EMERGENCY MEDICAL SERVICES-ECG JULY EDITION

Multifocal Atrial Tachycardia (MAT or MFAT) is an irregularly irregular tachycardia that is characterized by the presence of at least 3 differently shaped P waves without the baseline changes of atrial fibrillation or atrial flutter.

MAT is most frequently seen in patients with severe chronic lung disease such as COPD/Emphysema during an acute exacerbation but can also be seen in patients with CHF exacerbations. Patient will commonly have ischemic changes as well, particularly if they are hypoxic or are retaining significant CO₂, as both may lead to decreased perfusion of the relatively thick cardiac septum.

This patient has both ischemic changes and the irregularly irregular tachycardia of MAT. The changes of MAT improve with treatment of the underlying disease that is causing respiratory distress. If the ischemia is due to the respiratory emergency, it will also improve with treatment; but that is unlikely to occur prior to patient handoff at the hospital.

The patient has a history of COPD and is in severe respiratory distress, based on her abnormal positioning (tripoding) and 2-3-word sentences. Per TP-1237, Respiratory Distress, she should be started immediately on CPAP for severe respiratory distress, and albuterol 5mg (6mL) administered by nebulizer, preferably in-line through the CPAP device. Given the chest tightness and ECG changes, likely due to increase demand from hypoxia and work of breathing, it is reasonable to consider a secondary provider impression of suspected cardiac chest pain and provide aspirin per TP-1211, Cardiac Chest Pain. Patient also has an irregular tachyarrhythmia, and it would be acceptable to enter this as an additional provider impression. However, as there is no dysrhythmia-specific treatment associated with this tachydysrhythmia, suspected cardiac chest pain (which explains why aspirin was administered) is a preferable choice for the secondary provider impression.

The patient can be transported the MAR per L.A. County policy as she does not have any needs that require specialty center care.

The patient was started on CPAP in the field, received 2 doses of in-line nebulized albuterol, and multiple additional doses in the Emergency Department. In the ED she was transitioned to BiPAP and also received other hospital treatments to treat COPD exacerbations, including nebulized ipratropium, IV steroids, Azithromycin, and Magnesium Sulfate. Due to the early initiation of CPAP, she was able to avoid intubation, but was admitted for ongoing hospital treatments and BiPAP and was discharged on hospital day #4. By the time of discharge, her ECG returned to her baseline of sinus rhythm with intermittent premature atrial contractions (PACs).

Patients with respiratory distress often have abnormal ECGs. Multifocal Atrial Tachycardia (MAT or MFAT) is one of the possible abnormal ECG patterns that can be found in this situation. Despite the rate exceeding 150, it does not need to be treated as SVT. Treatment centers around treating the underlying disease, and the ECG changes improve or resolve with response to treatment.

In addition, patients with hypoxia, severe respiratory distress, and/or tachycardia can show ST depressions characteristic of cardiac ischemia. It is impossible to differentiate in the field between cardiac causes of these ST depressions (i.e. a non-STEMI) and demand ischemia related to the rate and hypoxia. The benefit of aspirin in a patient with chest discomfort and ischemic changes greatly exceeds the risk of administration if the patient has no contraindications. Document a secondary Provider Impression of Chest Pain, Suspected Cardiac to explain the use of aspirin in this patient.