76-M with severe valvular aortic stenosis awaiting AVR presented to the hospital with recurrent dizziness and a witness syncopal event. In the ER, he is ‘dizzy’ and somewhat ‘drowsy’. His BP was measured at 90/60 mmHg with a pulse rate of 140/min. A 12-lead ECG was obtained and shown to you.
1.What does the ECG show?
2.What is the next step in management?
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Atrial flutter with variable block, stenotic lesions such at severe AS do not do well with high chronotrope, since they are afterload fixed and preload dependent. Managing this patient with shock as first line therapy. Other options would be to slow him with a short acting bb such as esmolol. Keep some phenylephrine ready in case it is needed.
this ECG is showing atrial flutter with variable conduction block
with this hemodynamic situation his appropriate mangment should be synchronized cardioversion (50 jouls)
but why would a tachycardia of 140 cause this much of hemodynamic instability ( the patient had multiple episodes of syncope , feeling dizzy, and his BP is low),
so I will proceed with ECHO: to look for :
1- signs of P.E ( RV strain): which can explain all his symptoms and hemodynamic instability.
2- severity of Aortic stenosis, which could be the cause of his hemodynamic instability on top of his tachyarrythemia
3-evidence of ischemia (regional wall abnormality), which could be the reason for his hemodynamic instability.
4- evidence of tamponade ( there is variety in the voltage of the QRS , prominent more in limb leads). although this possibility is far less likely ( because there is no "low voltage" especially in chest leads) , but still i will look for it.
also i will do ultrasound scanning to verify whether his shock is cardiogenic in nature or due to any other cause : scan IVC ( pethoric or collapsed), lungs ( to look for tension pneumothorax), FAST ( any peritoneal bleed) , aortic disection, or AAA.
if any scan showed any abnormality then i will treat accordingly, otherwise i will go ahead and cardiovert him with 50 joules