the proper interpretation of tachycardias the proper interpretation of tachycardias breaking through...
TRANSCRIPT
The Proper Interpretationof Tachycardias
The Proper Interpretationof Tachycardias
Breaking through the barriersBreaking through the barriers
Raymond L. Fowler, M.D., FACEP
Raymond L. Fowler, M.D., FACEP
Associate Professor of Emergency MedicineAssociate Professor of Emergency MedicineThe University of Texas SouthwesternThe University of Texas Southwestern
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Deputy EMS Medical DirectorDeputy EMS Medical DirectorThe Dallas Metropolitan BioTel SystemThe Dallas Metropolitan BioTel System
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Co Chief in the Section onCo Chief in the Section onEMS, Disaster Medicine, and Homeland SecurityEMS, Disaster Medicine, and Homeland Security
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Past PresidentPast PresidentNational Association of EMS PhysiciansNational Association of EMS Physicians
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Associate Professor of Emergency MedicineAssociate Professor of Emergency MedicineThe University of Texas SouthwesternThe University of Texas Southwestern
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Deputy EMS Medical DirectorDeputy EMS Medical DirectorThe Dallas Metropolitan BioTel SystemThe Dallas Metropolitan BioTel System
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Co Chief in the Section onCo Chief in the Section onEMS, Disaster Medicine, and Homeland SecurityEMS, Disaster Medicine, and Homeland Security
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Past PresidentPast PresidentNational Association of EMS PhysiciansNational Association of EMS Physicians
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www.utsw.wswww.utsw.wswww.utsw.wswww.utsw.ws
www.rayfowler.comwww.rayfowler.com
Thoughts for the Day:Thoughts for the Day:
•I was thinking that women should put pictures ofmissing husbands on beer cans!
•If it’s true that we are here to help others, thenwhat exactly are OTHERS here for?
•How much deeper would oceans be ifsponges DIDN’T live there?
•If a cow laughed, would milk come out her nose?•Why don’t they just make MOUSE flavored cat food?•How come ABBREVIATED is such a long word?•I just got skylights put in my place…and the
people in the apartment above me are FURIOUS!•So, what’s the speed of “DARK”?
•I was thinking that women should put pictures ofmissing husbands on beer cans!
•If it’s true that we are here to help others, thenwhat exactly are OTHERS here for?
•How much deeper would oceans be ifsponges DIDN’T live there?
•If a cow laughed, would milk come out her nose?•Why don’t they just make MOUSE flavored cat food?•How come ABBREVIATED is such a long word?•I just got skylights put in my place…and the
people in the apartment above me are FURIOUS!•So, what’s the speed of “DARK”?
The emerging ofa subspecialty:
The emerging ofa subspecialty:
ParamedicineParamedicine
Approaching thePatient
Approaching thePatient
“See what you see!”“See what you see!”
““People look, but theyPeople look, but theydon’t see”don’t see”
……A. Fowler, Jr.A. Fowler, Jr.
““People look, but theyPeople look, but theydon’t see”don’t see”
……A. Fowler, Jr.A. Fowler, Jr.
Alertness? Level of distress?Noises?Respirations?The pulse rate?Skin?Obvious things (bleeding)
Alertness? Level of distress?Noises?Respirations?The pulse rate?Skin?Obvious things (bleeding)
The most common signof illness . . .The most common signof illness . . .
Elevated pulse rateElevated pulse rate
What normally acceleratesthe pulse rate?
What normally acceleratesthe pulse rate?
EpinephrineEpinephrine
Specifically:In response to stress,
epinephrine is releasedfrom the adrenal glandsmaking the heart beat
stronger and faster
Specifically:In response to stress,
epinephrine is releasedfrom the adrenal glandsmaking the heart beat
stronger and faster
Signs of ShockSigns of Shock
Weak, thirsty, lightheadedPale, then sweaty
TachycardiaTachypnea
Diminished urinary output
Weak, thirsty, lightheadedPale, then sweaty
TachycardiaTachypnea
Diminished urinary output
HypotensionAltered LOC
Cardiac arrestDeath
HypotensionAltered LOC
Cardiac arrestDeath
EarlyEarly
LateLate
What does a lowWhat does a lowblood pressure mean?blood pressure mean?
