# 47 y/o female syncopal episode



## rhan101277 (Nov 14, 2011)

We get a call about a 47 y/o female with a syncopal episode whom has a heart history.  She has a 4cm hole in her septal wall.

We arrive to find her lying on the floor and her husband saying she got dizzy on the couch and tried to get up and walk and then decided to lie on the ground.

She is AAOx3 and states she had some chest pain about 2 hours ago and it went away.  The pt is currently having some left shoulder pain and pain located behind her left scapula.  She appears in no serious distress.

The patient is put on the monitor and afib with RVR is noted at 147 rate.

Blood pressure is 76/42

12 lead shows ST elevation in V1 and aVL.  Marked ST depression in II,III,avF, V3-V6.  A right sided 12 lead is done and shows no elevation or depression.  No time to do a posterior.

Patient is administered 324mg ASA, NTG is not given due to BP.  An IV could not be established after 4 attempts.  The patient remained AAO in route to ER, blood pressure dropped as low as 54 systolic but patient is still responding and doesn't have further complaints.

I activate a STEMI alert and show doc the 12 lead when we arrive.  STEMI is activated and she goes right to a room.  Later STEMI is cancelled, it takes nurses 10 attempts to get IV.  Doc orders cardizem to slow rate.  It is later found her troponin was 1.47 and eventually went up to 8.  I talked to doctor a few days later who said she was thankful I activated and it wasn't a "classic" activation and she had a NSTEMI MI.

My question is:

I was concerned about cardioverting her since it was possible this rate problem was due to ischemia or problems with low perfusion that existing in the SA/AV nodes.  

If she would have been unresponsive I would have done it, but she was talking and I thought it could do more harm than good with her history.

I realize they administered cardizem to slow the rate but they seems like a risk/reward scenario.  CCB's will diminish cardiac contractile force and hamper the bodies ability to raise blood pressure.  They did have some fluids running concomitantly, but something needed to be done.

What are your thoughts?  What would you have done?


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## usalsfyre (Nov 14, 2011)

54 systolic off of an automated cuff or manually?


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## Dwindlin (Nov 14, 2011)

Tough case.  Thanks for posting.  In this situation I would have cardioverted.  If you were concerned for AMI (which you correctly were) reducing oxygen demand is important.  Increased rate directly increases O2 demand, by cardioverting hopefully to a lower rate you can actually decrease O2 demand as well as improve supply to the heart by increasing time spent in diastole.


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## Handsome Robb (Nov 14, 2011)

In my limited experience I probably wouldn't have called a STEMI but would have communicated with a doc and transmitted the 12 lead. With no access your kind of stuck, if her LOC had diminished I'd start looking for an EJ or drill an IO, flush with lido and pressure infuse a NS bolus. If it's chronic A-fib I wouldn't be in a hurry to convert the rhythm in fear of throwing a clot. 

Maybe a pressor if I had IV access but I might be wrong in that thought. I'm thinking Dopamine at a higher dose 10-15 mcg/kg/min for the alpha effects and titrate to effect (80-90 SBP). Norepi may be more appropriate though if it's available to try and avoid the "spill over" effects of the Dopamine and focus the affects on the alpha 1 receptors. Especially with a suspect MI you don't want to increase myocardial O2 demand.

All the smarter people tell me what you think


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## usalsfyre (Nov 14, 2011)

I probably would have done diltiazem as well (easy to say now I know lol). The problem with something like afib w/RVR is the most probable cause of hypotension is diastolic failure due to rate and loss of atrial kick.  Inotropes that cause tachycardia (dopamine) will worsen this. Unless there's a comorbidity preventing vasoconstriction pressors are likely to be of limited utility as well.

She's conscious, alert and oriented without major respiratory comprimise so I'm not going to light her up. If she wasn't prefusing her vital organs she'd be altered.


