There are case reports and studies that describe stable WCT deteriorating to ventricular fibrillation after adenosine administration.There is observational research to support the use of adenosine in the treatment of stable monomorphic regular WCT.If a patient who is experiencing WCT is pulseless, then they should undergo cardiopulmonary resuscitation and defibrillation as soon as possible. If a patient who is experiencing WCT is deemed unstable, then they should undergo synchronized cardioversion. When treating a patient with wide complex tachycardia it is important to treat circulation, airway and breathing in accordance with standard ACLS guidelines.Teaching points about wide complex tachycardia (WCT): Cardiology recommended discharge home with instructions to stop flecainide and to increase his metoprolol dose with outpatient clinic follow-up. Cardiology formally interpreted his ECG as “atrial flutter with 1:1 conduction, ventricular rate 192 bpm, with a bundloid QRS morphology”. Cardiology was consulted early in the patients ED course and reported his WCT likely represented flecainide toxicity causing QRS prolongation and atrial flutter with 1:1 conduction. The patient was consented for synchronized cardioversion which successfully terminated the arrhythmia with reversion to normal sinus rhythm. Adenosine was administered twice (6mg followed by 12 mg) without success and no notable pauses were observed. This patient’s R-R interval was normal prompting attempts at vagal maneuvers as supraventricular tachycardia (SVT) with aberrancy was on our differential diagnosis list, but we were unsuccessful. Old electrocardiograms were reviewed and did not reveal any signs of Wolff-Parkinson White syndrome (WPW). This ECG shows monomorphic wide complex tachycardia (WCT) at a rate of 192 bpm, extreme axis deviation, QRS duration of 160 msec, positive concordance in precordial leads V1-2, negative concordance in precordial leads V3-6 and absence of capture/fusion beats An electrocardiogram (ECG) was performed as shown below. The patient reported uninterrupted anticoagulation. Otherwise, the patient had a normal blood pressure, a normal respiratory rate, normal work of breathing, normal mental status, a cap refill less than 2 seconds in all four extremities and no obvious signs of acute instability. The patient’s heart rate was noted to be tachycardic at 192 beats per minute. He related he had undergone transesophageal echocardiographic guided cardioversion in the past for similar symptoms. Ben Arnold, MDĪ 65-year-old male with a past medical history of atrial flutter on metoprolol, flecainide and eliquis reported to the Emergency Department for evaluation of palpitations. Flecainide Induced Atrial Flutter Causing Monomorphic Wide Complex TachycardiaĪuthors: Dr.
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