What does a lowWhat does a lowblood pressure mean?blood pressure mean?
EitherEither......EitherEither......
•Loss of volumeLoss of volume•Low cardiac outputLow cardiac output•Increased vascularIncreased vascular
spacespace
•Loss of volumeLoss of volume•Low cardiac outputLow cardiac output•Increased vascularIncreased vascular
spacespace
Or a combinationOr a combinationof any of theseof any of these
…from BTLS, editions 2, 3, 4, and 5 Fowler et al…from BTLS, editions 2, 3, 4, and 5 Fowler et al
ShockShock
CardiogenicRapid pulseDistended neck veinsCyanosis
CardiogenicRapid pulseDistended neck veinsCyanosis
Volume LossRapid pulseFlat neck veinsPale
Volume LossRapid pulseFlat neck veinsPale
VasodilatoryVariable pulseFlat neck veinsPale or pink
VasodilatoryVariable pulseFlat neck veinsPale or pink
Our pulse can only go so fast under sympatheticstimulation:
Our pulse can only go so fast under sympatheticstimulation:
220 minus age220 minus age
Baby = (220 – 0) = 220
Snerd = (220 – 53) = 167
Aunt Minnie = (220 – 70) = 150
Baby = (220 – 0) = 220
Snerd = (220 – 53) = 167
Aunt Minnie = (220 – 70) = 150
Put another way:Put another way:
Our pulse rates canonly go as fast as
epinephrine can makethem go...
Our pulse rates canonly go as fast as
epinephrine can makethem go...
…unless there is a conduction abnormality
…unless there is a conduction abnormality
So, REALLY . . .So, REALLY . . .
. . . ya got SINUS TACH . . .. . . ya got SINUS TACH . . .
. . . and everything else . . . and everything else
Sinus TachSinus Tach
oror
PSVT, Afib, Aflutter, MAT, or VTachPSVT, Afib, Aflutter, MAT, or VTach
THE ONLY PROBLEMIS TELLING THEDIFFERENCE!!
THE ONLY PROBLEMIS TELLING THEDIFFERENCE!!
Many medics are not adept
at EKG interpretation
WHY???
Many medics are not adept
at EKG interpretation
WHY???
Because many EKG courses are too long, too boring,
and teach difficult conceptsto medics
who will never use that information
Because many EKG courses are too long, too boring,
and teach difficult conceptsto medics
who will never use that information
Rhythm Strip InterpretationRhythm Strip Interpretation
Anatomically
Anatomicallyspeaking...
speaking...
Anatomically
Anatomicallyspeaking...
speaking...
1856 - First action potential described by von Koelliker and Muller
1887 - First EKG by Waller recorded on a lab technician named Thomas Goswell, in London
1893 - Einthoven introduces the term ‘electrocardiogram”
1895 - Einthoven names P QRS and T
1905 - Einthoven starts transmitting EKG’s from the hospital to his laboratory 1.5 k away via telephone cable, the first one on 3/22, the first ‘telecardiogram’
1910 - First American review of EKG’s, by James at Columbia and Willaims at Cornell
1912 - Einthoven described the Leads 1, 2, 3, later called Einthoven’s triangle”
1920- Pardee publishes the first EKG of an acute MI, describing the T wave as being tall and “starts from a point well up on the descent of the R wave”
1924 - Einthoven wins the Nobel for inventing the EKG
1932 - Wolferth and Wood describe the clinical use of chest leads
1938 - The AHA and the Cardiac Society of Great Britain define the standard positions, and wiring, of the chest leads V1 – V6
1942 - Emanuel Goldberger adds the augmented limb leads avR, avL, and avF to Einthoven’s three limb leads, making the first 12 lead EKG
1856 - First action potential described by von Koelliker and Muller
1887 - First EKG by Waller recorded on a lab technician named Thomas Goswell, in London
1893 - Einthoven introduces the term ‘electrocardiogram”
1895 - Einthoven names P QRS and T
1905 - Einthoven starts transmitting EKG’s from the hospital to his laboratory 1.5 k away via telephone cable, the first one on 3/22, the first ‘telecardiogram’
1910 - First American review of EKG’s, by James at Columbia and Willaims at Cornell
1912 - Einthoven described the Leads 1, 2, 3, later called Einthoven’s triangle”
1920- Pardee publishes the first EKG of an acute MI, describing the T wave as being tall and “starts from a point well up on the descent of the R wave”
1924 - Einthoven wins the Nobel for inventing the EKG