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## Handsome Robb (Nov 14, 2011)

usalsfyre said:


> I probably would have done diltiazem as well (easy to say now I know lol). The problem with something like afib w/RVR is the most probable cause of hypotension is diastolic failure due to rate and loss of atrial kick.  Inotropes that cause tachycardia (dopamine) will worsen this. Unless there's a comorbidity preventing vasoconstriction pressors are likely to be of limited utility as well.
> 
> She's conscious, alert and oriented without major respiratory comprimise so I'm not going to light her up. If she wasn't prefusing her vital organs she'd be altered.



See, this is why the scenario forum is my favorite part of this site. 

Now, with cardiac history and Afib with RVR how worried would you be about throwing a clot? Diltiazem won't convert the afib though...see now I'm just thinking out loud :wacko:


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## usalsfyre (Nov 14, 2011)

It's still a minor concern, but remember the primary mechanism for throwing a clot is indeed actual conversion of the rhythm (the atria start kicking out all the stuff that's pooled in them). 

Another thing I forgot to mention is I'd take a hard look at hydration status...


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## Handsome Robb (Nov 14, 2011)

usalsfyre said:


> Another thing I forgot to mention is I'd take a hard look at hydration status...



That goes back to the issue of access.

With the risks associated with an EJ combined with the trend of falling BP and arrhythmia of this patient would you consider it? What if signs of dehydration were present since it wasn't stated in the OP? Sure if she hits the deck you could drill an IO pretty quickly but do you want to be stuck chasing your tail with your patient circling the drain?

Not arguing, just wondering.


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## DrankTheKoolaid (Nov 14, 2011)

*re*

Personally I would have cardioverted her on the spot with no 12 lead needed.  She is symptomatic Afib w/rvr ( shoulder / scapular pain ) and hypotensive.  If regularity is questionable and you don't have time to march it out close your eyes and turn up the qrs volume.  You will hear a irregularity before you can see one. 


Just wanted to also note.  What came first the chicken or the egg?  Was the MI secondary to her poorly perfused afib w/rvr or visa versa?  Remember that as long as patient is tachy at that rate the systolic diastolic ratio is like 70%s and only 30% diastolic ( cardiac perfusion ).


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## usalsfyre (Nov 14, 2011)

She's sick enough for an EJ. Utilizing proper technique they're not that much riskier than any other perhipreal line. IO I'm a little iffier on.


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## usalsfyre (Nov 14, 2011)

Corky said:


> Personally I would have cardioverted her on the spot with no 12 lead needed.  She is symptomatic Afib w/rvr ( shoulder / scapular pain ) and hypotensive.  If regularity is questionable and you don't have time to march it out close your eyes and turn up the qrs volume.  You will hear a irregularity before you can see one.



Just for an anginal equivalent and perceived hypotension?

And why no 12 lead? It takes about 30 seconds and is often of use down the road.


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## Dwindlin (Nov 14, 2011)

NVRob said:


> See, this is why the scenario forum is my favorite part of this site.
> 
> Now, with cardiac history and Afib with RVR how worried would you be about throwing a clot? Diltiazem won't convert the afib though...see now I'm just thinking out loud :wacko:



Risk is pretty low, like 2% if my memory serves, in chronic a-fib with no anticoagulation.


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## Medic87 (Nov 14, 2011)

rhan101277 said:


> We get a call about a 47 y/o female with a syncopal episode whom has a heart history.  She has a 4cm hole in her septal wall.
> 
> We arrive to find her lying on the floor and her husband saying she got dizzy on the couch and tried to get up and walk and then decided to lie on the ground.
> 
> ...



"Doc orders cardizem to slow rate" 
Cardizem with hypotension???


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## Dwindlin (Nov 14, 2011)

usalsfyre said:


> Just for an anginal equivalent and perceived hypotension?
> 
> And why no 12 lead? It takes about 30 seconds and is often of use down the road.



