBB). Treated the arrhythmia with Amiodarone and rapid transit.

Hard to say.

 

[leviathan]

Hello all!

The other day I had this interesting call. A 61 yr old man clammy, cool, diaphoretic with chest pain (4 out of 10). Pt was mentating fine A&O X3 and had no difficulty breathing. Vitals= Resp 18, Pulse 130, B/P- inaudible, and I couldn't palpate a radial pulse. Soooo I put him on my monitor and sure enough he was in a v-tachy like rhythm, a wide complex tachycardia @ 130ish. I hung a bag and gave him a fluid bolus 250 N.S., ASA 325mg, and sync cardioversion @ 100J. Whether I wanted to cardiovert him or not, I had to because his blood pressue (even after the fluid bolus) was about 90/nothing. Now at the hospital he was still in this rhythm and they gave him 150mg of amiodarone and it broke. The call went fine, and I was satisfied knowing I did what I could do.

My Question.....

If a wide complex tachycardia can be cardioverted at 130 (as in my case) or 180 as in v-tach; can it be cardioverted at a rate of 80, or 90 or 100bpm? Let's say the pt was perfusing well enough to be mentating well (but didn't have a b/p to support pharmacological methods of cardioversion). I mean you wouldn't want to pace an IVR (unless it was super slow), so why couldn't you cardiovert? I am a cardiologist by no means, and I understand defibrilation as an outside current trying to 'reorganize' a chaotic or simply a non-perfusing electrical activity or rhythm.

I hope this makes some sense... and thank you for the responses before hand... Stay Safe!

Just be careful with those fluid boluses if you aren't sure about volume status or if there is acute heart failure +/- cardiogenic shock.

 

[fiznat]

Huh. I'd think twice about cardioverting at 130 even. As the rate gets lower (and 130 aint that fast) you should start thinking that maybe the hypotension isn't actually a rate problem. There could be any number of other factors contributing to the BP other than tachycardia-- especially when the rate is 130. Did you get a 12 lead? There are plenty of other causes of wide rhythms besides VT also...

Cherry picking after the call is easy though...