1932 - Wolferth and Wood describe the clinical use of chest leads
1938 - The AHA and the Cardiac Society of Great Britain define the standard positions, and wiring, of the chest leads V1 – V6
1942 - Emanuel Goldberger adds the augmented limb leads avR, avL, and avF to Einthoven’s three limb leads, making the first 12 lead EKG
Einthoven1912
Einthoven1912
Goldberger 1942
Goldberger 1942
AHA and Cardiac Society of Great Britain 1938
AHA and Cardiac Society of Great Britain 1938
SASA
AVAV
Bundle of HisBundle of His
Bundle BranchesBundle Branches
Heart Electrical Conduction Heart Electrical Conduction
RhythmStripInterpretation
RhythmStripInterpretation
RateRhythmPPRQRSSTTUAssessment
RateRhythmPPRQRSSTTUAssessment
Basic InterpretationBasic Interpretation
•Rate•Rhythm•P Waves•PR Interval•QRS Complex
•Rate•Rhythm•P Waves•PR Interval•QRS Complex
•ST Segment•T Wave•U Wave•Summarization
•ST Segment•T Wave•U Wave•Summarization
RateRate
RhythmRhythm
Axis
Hypertrophy
Infarction
Axis
Hypertrophy
Infarction
P
PR
QRS
ST
T
U
Assessment
P
PR
QRS
ST
T
U
Assessment
The first thingyou do is
to perform a “primary survey”of the EKG strip
The first thingyou do is
to perform a “primary survey”of the EKG strip
Speaking of rate, I have found thatbeing able to boogie makes a big difference in being able to tell one rhythm from another
Speaking of rate, I have found thatbeing able to boogie makes a big difference in being able to tell one rhythm from another
I mean. . .if you ain’t gotrhythm, what you gonna do?I mean. . .if you ain’t gotrhythm, what you gonna do?
IMPORTANT:IMPORTANT:
•Sinus tachycardia with a rate of 150 or aboveSinus tachycardia with a rate of 150 or aboveand PAT/PSVT look very similarand PAT/PSVT look very similar
•PAT/PSVT are not usually life threatening PAT/PSVT are not usually life threatening except in the rare setting of a except in the rare setting of a patient having myocardial ischemia patient having myocardial ischemia (chest pain, diaphoresis, or dyspnea)(chest pain, diaphoresis, or dyspnea)
•Sinus tachycardia with a rate of 150 or aboveSinus tachycardia with a rate of 150 or aboveand PAT/PSVT look very similarand PAT/PSVT look very similar
•PAT/PSVT are not usually life threatening PAT/PSVT are not usually life threatening except in the rare setting of a except in the rare setting of a patient having myocardial ischemia patient having myocardial ischemia (chest pain, diaphoresis, or dyspnea)(chest pain, diaphoresis, or dyspnea)
Even More Important:Even More Important:
•When you can’t tell if a rhythm isWhen you can’t tell if a rhythm issinus tachycardia or PAT/PSVT,sinus tachycardia or PAT/PSVT,be wary of the more serious causebe wary of the more serious cause
•It may be difficult, or even impossible,It may be difficult, or even impossible,to see any irregularity in very fast to see any irregularity in very fast atrial fibrillationatrial fibrillation
•When you can’t tell if a rhythm isWhen you can’t tell if a rhythm issinus tachycardia or PAT/PSVT,sinus tachycardia or PAT/PSVT,be wary of the more serious causebe wary of the more serious cause
•It may be difficult, or even impossible,It may be difficult, or even impossible,to see any irregularity in very fast to see any irregularity in very fast atrial fibrillationatrial fibrillation
The most common causeof tachycardia in Parkland ER
is probably albuterol……followed by
amphetamine, cocaine,sepsis, DKA…
The most common causeof tachycardia in Parkland ER
is probably albuterol……followed by
amphetamine, cocaine,sepsis, DKA…
The most common causeof bradycardia in Parkland ER
is probably beta blockers…
…probably ISN’T greatphysical conditioning…
The most common causeof bradycardia in Parkland ER
is probably beta blockers…
…probably ISN’T greatphysical conditioning…
The incidence of bradycardia
post-hemorrhage,especially
intraperitoneally,is published to be
as high as 7 to over 20%
The incidence of bradycardia
post-hemorrhage,especially
intraperitoneally,is published to be
as high as 7 to over 20%
Always explain a tachycardia...
