The following is a great case from Mordy E, and as always some details have been changed to protect patient privacy.
You and your partner are refueling your ambulance at a gas station when a woman walks up and asks if you could, "come check out my husband."
As you walk over to their car she states that, "he's had chest pain for almost 5 hours now and didn't want me to call 911."
Your patient is standing, pumping gasoline, and appears unwell and diaphoretic. He seems reluctant to accept care at first, but you encourage him to let you check him out and he admits to chest discomfort.
He sits down in the passenger seat and lets you evaluate him.
- Onset: 5 hours ago
- Provocation/Palliation: nothing makes it better or worse
- Quality: "pressure"
- Radiation: "to my jaw"
- Severity: "it isn't that bad"
- Timing: constant
Your partner puts the monitor on the back seat and places electrodes while you get a set of vitals.
- Pulse: 150, weak at the radials
- BP: 102/68
- Resps: 22, unlabored, clear bilaterally
- SpO2: 94% r/a
As the initial rhythm strip prints and your partner places electrodes for a 12-Lead, you get a quick medical history.
- PMHx: hypertension, hyperlipidemia, palpitations
- Meds: "some pressure medication"
- Allergies: seasonal allergies, NKDA
- Last In's/Out's: breakfast
- Events: sudden onset of chest discomfort which woke him up this morning
Your partner hands you the rhythm strip and leaves to grab the stretcher as the 12-Lead prints.
You tear off the 12-Lead and the patient asks, "well, is something wrong with my heart?"
Your partner places the stretcher in front of the patient and says, "yessir, your heart is going too fast. Let's get you on our cot and into the back of our office so we can do something about that."
As you wheel the patient to the unit, your partner asks:
- What is our patient's rhythm?
- What did the 12-Lead show?
- How should we treat this patient?
Going to throw in with the A-Flutter crowd. O2 (NRB @ kbo- keep bag open), IV TKO w/ a 500mL challenge as long as LS remain CTAB. NTG per pain/BP. Serial 12 leads.
Jason- our protocols are 15 lpm NRB for any "cardiac event". We have be "fussed" at by our cardiologist for not having a pt on 15 lpm when they were 100%sat RA when the C/C was "chest pain" even when it was actually anxiety with hyperventilation. All our chest pain/discomfort calls get "reviewed" by a cardiologist regardless of eventual Dx. That being said… High flow won't hurt 'em & might help by loading all the hemoglobin up in the event things go very bad very quickly & they need that little extra for later. Being a "green" medic, I make sure to follow as many rules as possible when dictated by the cardiologist (when I can understand what he says since English is his 4th or 5th language)
Interested in the thought that some people would like to DC cardiovert the patient at this stage – he's GCS 15 with a SBP >100 and only a marginally raised resp rate. He may well need cardioversion but does he really need it right now?
Assuming you do decide to electrically cardiovert in the back of the ambulance then what agents do you guys have for providing procedural sedation (do you have the authorisation to use propofol / ketamine)? I don't work in the US so not familiar with your protocols and the drugs that EMTs are authorised to use – in the UK paramedics can't use anaesthetic agents and are limited to morphine (+/- midazolam) which wouldn't be an optimal option for this patient. (I work as a PreHospital Care HEMS physician and if we needed to DC cardiovert a patient then we'd probaby go for propofol or ketamine in the field, although with those vitals I'd be keen to avoid electricity unless the patient started to deteriorate significantly).
Surely it does also depend how far you are from the ED? This patient doesn't sound like he's going to crash in the next 20-30 mins so might be better waiting until you're in the ED with a trained Emergency Physician able to interpret the ECG and provide electrical cardioversion, if required, in more controlled surroundings.
@Bryan L – Nice call-back! Lewis can certainly play a role in teasing out atrial-flutter vs. sinus tach, but without actually running one here, I wouldn't be able to comment on it's efficacy on this exact patient. If you wanted to go down that route, I would suggest playing around with electrode placement a bit (different intercostal-spaces on either side of the sternum) while looking at different leads on the monitor if you're not seeing what you want right away.
For an example of subtle a-flutter that JUMPS out with the Lewis lead, click my name above here, check out my first post on atrial flutter, and scroll down to section 4.5. I'd add a link in this comment, but then it would probably get filtered out by this site's spam filter.
@ Emergency Doc -I Wouldn't even consider synch cardio at this point.
In our area, we're currently using Etomidate for SC. What are your thoughts on the drug for SC? Currently, we're having a significant drug shortage in the states, and will soon be getting propofol as well as ketamine.
Cheers.
@ Michelle – I think you and your cardiologist are living in the prehistoric era (even if he speaks 4 different languages). The AHA guidlines as well as many literature reviews are beginning to show adverse side effects w/ hyperoxygenation. 94% seems very reasonable to me.
Emergency Doc,
Perhaps it is a limited to our region, but if I let a patient ride to the hospital with a tachyarrhythmia without any treatment I would be in serious trouble. Our ED docs expect us to interpret the 3/12-Leads and treat the rhythm. If we're in one of those gray areas–say WPW or maybe a young kid with a WCT–then we call for advice/orders, but rarely we'll be told just to watch and transport.
Different expectations I guess.
