My partner and I were called in as medical backup for another ALS crew for a female in her 80's at a private residence card 28 (query stroke). When the original crew arrived, they found the patient to be bradycardic with a heart rate of 37. The ACP administered Atropine which increased the patient's heart rate to the 140's and into ventricular tachycardia.
When I arrived on scene, the crew already had the patient in the ambulance, still in ventricular tachycardia, with a pulse and unstable. We attempted cardioversion x 2, increasing the energy from 100 to 200 J with no effect. The crew transported the patient to PLC ED.
When I arrived at PLC shortly after, it sounds like the receiving physician was querying a bleed.
Dr. Ian Walker
Finally had a chance to pull it all up and have a look. Interesting case.
Unsurprisingly, she had a large ICH with SAH extension. Not compatible with life. That would explain her progressive HTN and bradycardia.
Looking at the EKG's, I actually think this is likely NOT VT, although of course the "if you are not sure, assume VT" truism remains in place for a reason, and certainly people CAN get VT and other cardiac arrhythmias secondary to big intracranial bleeds.
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My reasons for thinking that it is sinus with conduction delay are a few fold.
The clinical scenario. If you think about it, the reason for the bradycardia in here was a Cushing response, which is vagally mediated. Thus you would expect a vagal blockade to result in a pretty good going tachycardia (as opposed to those people who have diseased AV nodes who tend to get a pretty muted response.). the rhythm is nearly perfectly regular, but not quite. VT is usually incredibly regular. There is no way you would notice that without printing out the EKG and actually measuring out each RR interval (which i did) i dont see any fusion beats of retrograde p's, which you will often see in VT. The absence of them doesnt prove that its not, but it is another thing to look for The axis of the QRS is the same between the initial EKG and the WCT one. If someone were in true VT, the origin of the QRS and therefore the direction of depolarization is going to be different. Her WCT complexes are a touch wider than her original EKG, but the morphology is otherwise the same. This is probably the biggest thing that convinced me that this was not VT. In any case, the case is interesting for sure and i think your care was excellent. i would have done the exact same thing in your situation, including the attempt to shock. Given the high index of suspicion of an ICH, you have to assume that she needs that HTN to maintain her cerebral perfusion pressure, so, other than shocking her, i dont know that i would have done anything else to slow her down.
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