19F Chest pain - confused me

[socalmedic]

I am wondering what the ECG would look like if you where to slow the print out from 25mm/sec to 50mm/sec. I am wondering if some P waves would magically appear out of the "SVT" that is what your instructor should have had you do if there is any question, just remember to change it back when done.

 

[Melclin]

This wasn't a real patient is was a actress.

Most of the answers to these questions were in my previous post but...

The fent was listed as an option for when hugs didn't work. I clearly said that.

If I couldn't reduce the rate and in turn the discomfort with "hugs" I would have:

Fentanyl may have been chosen for multiple reasons. It would help relax the patient. If it was actually cardiac in nature it is quickly becoming a favored treatment. Just to name two quick ones.

I chose the IN route because I see no reason in unnecessarily cannulating people. The benefit is obvious. You don't have to cannulate them. She was particularly afraid of needles, and while this would make little difference to sticking her if she needed it, I saw no reason why she should be cannulated at that stage.

The 25/50mm is something is something I would like to have done in retrospect. Unfortunately, settings on the monitors at uni are locked with a password. I'll keep it in mind for the future and hope that the service's monitors aren't similarly and unnecessarily "protected".

 

[Boston.Tacmedic]

Mel said it was for anxiety and the slight chest discomfort that the pt was complaining of.
I agree with what others have said, this pt is not in any emergent need of electrical or pharmacological intervention, and as one person so perfectly put it, she "needs hugs, not drugs".
That being said, I'm just throwing this out there, but why not give her some adenosine/vagal maneuvers? If you are going to call it SVT you could certainly argue that her anxiety may have some basis from her heart going 170 mph and fixing the rhythm may relieve some of her anxiety. My understanding is that adenosine would be indicated in this person, but what makes some of you smarter and more experienced medics than myself say that adenosine is too risky/ not warranted in pre-hospital treatment. (I'm just trying playing devils advocate and trying to learn a little, I would have tried vagal maneuvers and tried to calm her down myself.)

"Hugs not Drugs" Lol,

I agree this PT needs a tall glass of sukitdafukup sheesh. Also we give morphine for the calming effect decreased HR = decreased o2 demand (also decreased venous pooling) I can't state this with more emphasis Fentanyl would be a gross mistreatment for the above PT. Fentanyl is something I use for a Combat injured PT who is in REAL PN and burned and his/her airway does not need further compromise. Fentanyl is a wonderful drug but not for a 19yo girl who needs nothing more than a little understanding. A HR of 170 with her Hx seems completely feasible.

 

[rhan101277]

Panic attacks can do this, I have them but they are under control. Your sympathetic nervous system just goes into overload for lack of a better term. No matter how you try to change your thoughts to something pleasing it doesn't seem to work once epi is introduced into your body from the adrenal glands.

I drank about 8 (12) ounce mountain dews. Two doses of adenosine did not fix me. Just goes to show you that it wasn't an ectopic. I remember looking up at the ceiling and thinking that, well its time to check out I guess. Anyhow this was back in 1999.

 

[18G]

I can see where some would consider sinus tach and other's SVT. The little blip, notch, or whatever you want to call it could be p-waves imposed upon the T waves.

I would try calming measures and vagal maneuvers to see if there was any change in heart rate. If after a few minutes the patient did not respond I would try adenosine. It's a safe drug and can be used diagnostically. If the patient is jacked up on caffeine the adenosine is gonna be antagonized and may not be as effective especially with all the catecholamines in the system.

Sinus tach will only go so fast... meaning epi will only induce so fast a rate. At 170 and this patients HPI I would be thinking more SVT than sinus tach. But I would start less intensive and go from there.

 

[18G]

STUDY
Recent caffeine ingestion reduces adenosine efficacy in the treatment of paroxysmal supraventricular tachycardia.

CONCLUSIONS: Ingestion of caffeine less than 4 hours before a 6-mg adenosine bolus significantly reduces its effectiveness in the treatment of SVT. An increased initial adenosine dose may be indicated for these patients.

http://www.ncbi.nlm.nih.gov/pubmed/20003123

 

[Aidey]

She is 19. You can't daignose SVT based just on a rate of 170. 220 - 19 = 201.

 

[18G]

"220 - age" isn't set in stone... its just a guide rule... it's generally accepted that any rate above 150-160 should be suspicious of SVT. Even if you can see what appears to be p waves imposed upon the T-waves how do you know for sure they are sinus in nature?

There are many things ringing SVT.

 

[Aidey]

What aside from rate indicates SVT? No that is not a set in stone guideline, but it needs to be considered. Young people can get quite tachy without it being pathological, and her rate can be completley explained by her age, anxiety and caffeine intake.

