Friday, December 22, 2017

Atrial Fibrillation with Ventricular Escape Beats

Atrial Fibrillation with Ventricular Escape Beats.  The initial rhythm is atrial fibrillation. A pause follows the 4th complex and this is followed by three ventricular escape beats that occur late in the cardiac cycle.  The rate of the escape rhythm is around 38 bpm, which is what you would expect of a ventricular rhythm




Thursday, December 21, 2017

Cardiac Arrest

A 50 year old was brought in by EMS in cardiac arrest.  PMH includes hypertension and diabetes.  He had a pulse during transport.  He is transferred from the stretcher to the ER bed in the trauma room.  No pulse is detected.












CPR is initiated and an IV is started in the left AC.  Epinephrine 1 mg is given for PEA.  CPR continued after the epinphrine.  The patient was quickly intubated with a 8.0 ETT tube.  End tidal CO2 detector show a positive color change.  Bilateral breath sounds with symmetrical chest movement was noted.


CPR is paused and a rhythm check is performed.  The patient was found to be in ventricular tachycardia.  He remained pulseless.  He was defibrillator with the Life Pac 20 at 200 joules.  CPR was immediately resumed after the shock.










Epinephrine 1 mg was given followed by a saline flush.  CPR with positive pressure ventilations continued.  A rhythm check showed the patient to be in ventricular fibrillation.  A second shock was given at 360 joules

After the second shock, CPR was restarted.  The MD elected to continue with epinephrine.  Epinephrine 1 mg IV was repeated. After a rhythm check, a third shock was given at 360 joules. Some organized complexes were seen briefly.  No pulse was detected.  CPR resumed.










The few organized complexes soon disappeared and the patient was in refractory ventricular fibrillation.  At this time Amiodarone 300 mg IV was given.  CPR continued and the rhythm was reanalyzed.  The rhythm check showed persistent VF.  A fourth shock was given at 360 joules.










A second dose of Amiodarone of 150 mg was given.  CPR was in progress.  The rhythm checked showed ventricular fibrillation.  A fifth shock at 360 joules was given. The post shock rhythm showed a few organized complexes but the patient remained pulseless. 











CPR was continued.  The patient showed an agonal rhythm.  It was decided to end further resuscitative efforts. 

Wednesday, December 20, 2017

Cardiac Arrest in a Patient With a Left Ventricular Assist Device

A 70 year old woke up with his LVAD “low flow” alarm going off.  He called his LVAD coordinator and was told to call EMS.  He called EMS and during transport became unresponsive.  Because of the LVAD, no CPR was initiated.  The patient was unresponsive.  His pupils fixed and dilated at 5 mm.  JVD is present. He has an LVAD with a drive line coming from the RLQ.  He has two nephrostomy tubes in place.  With the exception of CPR, the ACLS protocol should be followed during a cardiac arrest. CPR may cause displacement of the drive lines in the patient and lead to uncontrolled aortic bleeding from the aorta.











The LVAD supplies were transported by EMS so he was immediately placed on AC power. No detectable pulses were present by Doppler. A mechanical hum could be heard over the apex of the heart.  Controller alarm status was “no flow.  Pump speed 5500.  Pump output 0.1 L/min.  Pump index 4.2.  Two IVs were quickly established in the right and left ACs and fluid resuscitation was initiated. Epinephrine 1 mg IV was given.  His LVAD coordinator was contacted for guidance. Blood sugar 73.  The LVAD coordinator only recommended at 500 ml bolus.  The patient had JVD which seemed to suggest some existing right heart failure, tamponade, or a PE.   The urine output in the nephrostomy bags was brown and had lots of sediment, so urospepsis was also a possibility.


He remained pulseless by Doppler.  No BP was obtainable.  A bedside ultrasound was done and showed little ventricular wall motion. No tamponade was noted.  Fluid resuscitation continued and Epinephrine 1 mg IV was given.  He was intubated with a 7.5 ETT tube.  Placement was confirmed via auscultation and endtidal CO2.  A CXR was done.   He was placed on the ventilator. Pulse oximetery readings were unobtainable. We were unable to obtain an ABG.  His heart rate improved after the Epinephrine










His heart rate slowed down after the epinephrine wore off.  He showed a complete heart block on the monitor. No pulses were detectable by Doppler.  Controller readings: Pump speed 5885, Pump output 0.2 L/min.  Pump index 4.2.  Atropine 0.5 mg was administered.  Dopamine 400mg/250 ml was started at 7 mcg/kg/min.











