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📘 Episode Summary:
In this episode of CardioCast, the crew shifts focus from narrow to wide complex rhythms, breaking down the clinical significance, risks, and treatment strategies for both wide complex tachycardias and bradycardias. These rhythms often trigger more concern due to their ominous appearance and potential for rapid deterioration. The team explores the role of hyperkalemia, ventricular tachycardia (VT), torsades de pointes, and ventricular electrical storms, including how EMS providers can rapidly identify and manage these critical presentations in the field.

🩺 Key Topics Covered:

1. Why Wide Complex Rhythms Are Clinically Concerning
   
   

   • Morphology often looks insidious and lethal.
     
     

   • Stable VT may appear deceptively benign.
     
     

   • Wide rhythms require increased diagnostic suspicion and urgency.
     
     

2. VTACH Management Strategies
   
   

   • Unstable = electricity (synchronized cardioversion).
     
     

   • Stable = pharmacologic treatment (amiodarone or lidocaine).
     
     

   • Importance of QRS width and morphology in decision-making.
     
     

   • "Really wide" QRS raises suspicion for hyperkalemia or toxicologic causes.
     
     

3. Hyperkalemia: The Great Mimicker
   
   

   • Presents with bradycardia, tachycardia, widened QRS, or sine wave.
     
     

   • Early signs: peaked T waves and bradycardia.
     
     

   • Treatment strategies:
     
     

     • Calcium chloride/gluconate to stabilize membranes.
       
       

     • Sodium bicarbonate (especially in intubated or dead patients).
       
       

     • Albuterol (large doses – not DuoNeb).
       
       

     • Insulin + glucose for definitive potassium shift.
       
       

   • Pitfalls: Avoid mixing calcium and bicarb in the same line.
     
     

4. Electrical Storm and Drug Strategy Evolution
   
   

   • High-dose amiodarone (300mg → 150mg) for VF/VT storm.
     
     

   • Lidocaine returning as a viable antiarrhythmic.
     
     

   • Movement away from “choose only one antiarrhythmic” dogma.
     
     

   • Consideration of dual sequential defibrillation and vector changes.
     
     

5. Torsades de Pointes
   
   

   • Differentiated by characteristic undulating morphology.
     
     

   • Treatment of choice: Magnesium sulfate (2g).
     
     

   • Often caused by hypomagnesemia, malnutrition, or alcoholism.
     
     

   • Sync attempts often ineffective due to lack of definable R wave.
     
     

6. Synchronized Cardioversion and Energy Settings
   
   

   • Narrows (atrial origin): Start at 50J.
     
     

   • Wides (ventricular origin): Start at 100J, may escalate to 200J+.
     
     

   • Consider patient body habitus and clinical picture.
     
     

   • Pediatric energy escalation: 2 → 4 → up to 10 J/kg as per PALS.
     
     

7. Wide Complex Bradycardias
   
   

   • Commonly hyperkalemia-related; pacing and atropine may fail.
     
     

   • Prioritize calcium, pressors (push-dose epi), and underlying cause correction.
     
     

   • Prepare for “go fish” approach with multiple simultaneous interventions.
     
     

8. Pediatric Considerations
   
   

   • Use Broselow tape, Handtevy, or apps for dosing support.
     
     

   • Pediatric VT/VF rare but possible—tools exist to simplify care.
     
     

9. EKG Pearls & Mimics
   
   

   • Differentiate VT from LBBB and other mimics.
     
     

   • Use 12-lead analysis (morphology, reciprocal changes, concave vs. convex).
     
     

   • Recognize patterns through clinical experience and morphology analysis.
     
     

10. Final Thoughts
    
    

    • Treat the patient, not just the rhythm.
      
      

    • Always search for the underlying cause.
      
      

    • In some scenarios, ECMO may be the only lifesaving option.
      
      

🔧 Field Tips for EMS Providers:

• Use all available resources (dual monitors, drug boxes, protocols).
  
  

• Know how to escalate care and when to consult medical direction.
  
  

• Don’t be afraid to go heavy on energy or albuterol if needed.
  
  

• Keep patient safety and provider safety in mind during transports and decisions about termination.
  
  

🧠 Memorable Quotes:

• “Wide just looks wrong—it doesn’t try to play by the rules.”
  
  

• “Make them not dead—that’s the goal.”
  
  

• “Albuterol? It’s all the albuterol.”
  
  

• “Would that T wave hurt if you sat on it? That’s how you know it’s peaked.”

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