Corollary:Corollary: Don't depend on the presence of a tachycardia to determine that
an emergency is present
Always explain a tachycardia...
Corollary:Corollary: Don't depend on the presence of a tachycardia to determine that
an emergency is present
Sinus Tachycardia:
A “physiological response”
Sinus Tachycardia:
A “physiological response”
Remember:
The Maximum Sinus Tachycardiafor a patient is
about 220 - age
Remember:
The Maximum Sinus Tachycardiafor a patient is
about 220 - age
What is this rhythm?What is this rhythm?
Correct answer:“It COULD be sinus tach”
Correct answer:“It COULD be sinus tach”
220 – 55 = 165220 – 55 = 165
If you forget everythingelse that I say:
Remember that Remember that patients havingpatients havingnear maximumnear maximum
sinus tachycardiasinus tachycardiaat restat rest
are dying!are dying!
If you forget everythingelse that I say:
Remember that Remember that patients havingpatients havingnear maximumnear maximum
sinus tachycardiasinus tachycardiaat restat rest
are dying!are dying!
Hemorrhagic shockSepsis
TensionTamponade
Ruptured aortaRuptured ectopic
Massive P.E.
Hemorrhagic shockSepsis
TensionTamponade
Ruptured aortaRuptured ectopic
Massive P.E.
Something Something mobilizing amobilizing a
massivemassivephysiological physiological
responseresponse
Something Something mobilizing amobilizing a
massivemassivephysiological physiological
responseresponse
Your job isto determine ifa rapid rhythm
MAY be sinus tach
Your job isto determine ifa rapid rhythm
MAY be sinus tach
If it is, If it is, you must take actionyou must take action
If it is, If it is, you must take actionyou must take action
What is this rhythm?What is this rhythm?
220 – 60 = 160220 – 60 = 160
Correct answer:“This HAS to bean arrhythmia
Correct answer:“This HAS to bean arrhythmia
RegularityRegularity
Is there Regular
Irregularity or
IrregularIrregularity?
Is there Regular
Irregularity or
IrregularIrregularity?
