A 61 y.o. woman is depressed because her cat died; she is drinking alcohol and is sent to the Psych pod.

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.

A toxicologist happened to be in the psych pod and suggested amiodarone not be used. Why?

BEWARE AMIODARONE

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:

ANd EXCEPT in patients at risk for hypomagnesemia

AND EXCEPT when the patient is in “slow v tach” because it might be a reperfusion arrhythmia, hyperkalemia or sodium channel blocker OD.

This is a case of v tach with av dissociation and fusion beats. courtesy of Amal Mattu

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.