The epinephrine was repeated and sodium bicarbonate was administered.  The low flow alarm continued to sound on the controller.  Pump speed 5789  Pump output 0.3 L/min  Pump index 4.4. We wanted to see if we improve inotropic action of the heart.  The Dopamine was increased to 10 mcg/kg/min.









The epinephrine was repeated and he was started on an epinephrine drip at 5 mcg/min. Maintenance fluids are at 100 ml/hr .  The patient remains unresponsive.  Pupils are fixed and dilated.  The patient will be airlifted out.  Some improvement was noted in the controller numbers. Pump speed 5300  Pump output 1.6 L/min  Pump index 8.9.









The patient remains unresponsive.  The pupils are fixed and dilated.  An arterial line was placed using ultrasound guidance.  The arterial line was zeroed and leveled and found to be 22/10.  The arterial waveform is flattened.  No dichrotic notch is seen.  The heart rate has slowed down.  The pump output has decreased.  Epinephrine 1 mg was repeated.  At the suggestion of the LVAD coordinator, hypothermic protocol was initiated.  Dopamine increased to 15 mcg/kg/min.  Epinphrine to 10 mcg/min.











Controller shows “low flow.”  Pump speed 5843.  Pump output 0.1.  Pump index 4.1.  ABG obtained. pH: 7.29, PCO2: 24.6, PO2 321, HCO3: 12.0.  The bedside ultrasound was repeated and continued to show little ventricular wall motion. Radial artery ultrasound shows little arterial pulsations. The CXR results showed a right side pleural effusion and atelectasis.









Aircrew arrived for transfer. Patient remains unresponsive.  Pupils fixed and dilated.  Dopamine at 15 mcg/kg/min.  Epinephrine 10 mcg/kg/min.  Cold saline infusion at 100/min.  Controller shows “low flow.”  Pump speed 5642.  Pump output 0.1.  Pump index 4.5.  The patient was transferred





Tuesday, December 19, 2017

Atrial Fibrillation With Failure to Sense

A patient with NSTEM admitted with atrial fibrillation.  The EKG showed a pacemaker  with failure to sense. The problem is that some of the pacemaker spikes are falling on the QRS complexes.  For this patient, the MD requested that her pacemaker be interrogated.  The pacemaker interrogation showed that she actually had a failure in the right ventricular lead.



Monday, December 18, 2017

Type I Block With 3:2 Conduction Changing to a 2:1 Conduction


This is the second patient that we have had like this in less than two weeks.  The patient was admitted with an ischemic stroke and has an underlying 1st degree heart block.  He has intermittent episodes of a type I block.  He begins with a second degree type I block with a 3:2 conduction and changes to a 2:1 conduction pattern.  For an interesting discussion of this, please see Vince DiGiulio's article The 12 Rhythms of Christmas: 2:1 AV-Block. http://www.ems12lead.com/2016/01/05/12-rhythms-of-christmas-2-1-avb/







Type II block changing from 3:2 conduction to 2:1 conduction



 The patient has a brief period of complete heart block

Sunday, December 17, 2017

Atrial Fibrillation With a Run of Ventricular Tachycardia

Atrial Fibrillation With a Run of Ventricular Tachycardia.  The patient has underlying atrial fibrillation.  The second complex is a PVC.  Notice the change in the complex morphology in lead III. It is followed by a run of nonsustained ventricular tachycardia.  The patient spontaneously converts back to atrial fibrillation.



Saturday, December 16, 2017

Complete Heart Block

An 80 year old with a history of hypertension and GERD came to the ED with complaints of generalized weakness.  Medications: Amlodipine 10mg, Losartan 50 mg daily, and Pantoprazole 20 mg daily. BP 165/90 - 183/82.  Hemodynamically stable.
The narrow QRS complexes suggest that the block is higher in the ventricle near the AV junction.



Friday, December 15, 2017

Atrial Flutter with Variable or Irregular Ventricular Response

Atrial Flutter with Variable Ventricular Response. The ventricular response is irregular and almost mimics atrial fibrillation.  The flutter pattern varies significantly in a 3:1, 4:1 up to a 10:1 conduction ratio. 



Wednesday, December 13, 2017

Sinus Rhythm With a Run of VT or AIVR

Sinus rhythm with a run of VT or AIVR

The ECG criteria for accelerated idioventricular are:  wide complex rhythm with no P waves associated, rate between 40 and 100 bpm.