Is there Regular
Irregularity:
•Bigeminy/Trigeminy•Wenckebach
The “guy with a limp”The “guy with a limp”
Is there Regular
Irregularity:
•Bigeminy/Trigeminy•Wenckebach
The “guy with a limp”The “guy with a limp”
RegularIrregularity:
•Bigeminy/Trigeminy
Underlying sinus rhythmUnderlying sinus rhythmwith PVC’s regularlywith PVC’s regularly
RegularIrregularity:
•Bigeminy/Trigeminy
Underlying sinus rhythmUnderlying sinus rhythmwith PVC’s regularlywith PVC’s regularly
BigeminyBigeminy
RegularIrregularity:
•Wenckebach
Sinus rhythm with Sinus rhythm with progressive prolongation progressive prolongation
of PR until dropped P waveof PR until dropped P wave
RegularIrregularity:
•Wenckebach
Sinus rhythm with Sinus rhythm with progressive prolongation progressive prolongation
of PR until dropped P waveof PR until dropped P wave
WenckebachWenckebach
IrregularIrregularity:
•Atrial Fibrillation•Variable Atrial Flutter
•MAT•Ectopy
The “stumbling drunk”The “stumbling drunk”
IrregularIrregularity:
•Atrial Fibrillation•Variable Atrial Flutter
•MAT•Ectopy
The “stumbling drunk”The “stumbling drunk”
IrregularIrregularity:
•Atrial Fibrillation
Irregularly irregular,narrow complex,chaotic baseline
IrregularIrregularity:
•Atrial Fibrillation
Irregularly irregular,narrow complex,chaotic baseline
Atrial FibrillationAtrial Fibrillation
Appears almostregular on thissmall portion ofthe strip
Appears almostregular on thissmall portion ofthe strip
A look ata larger strip
reveals theirregularity
A look ata larger strip
reveals theirregularity
IrregularIrregularity:
•Multifocal AtrialTachycardia
Irregularly irregular,narrow complex,
three or more P waves
IrregularIrregularity:
•Multifocal AtrialTachycardia
Irregularly irregular,narrow complex,
three or more P waves
Multifocal Atrial Tachycardia
Multifocal Atrial Tachycardia
IrregularIrregularity:
•Ectopy
Underlying sinus rhythmdisturbed by
PAC’s (narrow)or PVC’s (wide)
IrregularIrregularity:
•Ectopy
Underlying sinus rhythmdisturbed by
PAC’s (narrow)or PVC’s (wide)
IrregularIrregularity:
•Atrial Flutter withVariable Block
Sawtooth Baseline withVarying Ventricular
Response
IrregularIrregularity:
•Atrial Flutter withVariable Block
Sawtooth Baseline withVarying Ventricular
Response
Atrial Flutter withVariable Block
Atrial Flutter withVariable Block
Atrial Flutter withHigher Grade BlockAtrial Flutter with
Higher Grade Block
Regular•Sinus Tach
•PSVT•Aflutter with fixed block
Narrow complex,very regular and fast
Regular•Sinus Tach
•PSVT•Aflutter with fixed block
Narrow complex,very regular and fast
Regular•Sinus Tach
Narrow complex,usually see P waves,
defined by >100,Remember 220 – age!
Regular•Sinus Tach
Narrow complex,usually see P waves,
defined by >100,Remember 220 – age!
Sinus TachSinus Tach
Sinus Tachwith LBBBSinus Tachwith LBBB
Regular•PSVT
Narrow complex,often don’t see P waves,
typically >150,perhaps over 200
Regular•PSVT
Narrow complex,often don’t see P waves,
typically >150,perhaps over 200
Paroxysmal Supraventricular
Tachycardia
Paroxysmal Supraventricular
Tachycardia
Speaking of AdenosineSpeaking of Adenosine
…but just when we thought life was getting easier…
…but just when we thought life was getting easier…
Advanced Cardiac Life SupportAdvanced Cardiac Life Support
•…is commendable for its continuedsearch for the science ofemergency cardiac care
•…but, misses the boat in terms oftelling us how to assess tachycardia in a rememberable manner
•…is commendable for its continuedsearch for the science ofemergency cardiac care
•…but, misses the boat in terms oftelling us how to assess tachycardia in a rememberable manner
Advanced Cardiac Life SupportAdvanced Cardiac Life Support
It is insufficient to simply say“are the signs or symptoms
due to tachycardia?”or
“Rate-related signs and symptoms occur at many rates, seldom < 150 bpm”
It is insufficient to simply say“are the signs or symptoms
due to tachycardia?”or
“Rate-related signs and symptoms occur at many rates, seldom < 150 bpm”
Unstable TachycardiasUnstable TachycardiasThe ACLS StatementThe ACLS Statement
…it doesn’t sayEXAMINE THE PATIENT!
…it doesn’t sayEXAMINE THE PATIENT!
““Establish rapid heart rate as Establish rapid heart rate as cause of signs and symptoms”cause of signs and symptoms”
““Rate related signs and Rate related signs and symptoms occur at many rates”symptoms occur at many rates”
What is the ambient temperature?
