Piano Man causing Vtach

You are working with EMS at a Billy Joel concert. It’s a pretty tame evening and you resort to standing in behind stage and eyeing the crowd. As Billy Joel plays Piano Man. One man clutches his chest and looks up to the sky as if to break out in song with the famed Piano Man. However he doesn’t, and instead drops to the ground and does not move. His girlfriend is super impressed and thinks he was overwhelmed with emotion, and makes an instagram story out of the incident.  Fortunately, one of her “live followers”, is a nurse and urgently called her to intervene and call for help. You rush to the patient with your team and find him with thready pulses and unresponsive. Rhythm strip shows a wide complex, regular tachycardia. Which of the following is true?

A. In patients with ischemic cardiac history, procainamide has displayed fastest rate of conversion

B. SVT with aberrancy can be mistaken for VT in up to 20% of adult patients

C. Nonsustained VT is a predictor of sudden cardiac death

D. Faster rate VT should suggest toxicologic cause

——- References:

Brugada P et al. A new approach to the diagnosis of regular wide complex tachycardia. Circulation 1991; 83: 1649-59. PMID: 2022022

Hollowell H et al. Wide-complex tachycardia: beyond the traditional differential diagnosis of ventricular tachycardia vs supra ventricular tachycardia with aberrant conduction. Am J Emerg Med 2005; 23: 876-89. PMID: 16291445

Ortiz M et al. Randomized comparison of intravenous procainamide vs. intravenous amiodarone for the acute treatment of tolerated wide QRS tachycardia: the PROCAMIO study. Eur Heart J 2016. PMID: 23754046

Yealy D, Kosowsky JM: Dysrhythmias, in Marx JA, Hockberger RS, Walls RM, et al (eds): Rosen’s Emergency Medicine: Concepts and Clinical Practice, ed 8. St. Louis, Mosby, Inc., 2010, (Ch) 79: p 1034-63.

Blake Briggs