How to avoid a clean kill with wide complex tachycardias

Nov 20, 2024

Mindmap

Lecture Notes: ECG Mimics and Hyperkalemia

Introduction

  • Discussion on electrocardiography (ECG) mimic
  • Focus on one specific mimic over a 10-minute lecture
  • Real case of a 45-year-old male with palpitations and wide complex tachycardia

Case Study Overview

  • Patient: 45-year-old male, palpitations, blood pressure 115
  • Wide complex tachycardia observed

Drug Choices

  • Initial treatment with amiodarone was chosen by physicians
  • Amiodarone is not favored; procainamide preferred for regular wide complex tachycardias
  • Alternative drugs: lidocaine may have similar outcomes

Understanding Wide Complex Tachycardia

  • Regular Wide Complex Tachycardia (RWCT) vs. Really Wide Complex Tachycardia (R-RWCT)
  • Really Wide: QRS complexes greater than one large box (>200 ms)

Diagnosis and Treatment

  • First diagnosis for really wide complex tachycardia should be tox or metabolic issues
  • ACS guidelines recommend sodium channel blockers like lidocaine, amiodarone, or procainamide
  • Danger: these can be lethal in cases of hyperkalemia (K+ imbalance)

Hyperkalemia Insights

  • Hyperkalemia poisons sodium channels, similar to tricyclic overdose
  • Do not use sodium channel blockers if sodium channels are impaired

Recommended Approach

  • Empiric use of calcium and bicarbonate in suspected tox/metabolic cases
  • Empirical treatment counters potential harm from following ACLS guidelines

Hyperkalemia Case Studies

  • Various cases demonstrating misdiagnosis and mismanagement
  • Importance of recognizing too wide and too slow rhymes with tox/metabolic

Key Takeaways

  • Rate below 120 or wide QRS: consider tox/metabolic
  • Empirical treatment with calcium and bicarbonate saves lives
  • Correct diagnosis essential: VTach vs. tox/metabolic

Conclusion

  • Regular really wide complex tachycardia is not VTach by default
  • ACLS protocols can be dangerous in emergency department scenarios
  • Always think calcium/bicarbonate first in wide, slow tachycardia

Remember: "Primum non nocere" (First, do no harm). Following ACLS blindly in every regular really wide complex tachycardia can be fatal. Consider the underlying cause and treat accordingly with calcium and bicarbonate when suspecting tox/metabolic issues.