What is the ambient temperature?
What is the patient’s blood pressure?
What is the patient’s blood pressure?
Remember:Remember:
If you find a patient with a tachycardia,The first question to ask is
“could this be a sinus tachycardia”!
If you find a patient with a tachycardia,The first question to ask is
“could this be a sinus tachycardia”!
Of course, if the patient is on the monitor andyou see THIS…..
Of course, if the patient is on the monitor andyou see THIS…..
Remember too:Remember too:
80% of Wide Complex Tachycardiaswill be VTach
The rest will be sinus tach with abundle branch block
80% of Wide Complex Tachycardiaswill be VTach
The rest will be sinus tach with abundle branch block
Evaluation of TachycardiaEvaluation of Tachycardia
Ventricular rate over 100Ventricular rate over 100
Max sinus = 220 - ageMax sinus = 220 - ageWhat is the
patient’s maximum expected
sinus tachycardia?
What is the patient’s maximum
expectedsinus tachycardia?
Is it fast?(If so, keep going)
Is it fast?(If so, keep going)
If so, rule out and/ortreat cause(s),
such a hypovolemia, sepis, and other
shock states
If so, rule out and/ortreat cause(s),
such a hypovolemia, sepis, and other
shock states
Could it besinus
tachycardia?
Could it besinus
tachycardia?
YES
Is it narrow, perfectly regular,
and 150 or above?
Is it narrow, perfectly regular,
and 150 or above?
Paroxysmal supraventricular
tachycardia, unless sinustachycardia is possible
Paroxysmal supraventricular
tachycardia, unless sinustachycardia is possible
YES
Irregularly irregular, narrow
complex,probably
atrial fibrillationAlso consider
frequent ectopy,Variable Aflutter
and MAT
Irregularly irregular, narrow
complex,probably
atrial fibrillationAlso consider
frequent ectopy,Variable Aflutter
and MAT
Is it regular? Is it regular?NO
WIDE andPERFECTLY
regular,probably Vtach
WIDE and irregular,probably atrialfibrillation with
bundle branch block
WIDE andPERFECTLY
regular,probably Vtach
WIDE and irregular,probably atrialfibrillation with
bundle branch block
Is it wide?Is it wide? YES
Narrow OR wide,regular (usually),
with sawtoothbaseline
Narrow OR wide,regular (usually),
with sawtoothbaseline
Atrial flutter (fairly rare)
REMEMBER, the
block MAY bevariable in
flutter
Atrial flutter (fairly rare)
REMEMBER, the
block MAY bevariable in
flutter
YES
IMPORTANT:IMPORTANT:
•Sinus tachycardia with a rate of 150 or aboveSinus tachycardia with a rate of 150 or aboveand PAT/PSVT look very similarand PAT/PSVT look very similar
•PAT/PSVT are not usually life threatening PAT/PSVT are not usually life threatening except in the rare setting of a except in the rare setting of a patient having myocardial ischemia patient having myocardial ischemia (chest pain, diaphoresis, or dyspnea)(chest pain, diaphoresis, or dyspnea)
•Sinus tachycardia with a rate of 150 or aboveSinus tachycardia with a rate of 150 or aboveand PAT/PSVT look very similarand PAT/PSVT look very similar
•PAT/PSVT are not usually life threatening PAT/PSVT are not usually life threatening except in the rare setting of a except in the rare setting of a patient having myocardial ischemia patient having myocardial ischemia (chest pain, diaphoresis, or dyspnea)(chest pain, diaphoresis, or dyspnea)
Even More Important:Even More Important:
•When you can’t tell if a rhythm issinus tachycardia or PAT/PSVT,be wary of the more serious cause
•It may be difficult, or even impossible,to see any irregularity in very fast atrial fibrillation
•When you can’t tell if a rhythm issinus tachycardia or PAT/PSVT,be wary of the more serious cause
•It may be difficult, or even impossible,to see any irregularity in very fast atrial fibrillation
Case Studiesin
Tachycardia Evaluation
Case Studiesin
Tachycardia Evaluation
A 15 year old AA maleis found confused, sweaty, with
a respiratory rate of 36,a systolic pressure of 80, and
this EKG rhythm strip
A 15 year old AA maleis found confused, sweaty, with
a respiratory rate of 36,a systolic pressure of 80, and
this EKG rhythm strip
What is the “working impression”and what do you think
might be the cause of his problem?
