# Tachycardic dialysis patient



## energystar (Apr 13, 2013)

Get a call for a dialysis transfer to take patient back to her SNF. Pt is a 92 y/o female with dementia and renal disease, no cardiac. Upon finishing up dialysis treatment pt is tachy at 130. Dr at facility requests we take pt to ER rather than back home. With a 2 minute ETA to the closest receiving I decided to load and go. I am only an emt-b and I do realize this is an ALS call. With an ETA of 5-6 minutes for ALS, is it in the patients best interest to load with a short ETA to hospital like 2 minutes or call ALS and wait for their arrival? Thanks in advance for your opinions.


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## DesertMedic66 (Apr 13, 2013)

Go to the hospital. If all of the patients vitals are normal then ALS isn't going to do anything aside from possibly a IV and a EKG. I believe SVT is at a rate of 150 or higher (I believe there is some kind of equation that involves the patients age) and medics in at least my area can only treat SVT. However if the patient is hemodynamicaly (sp?) stable then the patient isn't going to get medics or Edison medicine (cardioverted). 

Sorry for the bad spelling, it's past my bed time


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## adamjh3 (Apr 13, 2013)

What was her BP? What were her pre and post dialysis weights?

And yeah, you made the right choice all things considered.


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## energystar (Apr 13, 2013)

Thanks for the quick responses. All vitals were stable BP at 136/68 RR 18 SpO2 98%. I chose to transport to arrive to a very disgruntled nurse who was not approving of my decision. At hospital I waited to see how the EKG turned out and it was ST normal. It's funny that I picked up the shift as overtime thinking it was a break from the 911 side and I get the most complicated call I have had all week. :wacko:


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## Aidey (Apr 13, 2013)

The equation is 220 - age. So 130 is still within the limits of sinus tachycardia for this pt. 

Was the pt symptomatic or complaining of anything? Keep in mind it is normal for people to feel run down/tired/generally crappy immediately post dialysis.


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## energystar (Apr 13, 2013)

I have never seen that equation, learned something new. No complaints minus being cold and altered which was normal for PT due to dementia. Staff and dialysis center said she was acting as she normally does.


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## truetiger (Apr 13, 2013)

DesertEMT66 said:


> Go to the hospital. If all of the patients vitals are normal then ALS isn't going to do anything aside from possibly a IV and a EKG. I believe SVT is at a rate of 150 or higher (I believe there is some kind of equation that involves the patients age) and medics in at least my area can only treat SVT. However if the patient is hemodynamicaly (sp?) stable then the patient isn't going to get medics or Edison medicine (cardioverted).
> 
> Sorry for the bad spelling, it's past my bed time



SVT isn't a rate, its a conduction problem.


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## Clipper1 (Apr 13, 2013)

Aidey said:


> The equation is 220 - age. So 130 is still within the limits of sinus tachycardia for this pt.
> 
> Was the pt symptomatic or complaining of anything? Keep in mind it is normal for people to feel run down/tired/generally crappy immediately post dialysis.



That equation is more of a myth rather than science. The problem is in the basic assumption that max heart can be predicted on the basis of age alone.

It was used to calculate max HR for exercise in the 70s and 80s and has since gone out of favor for many reasons. Some of the reasons include fitness condition, weight, medications, hereditary factors, congenital anomalies and electrolyte imbalances (which is a major concern of dialysis patients). Its origin was also in cardiac rehab but the studies were on a small sample. Somehow it became more of a fad in the aerobic exercise craze days.

Symptoms are also not always that obvious for elderly females especially when it comes to a cardiac situation.

Some patients also few better after dialysis so it is difficult to make assumptions about normal.


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## VFlutter (Apr 13, 2013)

Clipper1 said:


> That equation is more of a myth rather than science. The problem is in the basic assumption that max heart can be predicted on the basis of age alone.
> 
> It was used to calculate max HR for exercise in the 70s and 80s and has since gone out of favor for many reasons. Some of the reasons include fitness condition, weight, medications, hereditary factors, congenital anomalies and electrolyte imbalances (which is a major concern of dialysis patients). Its origin was also in cardiac rehab but the studies were on a small sample. Somehow it became more of a fad in the aerobic exercise craze days.
> 
> Symptoms are also not always that obvious for elderly females especially when it comes to a cardiac



+1, I hear a lot of people throw out that equation even though it was never meant to be a medical standard. I have had this argument a few times on here before.


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## Aidey (Apr 13, 2013)

220- age is still actively being taught *by *medical doctors, and *to *medical students. It might not be a perfect guideline, but it is a heck of a lot better than assuming everything over 150 is SVT, which is the other common guideline taught.


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## Clipper1 (Apr 13, 2013)

Aidey said:


> 220- age is still actively being taught *by *medical doctors, and *to *medical students. It might not be a perfect guideline, but it is a heck of a lot better than assuming everything over 150 is SVT, which is the other common guideline taught.



At one time doctors wrote protocols for EMS provides to give Lasix rather freely also. 

A broad formula like this has only a few practical purposes.  For a 90 year old dialysis patient, it might not be so practical.  

There are many guidelines available to assist in determining a rhythm which include more than just the rate. The shape of the QRS and the p waves are also important variables. The history of the patient is also important. Does the patient have a history of an arrhythmia? Controlled or uncontrolled A-fib or A-Flutter? MAT?  