On various websites there are a variety of rates listed for AIVR

Life in the Fast Lane: Rate 50-110 bpm.
ECG-pedia: 60-120 bpm
Emedicine Medscape 40 to 100 to 120 bpm
EKG Academy: 40 – 100 bpm.
ECGguru: 40 and 100 bpm



Monday, December 11, 2017

Atrial Fibrillation with Slow Ventricular Response

An 85 year old admitted with systolic failure.  Taking Digoxin 250 micrograms daily and Atenolol 75 mg daily.  He was admitted and started on IV Lasix.  The Digoxin was continued but held for HR < 60. The Atenolol was stopped and he was changed to Carvediolol (Coreg) 12.5mg daily, hold for HR < 60.


Sunday, December 10, 2017

Sinus Rhythm With a Run of VT or SVT Aberrancy?


Edward Burns, in Life in the Fast Lane, uses these criteria to distinguish between VT and SVT with aberrancy: 

https://lifeinthefastlane.com/vt-versus-svt-with-aberrancy/

These criteria favor VT:
Absence of typical RBBB or LBBB morphology
Extreme axis deviation (“northwest axis”) — QRS is positive in aVR and negative in I + aVF.
Very broad complexes (>160ms)
Positive or negative concordance throughout the chest leads,
RSR’ complexes with a taller left rabbit ear. This is the most specific finding in favour of VT. This is in contrast to RBBB, where the right rabbit ear is taller. 

In this strip we have a rSR' complex in V1.  The rabbit ear is taller on the right.  
The QRS complexes are positive in aVR and aVF and negative in lead I.  These do not meet the criteria for VT and suggest aberrancy. 


Saturday, December 9, 2017

Atrial Fibrillation With a Run of VT or SVT Aberrancy?

Atrial fibrillation with a run of VT or aberrancy.

This typically happens,  we have a patient that has some runs of nonsustained VT during the night.  We call it VT because Wide + fast + VT until proven otherwise.  The next morning, the cardiologist will make rounds and look at the strip and tell us that this is aberrancy and not VT.  

Floyd Miracle from ACLS Medical Training writes: 

Because the right bundle branch tends to have a slightly longer refractory period than the left bundle branch, at higher rates the right bundle branch may not be fully recovered from the previous cardiac cycle, which results in a right bundle branch block pattern.

Even though right bundle branch block aberrancy is more common than left bundle branch block aberrancy, both are possible


Edward Burns, in Life in the Fast Lane, uses these criteria to distinguish between VT and SVT with aberrancy: 

https://lifeinthefastlane.com/vt-versus-svt-with-aberrancy/

These criteria favor VT:
Absence of typical RBBB or LBBB morphology
Extreme axis deviation (“northwest axis”) — QRS is positive in aVR and negative in I + aVF.
Very broad complexes (>160ms)
Positive or negative concordance throughout the chest leads,
RSR’ complexes with a taller left rabbit ear. This is the most specific finding in favour of VT. This is in contrast to RBBB, where the right rabbit ear is taller. 

We don't have a 12 lead to look at, so we cannot use all of the criteria that are Edward Burns has listed. In this strip there are at least two criteria that favors SVT with aberrancy: 

1. The V1 lead shows a taller rabbit ear on the left (RSr')
2. During the run of "VT" the QRS complex is positive in aVR and aVR but negative in lead I


Friday, December 8, 2017

Sinus bradycardia with an R-on-T PVC

Sinus bradycardia with an R-on-T PVC.  This triggers an unusual pattern of couplets and bidirectional  beats.  The rhythm transitions into bigeminy and then into an atrial flutter.  The initial small positive R wave in aVR suggests a lead reversal problem.



Tuesday, December 5, 2017

Elective Cardioversion of Atrial Flutter Part II

This patient was admitted with a SVT.  She received adenosine 6 mg and 12 mg without conversion of the rhythm.  However, the adenosine did clarify the rhythm as an atrial flutter.  She was managed with a calcium channel blocker and anticoagulated.  An echo was done and no atrial clots were noted.  She underwent elective cardioversion and was successfully cardioverted after two attempts


12 Lead obtained in ICU



This is the strip off the monitor

These are the strips from the defibrillator/monitor.  This is the initial rhythm



The event summary strips











Follow up strip

Monday, December 4, 2017

Elective Cardioversion of Atrial Flutter Part I


This patient was admitted with a SVT.  She received adenosine 6 mg and 12 mg without conversion of the rhythm.  However, the adenosine did clarify the rhythm as an atrial flutter.  She was managed with a calcium channel blocker and anticoagulated.  An echo was done and no atrial clots were noted.  She underwent elective cardioversion and was successfully cardioverted after two attempts.  




Sunday, December 3, 2017

Pacemaker Failure: Failure to Capture

The patient was having intermittent episodes of failure to capture.  Her pacemaker was interrogated and she was transferred to back to the hospital that placed it. The underlying rhythm looks like second degree heart block type II.