What is the “working impression”and what do you think
might be the cause of his problem?
72 WF with a cardiac historypresents with palpitationsand shortness of breath
72 WF with a cardiac historypresents with palpitationsand shortness of breath
Her systolic is 130 andher lungs have rales
Her systolic is 130 andher lungs have rales
72 years old
220 – 72 = 148
72 years old
220 – 72 = 148
The Strip is at about 160What statement can you make?
The Strip is at about 160What statement can you make?
72 years old
220 – 72 = 148
72 years old
220 – 72 = 148
It HAS to be an arrhythmia!It can’t be sinus tach!
It HAS to be an arrhythmia!It can’t be sinus tach!
30 year old Sweet Suepresents with a systolic of 90and history of palpitationsplus abdominal pain today
30 year old Sweet Suepresents with a systolic of 90and history of palpitationsplus abdominal pain today
She ran out of her “heart pill”She ran out of her “heart pill”
30 year old femaleRate of 180
220 – 30 = 190
30 year old femaleRate of 180
220 – 30 = 190
What statement can you make?What statement can you make?
Is it PSVT (hx of palpitations?)or Sinus Tach?
Which is more dangerous?
Is it PSVT (hx of palpitations?)or Sinus Tach?
Which is more dangerous?
30 year old femaleRate of 180
220 – 30 = 190
30 year old femaleRate of 180
220 – 30 = 190
60 year old Aunt Minniepresents with systolic of 90
and no cardiac history
60 year old Aunt Minniepresents with systolic of 90
and no cardiac history
She has been ill for two daysShe has been ill for two days
60 year old with rate of 158220 – 60 = 160
60 year old with rate of 158220 – 60 = 160
What statement can you make?What statement can you make?
60 year old with rate of 158220 – 60 = 160
60 year old with rate of 158220 – 60 = 160
Does she need Adenosine?Does she need Adenosine?
Speaking of AdenosineSpeaking of Adenosine
Summary ThoughtsAbout TachycardiaSummary ThoughtsAbout Tachycardia
•Don’t be a careless EKG reader•Your patients’ lives depend on it•Make YOUR medical director proud•Remember that you start with
the patient’s maximum possiblepulse rate (220 – age), eliminate sinus tachycardia
if it is too fast or doesn’t look right, and then figure it out from there
•Don’t be a careless EKG reader•Your patients’ lives depend on it•Make YOUR medical director proud•Remember that you start with
the patient’s maximum possiblepulse rate (220 – age), eliminate sinus tachycardia
if it is too fast or doesn’t look right, and then figure it out from there
Synthesis
Synthesis
So,Who’s
Foolin’ Who??
So,Who’s
Foolin’ Who??
The scope of practiceof these EMS professionals
continues to growwith passing years
The scope of practiceof these EMS professionals
continues to growwith passing years
EMS professionalsare primary members
of the emergency medical team.
EMS professionalsare primary members
of the emergency medical team.
Let us then apply our best efforts
in training and periodic retrainingwith the sharpened focus
of clarity and simplification,pooling our individual creativities
for the greater goodof those we serve.
Let us then apply our best efforts
in training and periodic retrainingwith the sharpened focus
of clarity and simplification,pooling our individual creativities
for the greater goodof those we serve.
This Talk may be found atThis Talk may be found at
www.rayfowler.comwww.rayfowler.com
[email protected]@doctorfowler.com
This Talk may be found atThis Talk may be found at
www.rayfowler.comwww.rayfowler.com
[email protected]@doctorfowler.com
. . . and Good Afternoon!. . . and Good Afternoon!
Questions or comments?
Questions or comments?