 

[18G]

SVT.... rate of 170, unable to fully distinguish p-waves (are they sinus? or from somewhere else? I don't know 'cause I can't see the morphology.), young female with hx of excessive caffeine and anxiety.

Caffeine and anxiety can bring on sinus tach but both can also precipitate SVT. I'm not saying 100% it is SVT and I would have treated as to rule out one or the other beginning with a trial of calming measures and reassurance to see if any rate change.

I would also want to know if abrupt onset or gradual.

 

[Aidey]

What aside from the rate?

 

[18G]

Asked and answered...

unable to fully distinguish p-waves (are they sinus? or from somewhere else? I don't know 'cause I can't see the morphology.), young female with hx of excessive caffeine and anxiety.

Caffeine and anxiety can bring on sinus tach but both can also precipitate SVT.

 

[Aidey]

Caffeine and anxiety don't indicate SVT. So you are planning on giving this patient adenosine based on morphology and rate?

 

[emtchick171]

I had a call similar to this, except mine was a high school student, however she did have a history of heart complications (born with hole in heart, etc.)

As for this PT...tachy of 170 is extremely high, even with anxiety attacks. I do believe the energy drinks and lack of sleep played a large role in the way her ECG turned out. Caffeine and sugar can have a lot to do with the heart rate, especially in younger people.

To me the strip looks like SVT (from what I can tell). Would really love to see the 12 lead strip from this PT.

 

[18G]

Aidey... your right in that caffeine and anxiety do not in and of themselves indicate SVT. But combined with a rate of 170, the inability to clearly see P waves and considering the precipitating factors of for this patient I would strongly suspect SVT and not dismiss it.

This rhythm meets the rules for SVT.
1) Narrow complex & regular.
2) Rate above 150bpm.
3) Unable to clearly see p-waves.
4) No identifiable pre-existing conditions that would indicate compensatory rate (ie sinus tach).

Again, it could be sinus tach and calming measures should be tried. But with the caffeine onboard calming prob won't do much and adenosine may not either since caffeine antagonizes the adenosine receptors. If you strongly suspect sinus tach from the caffeine and anxiety how about getting orders for a benzo? If rate does not change than try adenosine.

Are you afraid to try adenosine in this patient?

 

[18G]

Sinus Tachycardia - Rate < 150 with visible p waves
[YOUTUBE]http://www.youtube.com/watch?v=cKXrzLrQOCc[/YOUTUBE]


SVT - Rate > 150, narrow, regular, and no visible p waves... just like the strip from the OP.
[YOUTUBE]http://www.youtube.com/watch?v=ReJo4aclOw8[/YOUTUBE]

 

[Aidey]

The ER doc would have my head on a plate if I tried adenosine on this patient!

What "rules for SVT"? There are some 10 odd types of SVT, most of which are narrow, but a couple of which can be wide, with a range of rates. A rate greater than 150 increases the index of suspicion for certain types of SVT, but considering her anxiety and caffeine intake, rate is not diagnostic in this case. We also have to consider the idea that she may be withdrawing from benzos since she has not had her Xanax today. Sleep deprivation can also cased an increased heart rate all by itself.

When you start running down the list of possible types of SVT this could be, it is pretty easy to eliminate most of them.

It's not MAT, A-Fib, A-Flutter, AVNRT (no retrograde P wave), AVRT (No delta wave and narrow), or JET (no retrograde P waves, or P waves buried in the QRS).

So that leaves us with Ectopic A-Tach, which we can't rule out off of the EKG we have, and then SANRT or Sinus Tach, which are indistinguishable from each other on EKG.

Given the quality of the EKG whether there are discernible P waves is hit or miss. However, there is more than enough evidence that this is non SVT sinus tach. Tachycardia is sinus tach until proven otherwise, and nothing is proving otherwise in this case with the information we've been given.

 

[18G]

The patient was stable and young and was tolerating the rate well so no need to become immediately worried.

Catacholamines can only make the heart go so fast which is why it's commonly stated that SVT falls within a range starting at 150. This patient was at 170 although OP said monitor was showing 183 I believe. Adenosine can be used diagnostically and is a very safe drug. I don't think a provider would have been wrong to give adenosine. I get what your saying though.

You can give a EKG to ten different cardiologists and get ten different interpretations.

 

[MonkeySquasher]

I realize it might be slightly reckless to say, but... It's not like Adenosine would flat out kill the person if they were wrong.

Read the strip. Is it a block? No? Okay. Are they hypotensive or in heart failure? No? Okay. Asthma or WPW? No? Okay.

The ONLY contraindication we can't rule out is Sick Sinus Syndrome, which could possibly be a DDx given the info available.

If we can prove it's not SSSyndrome, then I'd say give it, because if it's not an atrial rhythm, it won't have any affect. Corrent? Not to mention, the half-life is so short..