Wide Complex Tachycardia: Diagnosis And Management In The Emergency Department

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It's actually a slow day in the ED and you make the mistake of saying so. Suddenly, the EMS radio goes off and reports that they are en route with a dyspneic older male, status post recent syncopal event—ETA 10-12 minutes; an ECG rhythm strip is sent for your review (Figure 1, patient #1). He has a history of myocardial infarction (MI) with congestive heart failure (CHF). His vital signs include a blood pressure (BP) of 100/65 mm Hg, pulse (P) of 170 bpm, respiratory rate (RR) of 28/minute, and oxygen saturation (SAT) of 92% on 4l nasal cannula.

Seconds later, the charge nurse tells you that you should see the elderly lady in room 22 soon. Upon entering the room, you see an awake, alert, elderly female sitting comfortably on the stretcher. She is conversant and in no distress. Her vital signs include a BP of 170/120 mm Hg, pulse 170 bpm, RR of 22/minute, and SAT of 94% on room air; the 12-lead ECG reveals a wide complex tachycardia (WCT,Figure 2, patient #2).

Then, you hear “I need a doctor now” from room 9. You find a young adult male supine on the cot. He is alert and oriented, complaining of extreme dizziness and weakness. He is pale and diaphoretic. The monitor demonstrates a WCT (Figure 3, patient #3). The examination is significant for a BP of 85 mm Hg by palpation, pulse 190 bpm, RR of 34/minute, and SAT of 96% on room air.

Around the same time, you are called to the telephone regarding a patient a local internist is sending in for evaluation. An elderly male, aged 71 years, presented with palpitations. He has a history of stable angina managed with atenolol. His examination is remarkable for normal vital signs with the exception of a pulse of 190 bpm. The ECG rhythm strip demonstrates a WCT (Figure 4, patient #4).

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