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EMS 12-Lead
by Tom Bouthillet

ECG Challenge: The path 'more' traveled

EMS is called to a hardware store for a 59-year-old male with palpitations

By Tom Bouthillet

Here's an interesting case submitted by Adam Thompson from Paramedicine 101. Some changes have been made to preserve patient confidentiality. EMS is called to a hardware store for a 59-year-old male with palpitations.

On arrival the patient is found sitting in a chair in the storeroom. He appears anxious. Skin is pink, warm and moist. He states that this has "happened before" but it's "been a while."

The patient is a poor historian. He states that he's seen a doctor for palpitations before and they "wanted to some kind of procedure but I said forget it!"



Vital signs:

RR: 14
Pulse: Extremely rapid and irregular
NIBP: 138/91
SpO2: Does not register

The patient denies chest pain or shortness of breath.

Breath sounds are clear bilaterally.

The cardiac monitor is applied.

How would you treat this patient and why?

About the author

Tom Bouthillet is a Fire Captain/Paramedic with Hilton Head Island Fire & Rescue, Editor-in-Chief of the, Chief Content Architect of, host of the Code STEMI web series at First Responders Network, a member of the Editoral Advisory Board of EMS World Magazine, and developer of the 12-Lead ECG Challenge smartphone app. He has taught nationally in the Critical Care Transport (CCEMT-P) program out of UMBC and his writings have been referenced in the American Heart Journal, the Journal of the American College of Cardiology: Cardiovascular Interventions and the EP Lab Digest. Contact Tom at
The comments below are member-generated and do not necessarily reflect the opinions of or its staff. If you cannot see comments, try disabling privacy and ad blocking plugins in your browser. All comments must comply with our Member Commenting Policy.
Roger Hancock Roger Hancock Wednesday, March 05, 2014 3:33:17 AM Prepare for cardioversion just in case. Oxygen 4L NC, 12 lead ecg, 10mg cardizem over 2 minutes and reassess repeat 10mg in 5 minutes if rhythm didn't convert.
Ebtehal Elzaki Ebtehal Elzaki Wednesday, March 05, 2014 4:23:05 AM this is AF due to WPW delta wave indicate accessory pathway so amiodarone or fleicanide and radiofrequency ablation
Branka Ilic David Branka Ilic David Wednesday, March 05, 2014 6:47:22 AM Attach monitor, i.v. route, Valsalva with deep breath, if slowdown try to differentiate that deformation at the beginning of R is it or not a delta wave,oxygen, and if you aren't sure amiodarone , maybe it will slowdown.
Valérie Gagnon Valérie Gagnon Friday, March 07, 2014 10:20:05 PM Multifocal Atrial Tachycardia there's at least 3 distinct P-wave morphologies in the same lead. You need to treat the underlying cause
Brad Miller Brad Miller Wednesday, June 18, 2014 6:05:04 PM Not doing anything other than the basics till I see the 12 lead
B Dwayne Armstrong B Dwayne Armstrong Wednesday, June 18, 2014 6:26:15 PM get HX, O2, 12 Lead, IV, 5 mg Metoprolol up to 3 doses, continue monitoring the patient
Dawn Poetter Dawn Poetter Wednesday, June 18, 2014 6:35:56 PM That was exactly my thoughts too Valerie ;-)
Panther FyreMedic Panther FyreMedic Wednesday, June 18, 2014 6:43:27 PM Atrial Fib w/ Rapid Ventricular Response. O2, Monitor, IV Access. Since he appears hemodynamically stable, transport C-2 w/o further intervention unless Pt condition or complaints change. For extended transport times, consider amiodarone 150.0 mg.
Barry Strother Barry Strother Wednesday, June 18, 2014 6:46:47 PM O2 titrate to spo2 of 94%. Vagal maneuvers. IV, 12 lead. Etco2 monitoring via nasal cannula. Pt is stable. Monitor and transport. If 12 lead showed stemi or ischemia follow ACLS protocol. This rhythm is most likely AF. Why would you give drugs to a stable pt and potentially do more harm.
John Henry John Henry Wednesday, June 18, 2014 7:48:51 PM Prep for transport. IV,O2,monitor. Prepair for possibly cardiovert with cardizam.
Karin Featherston Karin Featherston Wednesday, June 18, 2014 7:49:09 PM WPW. O2 and procainamide
Scott Wright Scott Wright Wednesday, June 18, 2014 9:08:59 PM adenacard to slow down suspect a-fib but will see what the adenacard will do if a-fib will treat with diltiazam if new onset. If pt remains stable no need for cardioversion in the field
Megan Lorraine Crosby Megan Lorraine Crosby Wednesday, June 18, 2014 9:27:13 PM I would first treat with a low dose of morphine 5mg to slow his heart rate down evwn though it may cause a fast heart rate to start once the dosage is fully injected his heart rate would slow down. Reason being I would do so would be because he seems to be hyperventilating and he can then cause himself to go into cardiac arrest or any cardiac situation. So to prevent that would to be to slow his heart rate down.
Allen Ramsey Allen Ramsey Thursday, June 19, 2014 4:28:23 AM This is A-fib with WPW. This patient needs to be cardioverted as soon as possible due to the fact that patients that present with this are likely to have a sudden cardiac arrest and go into V-fib. If cardioversion is not am option procainamide or amiodarone are the preferred drugs. This patient needs a radio ablation as definitive treatment for this.
