80 Year Old Female: “Rapid Heart Rate”

You are dispatched to a nursing home for an 80 year old female with a “rapid heart rate.” You arrive on scene and the charge RN gives you report.

Per the RN, assistive staff were checking the patient’s vitals this morning when they noted her heart rate to be elevated. They consulted the RN, who found the patient to have a rapid and irregular pulse, so he in-turn consulted the nursing home physician, who requested the patient be transported to the community emergency department approximately 30 min away for further workup and management.

When you walk in the room, you find a pleasant-appearing woman sitting in a chair and smiling at you. She is in no distress and her breathing is not labored. You check a pulse and note it to be fast and irregular, while her skin is of normal color and temperature.

Vitals:

  • HR: ~120 bpm
  • SpO2: 96% on room air
  • BP: 154/86 mmHg
  • RR: 20 /min
  • Temp: 36.7 C

The patient initially denies any acute complaints, but upon further questioning admits that she has been feeling weaker than usual this morning, and short-of-breath on exertion. She also feels a bit lightheaded when she stands up, but attributes that to skipping breakfast. Yesterday she felt fine and was in her normal state of health. She denies any unusual pain or discomfort in her chest, back, or abdomen, though she suffers from chronic low back pain that is unchanged from baseline. No nausea or vomiting. No fevers or chills. No change in bladder or bowel habits. No recent falls or other injuries.

Physical Exam:

  • General: Well-appearing, well-nourished female who appears her age. Alert, calm, and cooperative.
  • Skin: Normal color and temperature. No diaphoresis. No generalized rashes or extensive bruising seen.
  • Head: No signs of trauma.
  • Eyes: Pupils of normal size and equal. Sclerae white. No conjunctival pallor.
  • Mouth: Oropharynx clear. Tongue moist.
  • Ears/Nose: No ear or nose discharge.
  • Neck: Normal movement. No abnormal jugular venous distension.
  • Chest: No abnormalities seen.
  • Heart: Increased rate and irregular rhythm. Heart sounds are difficult to hear, but S1/S2 are present—no murmurs, rubs, or S3/S4 heard.
  • Lungs: Breathing easy on room air. Auscultation clear bilaterally and symmetric. No accessory muscle use.
  • Abdomen: Soft and non-tender, without distension. No guarding or rebound tenderness. No masses or pulsations felt.
  • Back: Not examined.
  • Genitourinary: Not examined.
  • Upper Extremities: Radial pulses present and equal.
  • Lower Extremities: Dorsalis pedis pulses present and equal. No swelling.
  • Neuro: Alert. Oriented to person, place, time, and events. Eyes open spontaneously. Answers questions appropriately. Follows commands. Moves all four extremities. Speech clear. No motor impersistence.

You review her chart. She does not have a DNR or other advance directive.

Past Medical History:

  • hypertension (HTN)
  • hyperlipidemia (HLD)
  • type II diabetes (DMII)
  • myocardial infarction (MI) [3 years ago]
  • coronary artery disease (CAD)
  • depression
  • gastroesophageal reflux disease (GERD)
  • osteoporosis
  • hip fracture [1 year ago]

Medications:

  • alendronate (Fosamax)
  • aspirin
  • bupropion (Wellbutrin)
  • lisinopril (Zestril)
  • metformin (Glucophage)
  • omeprazole (Prilosec)
  • simvastatin (Zocor)
  • vitamin D

Allergies:

  • sulfamethoxazole/trimethoprim (Bactrim)

Realizing that you’ve dropped two other calls performing this workup, and content that you now know the patient better than you know yourself, you assist her to the stretcher, attach the cardiac monitor, and perform the following 12-lead on your way to the ambulance:

What’s your interpretation?

How would you manage this patient prior to hospital arrival?

 

4 Comments

  • Paul says:

    On first glance it looks like afib rvr new onset. Without marching the qrs complexes out though, it looks like they are pretty regular, like an accelerated junctional rhythm with every 4th beat dropped. Looks like a p wave can be seen in v1/2, but not sure and I would print a longer strip out to see if there’s any underlying sinus activity.

    There is diffuse St segment depression, it would be easy to write it off as rate related demand ischemia, but the rate of 120 makes me doubt that. With the high R/S in right precordial leads, I want a posterior 12 lead to look for an MI. At a rate of 120 with a questionable rhythm (not 100% convinced this is simple afib RVR quite yet) and a patient with stable vitals and not very symptomatic, I’d focus on supportive care, serial 12 leads, and transport to a PCI center if possible.

  • Goran says:

    It is regularly irregular rythm.It seems like Mobitz type 1 – Wenkebach ,secondary to sinus tachycardia.It is visible P wave in V1 lead.We should find primary cause of sinus tachycardia?

  • Goran says:

    No sinus rythm,but rather atrial flutter with Mobitz type 1 – Wenkebach phenomen

  • kevin says:

    RBBB – I.V., serial 12-leads, oxygen-etco2, position semi-fowlers, bilateral BP, patch EP for consultation if transport is 30 minutes.

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