Wide complexes not ventricular?

[canoehead, BSN, RN]

I was in a touchy situation recently, and took on a patient who was in vtach to my eye with diaphoresis and sob. The docs chose to wait for labs before treating the heart rhythm, and with one thing and another there were no new orders until 2h later when the IM consult arrived. (Yes I advocated for my patient, I am the loud mouth of my unit, but I was unsuccessful). 

I've never heard of a wide complex tachycardia being anything but vtach, but I was told it is aberrant conduction, not ventricular. Should it not be treated as a vtach, if s/he is symptomatic? We were needing 100%o2 to keep sats above 90%. I'll enclose the IM comment on the rhythm. The patient converted to an afib at about 2200.

"ECG at 1945 queries limb lead reversal. The rhythm suggests atrial
fibrillation with a rate of 150 beats per minute.  There is aberrant
conduction with QRS increased at 146 milliseconds with a large voltage in the
precordial leads.  Repeat tracing at 2215 showed atrial fibrillation at 139
beats per minute with a QRS narrowed to 106 milliseconds.  There is evidence
of a prior anterolateral infarct.  Corrected QT interval is now within normal
limits."

I'm looking to educate myself on this, so if anyone can point me to reading material, that would be great.

[Rose_Queen, BSN, MSN, RN]

Here’s one article I found

https://www.aerjournal.com/articles/differential-diagnosis-wide-qrs-tachycardias

Quote

Wide QRS tachycardias can be VT, supraventricular tachycardia (SVT) conducting with bundle branch block (BBB) aberration, or over an accessory pathway, and account for 80%, 15% and 5% of cases, respectively.

 

[canoehead, BSN, RN]

so in anyone experience, do you treat these wide complexes differently from a vtach? I would consider this an unstable vtach because of the sob and diaphoresis with high o2 need. 

I felt strongly that the patient should have been emergently cardioverted...was I wrong? 

thank you Rose Queen

My bedside monitor had qrs 0.3 but varying beat to beat.

[MunoRN, RN]

It's important to differentiate between QRS's that are wide because they originate in the ventricles, and QRS's that wide because they originate above ventricles (junction or above) but where there is an intraventricular conduction delay/ block.  

You're not going to have much luck cardioverting a patient out of a supraventricular rhythm with an intraventricular block, these rhythms are the vast majority of wide QRS rhythms.  

[MaxAttack, BSN, RN]

Yep, wide complex tachycardias can be supraventricular or ventricular in origin. If you put "wide complex tachycardia" into Google you'll find some good resources. 

Shortness of breath with tachycardia - especially if isolated without chest pain/AMS/hypotension/etc - I've found to be a grey area that I don't see cardioverted often. However a tachycardia that is truly unstable you would absolutely cardiovert regardless of origin.

Did he spontaneously convert and did the shortness of breath resolve afterwards?

If you're looking for a good deep dive into ACLS then check out the full AHA guidelines with concepts and rationales on their website: https://CPR.heart.org/en/resuscitation-science/CPR-and-ecc-guidelines/adult-basic-and-advanced-life-support

[ghillbert, MSN, NP]

"Unstable" in reference to rhythms means hypotensive, in which case you could cardiovert. I work in cardiac and very, very, VERY frequently a WCT is not VT but an SVT with BBB.

[canoehead, BSN, RN]

On 6/13/2022 at 4:29 AM, MaxAttack said:

 

Did he spontaneously convert and did the shortness of breath resolve afterwards?

 

He spontaneously converted...hed been asking for water and been denied because of the chance he'd need to be defibbed. As soon as we gave him a drink, he converted.

 

And THANK YOU everyone, now I have some reading to do.

[canoehead, BSN, RN]

On 6/17/2022 at 7:46 PM, ghillbert said:

"Unstable" in reference to rhythms means hypotensive, in which case you could cardiovert. I work in cardiac and very, very, VERY frequently a WCT is not VT but an SVT with BBB.

His BP was fine, but given diaphoresis and labored breathing on 100% O2, I wouldn't call him stable. His rate was also averaging about 150, and how long would that be maintained? (Turns out, about two hours, but it was ugly) 

I had him wired for a shock, should things go downhill. I don't think he got treated with the urgency he deserved.

[MunoRN, RN]

On 6/20/2022 at 6:34 PM, canoehead said:

He spontaneously converted...hed been asking for water and been denied because of the chance he'd need to be defibbed. As soon as we gave him a drink, he converted.

 

And THANK YOU everyone, now I have some reading to do.

Did he convert to a narrow QRS or still a wide QRS but with a slower rate?

[ghillbert, MSN, NP]

On 6/25/2022 at 1:40 AM, canoehead said:

His BP was fine, but given diaphoresis and labored breathing on 100% O2, I wouldn't call him stable. His rate was also averaging about 150, and how long would that be maintained? (Turns out, about two hours, but it was ugly) 

I had him wired for a shock, should things go downhill. I don't think he got treated with the urgency he deserved.

Not discounting your clinical judgement, obviously SOB on 100% isn't stable, but WCT with normal BP is a "stable" rhythm per ACLS with regard to need for DCCV/defib. Shocking someone has it's own obvious risks, and there are a lot of things to try before that. 

[MaxAttack, BSN, RN]

23 hours ago, ghillbert said:

Not discounting your clinical judgement, obviously SOB on 100% isn't stable, but WCT with normal BP is a "stable" rhythm per ACLS with regard to need for DCCV/defib. Shocking someone has it's own obvious risks, and there are a lot of things to try before that. 

Just throwing it out there that the AHA considers a rhythm causing chest pain, AMS, signs of shock, or acute heart failure unstable as well.

[Tegridy]

did he actually need all that O2 or was he just thrown on it like half the patient's in the ER are for the heck of it?