I would have done the 12-lead, but I also would have cardioverted.  I guess it depends how much you trust your BP.  For this patient my two big concerns are symptomatic a-fib with RVR and AMI, cardioversion can help both.  

That said I don't know that it matters how you slow her down, but personally I work in a system that doesn't carry a decent rate control drug.


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## usalsfyre (Nov 14, 2011)

Medic87 said:


> "Doc orders cardizem to slow rate"
> Cardizem with hypotension???



Entirely appropriate if the rates CAUSING the hypotension.


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## usalsfyre (Nov 14, 2011)

Dwindlin said:


> I would have done the 12-lead, but I also would have cardioverted.  I guess it depends how much you trust your BP.  For this patient my two big concerns are symptomatic a-fib with RVR and AMI, cardioversion can help both.
> 
> That said I don't know that it matters how you slow her down, but personally I work in a system that doesn't carry a decent rate control drug.


Even without a rate control drug I'd be hesitant to cardiovert. As far as B/P goes, it's just a number . If she's alert and talking, she's perfusing.

So who here would have provided this lady sedation prior to therapeutic electrocution?


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## Handsome Robb (Nov 14, 2011)

Dwindlin said:


> Risk is pretty low, like 2% if my memory serves, in chronic a-fib with no anticoagulation.



You don't have access for sedation/analgesia...yea she's symptomatic but not to the point to endure a painful intervention without proper medication, especially seeing as she is AAO... You could argue IN/IM route though however it is slower acting. I think transport time also plays a roll in this discussion as well.


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## Handsome Robb (Nov 14, 2011)

usalsfyre said:


> Even without a rate control drug I'd be hesitant to cardiovert. As far as B/P goes, it's just a number . If she's alert and talking, she's perfusing.
> 
> So who here would have provided this lady sedation prior to therapeutic electrocution?



After talking to you and doing a little more reading if I had access to give a NS bolus to help her pressure if it were to drop I'd probably do it. Especially with the retrograde amnesic properties of midazolam post-conversion.


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## DrankTheKoolaid (Nov 14, 2011)

*re*

In regards to her BP I would have also been checking skin temp.  If her hands and feet are cold I would most certainly believe that bp.   I don't care how good you are a 12 lead takes longer then 30 seconds.  And I am still a firm believer and preacher to my paramedic students that time = muscle.


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## usalsfyre (Nov 14, 2011)

And electricity destroys muscle as well....

It takes my partner consitently less than a minute to apply a 12 lead, but we run a lot of them. 

The B/P is something your uncomfortable with. The fact is she sounds as though she's perfusing somewhat decently.


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## Dwindlin (Nov 14, 2011)

If I had access (and good rate control drug) I would go that route.  As in this scenario I have neither with a roughly 20min transport (for me) I would go ahead with a couple mg of IN versed and light her up.


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## Handsome Robb (Nov 14, 2011)

Corky said:


> In regards to her BP I would have also been checking skin temp.  If her hands and feet are cold I would most certainly believe that bp.   I don't care how good you are a 12 lead takes longer then 30 seconds.  And I am still a firm believer and preacher to my paramedic students that time = muscle.



Is 30 seconds to a minute going to make that big of a difference? I doubt it. As a medic student, not even a full medic I can still place and acquire a 12 lead in about 1 minute.


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## DrankTheKoolaid (Nov 14, 2011)

*re*

Normal ground transport times for me are usually greater then 45 minutes to the local podunk ED and can be up to 2.5h to the closest cardiac/trauma center. And for the next 7 months air support is spotty at best with winter setting in here.  I would rather cardiovert and stabilize then transfer. Instead of being on a mountain peak with no help when she decides to really become unstable aka dead........


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## usalsfyre (Nov 14, 2011)

Not trying to state the obvious but I think a fairly good indication cardioversion wasn't indicated is that she didn't code enroute and the ED didn't elect to perform one...


