76 yo male cc heart problems, including mild chest discomfor | Figure 1

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76 yo male cc heart problems, including mild chest discomfort day before with mild SOB earlier this morning. Pt reports no prior significant cardiac history, takes lisinopril for HTN. Denies symptoms upon EMS arrival. Initial EKG is EKG 1. Never been diagnosed with a RBBB before. Upon loading him into the truck (after walking him 15 feet and down 5 steps to the stretcher), he flips into what you see on EKG 2. Self converts into EKG 3 by the time I have my IV established and getting ready for adenosine. One of the things I found most interesting is if you look at the rhythm strip, there appear to be alternating QRS complexes, half of which were non-pulsatile. I called it a tachycardia bigeminy? Ended up treating with 150 mg amio drip, with some resolution to HR (no longer upwards of 180+), yet still flipped in/out of the ectopic infused rhythm. By the time we got him to the hospital (15 or so minutes), he was then in Afib with RVR around 100-140. Pt remained asymptomatic throughout all of these events/during EMS presence. Other assessment otherwise unremarkable. Pressures stayed stable in the 130s/90s throughout transport. Thoughts on the tachycardia bigeminy/SVT etiology? Or potential long-term management of this patient?

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