She has snoring respirations and a rhythm strip is shown below.
What is the problem here and what is the treatment. Her EKG post resuscitation is shown below.
Amiodarone is marketed as a class III antiarrhythmic but actually is also a class I and blocks sodium channels. It should not be given in several situations where there is a wide complex tachycardia.
1. WPW with a fib( use procainamide)
2. Wide complex tachycardia in a patient on methadone. Methadone prolongs QT
3. Anyone with “slow v tach” (rate < 120). This kind of idioventricular rhythm can be due to reperfusion arrhythmias, TCA , cocaine OD or hyperkalemia. If amiodarone is given it can cause cardiac arrest.
Lidocaine is also contraindicted in an idioventricular rhythm and also can cause an arrest.
SO USE AMIODARONE:
Marill K, deSouza IS, et al. Amiodarone is poorly effective for termination of ventricular tachycardia. 2006. Ann Em Med. 47(3):217-24.
Ortiz M, Martin A, Arribas F. et al. Randomized comparison of IV procainamide vs IV amiodarone for acute treatment of wide QRS tachycardia. Eur Heart J. 2017 38:1329-35. Doi 10.1093eurheartj/ehw230.
ACC/AHA/ESC. Guidelines for management of patients with ventricular arrhythmias and prevention of sudden death. Executive summary. 2006. Circulation.
The EKGs except for our patient were taken from Amal Mattu’s lecture which is available free on the ACEP bonus free eCME web site. Thanks to Dr. Liss for the case.