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## Dwindlin (Nov 14, 2011)

usalsfyre said:


> *And electricity destroys muscle as well....*
> 
> It takes my partner consitently less than a minute to apply a 12 lead, but we run a lot of them.
> 
> The B/P is something your uncomfortable with. The fact is she sounds as though she's perfusing somewhat decently.



http://heart.bmj.com/content/80/3/226.abstract

Decent article about the effects of cardioversion on cardiac muscle.


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## usalsfyre (Nov 14, 2011)

Dwindlin said:


> http://heart.bmj.com/content/80/3/226.abstract
> 
> Decent article about the effects of cardioversion on cardiac muscle.



Interesting, very small sample size but I had been misinformed it always damaged the myocardium. Thanks for the article.


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## DrankTheKoolaid (Nov 14, 2011)

*re*

True, thankfully she did well.  This is the best part about the scenerio forum.. all the differant view points.  For the record we still carry Verapamil and the thought of giving CA and Verapamil again scares the hell out of me.  Verapamil I don't mind and have used it often with great results, but pretreating the hypotensive patients with Ca again scares the hell out of me.  


Yay for cardizem finally up for consideration in California!


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## Handsome Robb (Nov 14, 2011)

I still don't see how cardioversion is indicated here. She is relatively symptomatic with the shoulder/scapular pain as well as hypotension however her mentation still remained intact and showed no trend towards losing her mentation. like usals said BP is just a number. The other point that was overlooked, was the BP automated or manual? I'm not going to trust an automated BP with that SBP. 

Someone said check her skin, are her extremities warm? If so the pressure is more than likely higher than the number shows, especially with her mental status. 

Maybe I'm influenced by my short transport times <15 minutes to a Level II or cardiac capable hospital.


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## rhan101277 (Nov 15, 2011)

I forgot to mention that the rate varied from 110 up to 160.  When the rate would drop to 110 the pressure would come up some.  I hesitated cardioverting her due to her history, I could have called med control for some second opinion.  Our protocols state that rates below 150 rarely need cardioverting and the rate would be constantly changing which is understandable for RVR.

The ER did not cardiovert either


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## rhan101277 (Nov 15, 2011)

usalsfyre said:


> Even without a rate control drug I'd be hesitant to cardiovert. As far as B/P goes, it's just a number . If she's alert and talking, she's perfusing.
> 
> So who here would have provided this lady sedation prior to therapeutic electrocution?



This is exactly why I didn't cardiovert, everything isn't always textbook and I would continue to talk to her and she would be completely alert.  If at any point she became unresponsive or had altered mental status, I would have converted.


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## DrankTheKoolaid (Nov 15, 2011)

rhan101277 said:


> *I forgot to mention that the rate varied from 110 up to 160.*  When the rate would drop to 110 the pressure would come up some.  I hesitated cardioverting her due to her history, I could have called med control for some second opinion.  Our protocols state that rates below 150 rarely need cardioverting and the rate would be constantly changing which is understandable for RVR.
> 
> The ER did not cardiovert either



That is a totally different story.  variable Afib rate VS sustained RVR


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## rhan101277 (Nov 15, 2011)

We do have cardizem on board, if I could have gotten a line established I would have called but I really doubt they would order it without looking at the patient since she was so hypotensive.  Cardizem is contraindicated in severely hypotensive patients and in the absence of all the ER services I don't have in the back of my truck it would be concerning.

Something else to think about is this woman may run with pressures around 100 systolic and her body is used to operating this way.


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## Dwindlin (Nov 15, 2011)

Corky said:


> That is a totally different story.  variable Afib rate VS sustained RVR



Aye.  That little tidbit changes things quite a bit


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## boingo (Nov 15, 2011)

I doubt I would cardiovert, a judicious fluid bolus, a little Fentanyl IN for pain management and and EJ or IO for access.  An AF at that rate isn't that much of a concern and seems an unlikely cause for her hypotension in and of itself.  Rate control with Cardizem after some fluid might be appropriate.


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