Joshua Boylan Joshua Boylan Thursday, June 19, 2014 5:19:13 AM I would want a 12-lead first, I don't see enough evidence in lead II to definitely say he has WPW, but if the 12-lead shows a definitive delta wave Procainamide would be the drug of choice, of not available Amio or cardioversion would work.
Moe Sallaq Moe Sallaq Thursday, June 19, 2014 6:28:51 AM A-fib with RVR O2 and cardizam.
Michael Dyer Michael Dyer Thursday, June 19, 2014 6:59:10 AM Oxygen by nrb and transport....
Christy MacLaren Christy MacLaren Thursday, June 19, 2014 8:01:49 AM NC at 2 lpm. IV while trying vagal maneuvers and confirm Afib with RVR with 12 lead. If it is as such then diltiazem.
Lisa Thompson Lisa Thompson Thursday, June 19, 2014 8:03:46 AM A fib with RVR....vs stable only symptom palpitions. I would first try cardiizem but if became unstable at any time I would cardiovert...
Kevin Thomas Kevin Thomas Thursday, June 19, 2014 8:04:50 AM I'm leaning on WPW, however I'd like to see a 12 lead to confirm. If it is in fact WPW I'd like to treat with Amio 150mg since the patient is presenting stable. If conditions change or deteriorate I'd transition to cardioversion. I'm not normally one to over treat a stable patient, however WPW left untreated can rapidly deteriorate to sudden arrest.
Joshua Xpuonavopec Burleson Joshua Xpuonavopec Burleson Thursday, June 19, 2014 10:02:21 AM I really hope you don't have a license
Joshua Xpuonavopec Burleson Joshua Xpuonavopec Burleson Thursday, June 19, 2014 10:12:30 AM DAT DELTA WAVE! Need a 12-Lead, looks like WPW (DDx A-Fib w/ RVR)...Try vagal maneuvers, procainamide 10mg/kg if necessary and have the defib ready for cardioversion or defibrillation. I understand the desire not to "over treat" but WPW w/ afib can quickly deteriorate into VFIB/VTACH.
Derek Hawn Derek Hawn Thursday, June 19, 2014 11:37:44 AM O2 I'v monitor, pt is stable so just monitor and transport routine to Er.
Allyson Faye Katz Allyson Faye Katz Thursday, June 19, 2014 11:38:50 AM I'd do a 12 lead and iv
Christine Marie Cosulich Christine Marie Cosulich Thursday, June 19, 2014 11:52:27 AM Rapid atrial fibrillation. IV. Cardizem 0.25mg/kg after obtaining 12 lead EKG
Joshua Xpuonavopec Burleson Joshua Xpuonavopec Burleson Thursday, June 19, 2014 12:05:46 PM not w/ WPW - can send the pt into VFIB/VTACH
Jose De Jesus Jose De Jesus Thursday, June 19, 2014 12:51:36 PM O2 4lpm CN , .9nss IV slow , 12 lead monitor and if is necesary prepare cardioverson or vagal maneuver if the patient has no history of clots
Jose De Jesus Jose De Jesus Thursday, June 19, 2014 12:53:30 PM and transport to an appropriate treatment facility for cardiac conditions
Megan Lorraine Crosby Megan Lorraine Crosby Thursday, June 19, 2014 1:02:06 PM Befor you start talking shit my friend posted that on my phone and yes I do have my licence. So before you go and run your mouth you might want to think about what else it could be. And honestly asshole I would not do anything but make the person as comfortable as possable until we got to rhe ER. I would however keep an eye on his vitles and heart rate and if any major changes happen then I would do my duity. So shut your face.
Joshua Xpuonavopec Burleson Joshua Xpuonavopec Burleson Thursday, June 19, 2014 1:16:28 PM Megan Browning girls maaaaad, don't let friends post crappy interventions under your name if you don't want people telling you that those interventions are not effective and represent a dangerous lack of knowledge regarding both pharmacology and pathophysiology...
Megan Lorraine Crosby Megan Lorraine Crosby Thursday, June 19, 2014 1:22:28 PM She took my phone and told me she was plating a game had no clue she was on any of my private profiles that does make me mad I just messaged her to let her know she is a complete utter dumb ass and she can never touch my phone again I guess thats what I get for being a nice person oh well mistakes can always be learned from.
Nelson Poythress Nelson Poythress Thursday, June 19, 2014 4:33:45 PM Load pt. apply O2, iv access and cardiac monitor. Attempt vagal maneuvers in an attempt to slow rate, above all obtain a 12 lead before further treatment is administered.
Krista Gregory Krista Gregory Thursday, June 19, 2014 7:22:29 PM O2, Vagal Maneuvers while obtaining 12 lead estab IV then consider adenosine or procainamide. Depending on 12 lead interpretation.
Bobby Don Shelton II Bobby Don Shelton II Thursday, June 19, 2014 9:02:53 PM Afib with rvr. Cardizem since he is non symptomatic
Ceejay Jara Ceejay Jara Friday, June 20, 2014 6:29:21 AM yeah it looks like afib it has delta waves so wpw?
Johnathan Harrison Johnathan Harrison Saturday, June 21, 2014 7:43:44 AM No cardizem with suspected WPW
Paul Bishop Paul Bishop Thursday, July 31, 2014 7:44:58 PM Amiodarone is CONTRAINDICATED for WPW
Iliyas Sheikh Iliyas Sheikh Thursday, July 31, 2014 11:51:57 PM A.fib with rapid v.response, Amiodarone &/if fail Cardioversion
Geoffrey Miller Geoffrey Miller Friday, August 01, 2014 1:48:08 AM Most people don't understand the pharmacokinetics and dynamics of the mess they use or they would know it contraindicated and why.