Does the rate get slower with rest and stay slower to a reasonable baseline?
Is the patient febrile?  On any stimulants? Pain? Dehydration? Electrolyte imbalance?

A 20 year old could be athletic and get their heart rate to 200. But, the same 20 year old could also get dehydrated causing an electrolyte disturbance or have their previously undiagnosed conduction disturbance show up. There are also some obese or out of shape or very skinny 20 y/o who I would not like to see their heart rates be at 200 especially if they were not intentionally exercising.

Doctors might teach this to med students but hopefully only as a guideline for what is "possible" for a healthy heart.  If the patient is seeing a doctor for some reason, chances are there might be health issues involved which also must be taken into consideration.   I think today even assuming some 18 year olds have healthy hearts is a broad assumption especially with the American diet.  Even those who are not obese may consume foods which are high in cholesterol and lead to early signs of heart disease.  For these reasons along with the others listed, 220 - 20 has fallen out of favor in the medical professions.   Textbooks publish new editions frequently and teachers much update their material regularly for good reasons.


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## VFlutter (Apr 13, 2013)

Aidey said:


> 220- age is still actively being taught *by *medical doctors, and *to *medical students. It might not be a perfect guideline, but it is a heck of a lot better than assuming everything over 150 is SVT, which is the other common guideline taught.



In what speciality? Emergency Medicine? Is this in standard curriculum or just something a few doctors tell their residents. 

Ask a cardiologist or better yet an electrophysiologist. Spend some time in an EP lab if you get the opportunity. You would quickly see that the 220-age rule rarely holds true and does not accurately predict what is and isn't likely to be a reentry rhythm.

Just a few weeks ago I had a 19 year old patient who got an ablation for AVNRT that never went above 160.


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## energystar (Apr 13, 2013)

I appreciate all the responses. As a basic a lot of this stuff well over my base of knowledge. That being said *where do you draw the line* (if there is one) between BLS transport with a short (2min hospital ETA) and ALS intervention with a patient only displaying an increased heart rate. 

I have been working in the LA 911 system for over a year (yeah I know its a crappy one) and am familiar with how calls are ran by fire department ALS. Once dispatched by 911 you are looking at a solid 15-20 minutes *(responding to scene, assessment, 12 lead, base contact)* before transport. Would sitting on scene with the patient, calling 911 and waiting for ALS to respond be less beneficial for the patient when a higher level of care can be provided in less time?


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## PaddyWagon (Apr 13, 2013)

Anecdotal story from my basic class in Long Beach where this kind of question came up: this would be to wait on scene and request ALS backup because it's cardiac; medical control could take into consideration your assessment, travel time to ER and ALS arrival time and tell you to load and go if they wanted.  In any case, in class we decided that it was an issue for medical control rather than a basic's call.

Same would apply if you were already in transit and got those vitals, medical control would advise to rendezvous with ALS or head to ER directly.

I may be wrong, this was just us talking in class.


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## wanderingmedic (Apr 13, 2013)

i'd say ya did the right thing. wether your company's insurance thinks so is another story........


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## energystar (Apr 13, 2013)

azemtb255 said:


> i'd say ya did the right thing. wether your company's insurance thinks so is another story........



That is exactly how I felt after the call but rather than get caught up in that I wanted to try to learn from the call. I want to be a paramedic and enjoy learning through my experiences to increase my knowledge for future reference.


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## Carlos Danger (Apr 15, 2013)

energystar said:


> That being said *where do you draw the line* (if there is one) between BLS transport with a short (*2min hospital ETA*) and ALS intervention with a patient only displaying an increased heart rate.



If it really was only a 2 minute transport, I cannot think of a single scenario where waiting for an ALS intercept would be beneficial to your patient, because you can almost certainly have the patient in the ED before paramedics arrive at your scene.


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## cspinebrah (Apr 15, 2013)

*response.*

Was the patient altered in any way? in other words have you picked the pt up before and was she/he acting different? 

If i was in your shoes i would load and go.


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## energystar (Apr 15, 2013)

Halothane said:


> If it really was only a 2 minute transport, I cannot think of a single scenario where waiting for an ALS intercept would be beneficial to your patient, because you can almost certainly have the patient in the ED before paramedics arrive at your scene.



That was the same reasoning I used. 

The patient was altered but she has a hx of dementia. I have never seen her before but the dialysis staff said she was acting normal for her mental status. That being said I don't know how valid that statement is but it was all I had to go off of.


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## 18G (Apr 16, 2013)

If you can be at the hospital before you can meet with an ALS unit then go to the hospital. Think of the hospital as your ALS unit. 

If you called me with a 2min ride to the hospital I would a) ask you why you waited and b) not have time to do anything on the ride over to the hospital. I'm not gonna take 15mins onscene when I can be at the hospital in 2. Unless, immediate interventions needed done but that wasnt the case. Just go.


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## systemet (Apr 16, 2013)

I think this all depends on what sort of hospital you're transporting to, and what the accepted practices are in your system.  

This patient doesn't sound particularly sick.  Possibly they've been over-dialysed.  Outside chance of some sort of concurrent infection, or even an AMI.  Even less likely, an error in the dialysis solution.

If your ER is going to be able to see this patient quickly, and you're not going to be waiting for a couple of hours without an ECG, relying on a quick BLS assessment, then going is probably ok.  Not sure that this warrants L&S transport.

I don't think six minutes is likely to impact outcome here either way.


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