I second that Chris. We are expected to interpret and if the patient is symptomatic (this one is) we are to treat. If I have a borderline patient and I have the ability (radios suck and cell coverage sucks) I contact OLMC if I'm unable to contact OLMC I have a judgement call. I dont see a reason to cardiovert this gentleman yet but it probably wouldnt be a bad plan to have the defib pads placed if my previous treatments did not work.
Emergency Doc,
I cant speak for all states but in Oregon Paramedics are allowed to use any medication that their physician advisor approves. e.g. I know of at least one that carries anti-biotics, we carry some heavy hitters for a STEMI but only versed, morphine, and fentanyl for pn/sedation. I agree that adenosine is going to be unpleasent, but I have two options, sit and do nothing IMHO not an option. Or treat the rhythm/symptoms. I would (due to long transports) treat the patient. 150 seems a little fast for hypovolemia either regardless of cause, but I suppose its possible so add in my treatment (earlier post) a fluid challenge prior to the adenosine.
I am be curious to see why some label the tachycardia to be the problem but then treat with MI protocol. Why would you use nitroglycerin for MI and then cardizem for rate control. I believe that if you give the nitroglycerin first, attempting mulitple doses, and then giving meds for rate control your patient's blood pressure is going to tank. They will then need to be in compensatory tachycardia, which you would have taken and made nearly impossible. I personally have never seen an MI with tachycardia in a regular rhythm, maybe someone else could bring a scenario to the table with this presentaion.
If someone could explain to me the rational for why the earlier method listed would be more appriopriate.
Differentials to include AVNRT vs AFlutter 2:1. Leaning heavily towards AVNRT. AHA guidelines state to withhold O2 in an ACS patient if SPO2 is 94% or higher (unless there is dyspnea or cardiogenic shock). Per protocol (Denver). 12 mg of Adenosine, rapid push. Follow with second dose of 12 mg if necessary. If no conversion then fluid bolus and transport. Don’t think this patient warrants cardioversion in an ambulance. Don’t carry calcium channel or beta blockers.
ST? – Sudden onset. No underlining cause.
SVT? – Too slow…………really
A-fib? – Too regular.
2:1 A-Flutter – Narrow complex tachycardia?…….Check. No decernable PW’s?…..Check. Rate approx 150?…..Check. F-Waves?……Check and best seen in lead I and aVR.
It’s a 2:1 A-Flutter
Christopher,
Telling us that you treat every tachyarrhythmia is very suprising to me. I suppose that you have a bottomless bag of medicine to appropriatley treat every patient you come across. More so is that you would get in trouble for using your clinical judgement. Sorry to hear your service is still forcing medics to work in a tight protocol box without the ability to think things out in a rational manner.
I'm not sure how an expectation of treatment for symptomatic arrhythmias is being placed in a "tight protocol box." Sitting on your hands simply requires an explanation, just it had better not be, "well I couldn't figure it out so we just took them to this hospital."
Christopher,
I actually have a lot of respect for your knowledge, professionalism, and cases you bring forward to this site. My dark and twisted side wanted to see if I could get you going with my last comment. Obviously it couldn't and you are a good guy,
Sorry Chris
How can you test the limits of our advice if you don't push them? Trust but verify.
Christopher,
I have a question for you,
wiggy762's comment at the top of this page says that he would give a 500 fluid bolus and also treat with Nitro for pain. I agree with a bit of fluid to increase preload therefore ejection fraction via the Starling mechanism, but to then follow that up with Nitro which may decrease preload? Would we be chasing our tail here?
Also, what do you think is the cause of this guys pain? Given his history I'm sure his arteries are sclerosed and he may find relief with Nitro, but if his pain is rate related then my thought would be to fix the rate first. Thoughts?
Thanks
I think if you didn't catch that this was not sinus tachycardia, you could fall into the trap of treating it as a problem not related to the rate.
That being said, if this were sinus tachycardia at 150, nitro is likely contraindicated as the patient is compensating significantly for some pathophysiology! Compensatory tachycardias should be treated by fixing their underlying problem instead and if this were a tachycardia at 150 due to ACS…they probably are in cardiogenic shock.
Does that help?
That helps Thank you,
Another question I have is about the use of Adenosine in an Atrial Flutter with variable conduction or A Fib. It's my understanding that it can be very dangerous to give Adenosine in WPW where there may be a Kent bundle or accessory pathway. I believe this happens because Adenosine decreases conduction through the AV node but not the accessory pathway therefore we would be creating a perfect situation for reentry. Do you know why it is dangerous in AFlutter or AFib? I understand that it just wouldn't work due to the fact that these rhythms are generated from ectopic foci in the atrium. But dangerous?
Thanks again!
Adenosine could be dangerous in irregularly irregular rhythms where the AVN serves as a buffer against 1:1 ventricular conduction. In regular, narrow complex rhythms it is safe. AF (or AFlut) w/ WPW has a very distinctive look, wide/irregular/bizarre changing morphology. In AF w/ WPW or AFlut w/ WPW you are not worried about reentry but instead that these are automatic (in the view of ventricles, a-flutter is functionally automatic). Adenosine will not stop them nor decrease conduction through a bypass tract.
Reentry rhythms can be safely terminated with adenosine, whether or not they are dependent on a bypass tract, because they are still dependent on the AVN in order to continue.