Medical Scenario III

[Trapper John]

Which lead on the ECG are we looking at?

First, impression is A-fib (absent P wave with irregular HR ~160 bpm). Patient needs a full cardiac workup. Transport to ER with IV NS slow drip (10 gtt/min) just to have a line open. (Bet ya thought I was gonna say Dextran ). O2 nasal cannula. Transport semi-reclined. Aspirin sublingual wouldn't hurt to prevent clotting and possible occlusive stroke.

[adal]

Agree with Trapper. Be ready if she converts. I've had this convert simply by moving them from bed to gurney. If she has been this way for a few days (greater than 24 hrs) you could be getting ready for PE or stroke.

[Sdiver]

Originally Posted by Trapper John

Which lead on the ECG are we looking at?

Lead II

Don't have a 12-lead. Sorry.

[Trapper John]

Originally Posted by Sdiver

Lead II

Don't have a 12-lead. Sorry.

Ok thanks! Sticking with AF.

[PedOncoDoc]

Originally Posted by Trapper John

Which lead on the ECG are we looking at?

First, impression is A-fib (absent P wave with irregular HR ~160 bpm). Patient needs a full cardiac workup. Transport to ER with IV NS slow drip (10 gtt/min) just to have a line open. (Bet ya thought I was gonna say Dextran ). O2 nasal cannula. Transport semi-reclined. Aspirin sublingual wouldn't hurt to prevent clotting and possible occlusive stroke.

I agree with your assessment of the rhythm, but I am worried that she already had a thromboembolic stroke given her altered mental status.

[Trapper John]

Originally Posted by PedOncoDoc

I agree with your assessment of the rhythm, but I am worried that she already had a thromboembolic stroke given her altered mental status.

Agree. Probable TIAs. My question for you, Doc, is TPA indicated here?

[PedOncoDoc]

Originally Posted by Trapper John

Agree. Probable TIAs. My question for you, Doc, is TPA indicated here?

TIA can only be diagnosed in hindsight - if symptoms last for <24 hours without residual neurologic sequelae. I would consider this an acute thromboembolic stroke until proven otherwise.

If she seemed confused this morning, the stroke could've happened overnight, so it may not be outside of the therapeutic window for TPA. Then again - I coudln't tell you the last time I took care of an acute stroke in an elderly patient with AF, so I'm not sure on SOPs here.

I think a baby aspirin is 81mg (not 80), and (getting on my pediatric high horse here) never give aspirin to a pediatric patient unless advised to do so by a cardiologist.

[Trapper John]

Originally Posted by PedOncoDoc

TIA can only be diagnosed in hindsight - if symptoms last for <24 hours without residual neurologic sequelae. I would consider this an acute thromboembolic stroke until proven otherwise.

If she seemed confused this morning, the stroke could've happened overnight, so it may not be outside of the therapeutic window for TPA. Then again - I coudln't tell you the last time I took care of an acute stroke in an elderly patient with AF, so I'm not sure on SOPs here.

I think a baby aspirin is 81mg (not 80), and (getting on my pediatric high horse here) never give aspirin to a pediatric patient unless advised to do so by a cardiologist.

Thanks for the info Doc! Yeah, 81 mg (not 80 mg). Rounding error

I have often wondered why the 81 mg aspirin was called "baby aspirin" anyway. I always thought it contra-indicated in children under 2 yo (maybe even 3 yo)?

[PedOncoDoc]

Originally Posted by Trapper John

Thanks for the info Doc! Yeah, 81 mg (not 80 mg). Rounding error

I have often wondered why the 81 mg aspirin was called "baby aspirin" anyway. I always thought it contra-indicated in children under 2 yo (maybe even 3 yo)?

We worry about Reye syndrome if children receive ASA while having viral illness - so it is not used in children <12 if recovering from varicella or flu-like illness. ASA is only used in children with a clear cardiac indication or an acute thromboembolic stroke. ASA can be used at any age (no absolute age cutoff), but we are very careful about dosing.

Back to the scenario: Looking at current ASA guidelines, I would administer 325mg x1 with plans for a baby ASA daily thereafter.

[adal]

Doc I,
Generally the only rhythm that is irregularly irregular is AF. Even the SVT's are regular for the most part. At least in my train of thought, there would be some sort of pattern to it.

A 12-lead would be nice.

Our protocols for ASA are 324mg PO. 4 x 81mg.

O2 until SPO2 above 92-94%.

[Trapper John]

Originally Posted by adal

Our protocols for ASA are 324mg PO. 4 x 81mg.

O2 until SPO2 above 92-94%.

Thanks, Adal, for the lesson.

So can you explain the cardioverting to me as well? That's a new one on me.

[Trapper John]

Originally Posted by Brush Okie

It is like defibrillation, however the monitor times the shock with the rhythm so that it will happen within a specif part of the rhythm. If and that is a big if I remember correctly it happens during the QRS complex to avoid the T wave.

Thanks BrushOkie. BTW, interesting assessment. I learned a few things.

Why do you select D5W in this case instead of NS? From your questions, it looks like your thinking dehydration. Wouldn't D5W exacerbate dehydration?

With your assessment I understand the atropine. Good call IMO. If you are correct.

Doesn't heart block lead to bradycardia? Don't see that here so I am curious. I briefly thought about atropine in this patient, but dismissed it. Thought it too risky. Could you expand on your reasoning a bit? I find this interesting.

[NurseTim]

Cardioversion would be no bueno if she has been in afib for >24 hrs due to possibility of loosening a clot in the right atrial appendage. But she is symptomatic. There is a list of criteria for thrombolytic therapy that I don't recall off the top of my head.

I agree with Trapper John. If possible, TEE just prior to cardioversion to ensure no thrombus in the appendage.

Her ventricular rate is tachy so I don't think I'd give atropine.

[Trapper John]

Originally Posted by DocIllinois

The R-on-T of the ECG has rattled the cobweb cage of school knowledge, bringing back the image of a paroxysmal SVT. The low BP and lack of alertness are S&S, but usually more abrupt and episodic.

Is it possible for a paroxysmal ventricular tachycardia patient to exhibit these over such a time?

I'm no cardiologist Doc, but I did sleep at a Holiday Inn Express, and I'm sticking with AF. If memory serves VT ECGs show a fusion of the QRS - T wave complex. Also broadening of the QRS complex. We see a T-wave here (not pretty) but may be a function of the conditions (2 lead ecg) field conditions, patient moving, etc. Also, I think the rhythm in VT is regular and faster. This patients rhythm is irregular. No broadening of the QRS. All things considered and the absent P wave -just MO - this is more consistent with AF than VT.

Final point: IF this were VT the ambulance run would be to pick up a body.

[longrange1947]

K OD?