# 19F Chest pain - confused me



## Melclin (Sep 22, 2010)

Had a standard patient at uni today present like this. I was playing the role of driver, so I was involved and treating but only at the direction of the "jockey" who was being assessed. 

*11:34 - CODE 1: Chest pain, 19yrs Female.*

*O/A*: The patient looks relieved to see the crew and states, “I feel like my heart is about to leap out of my chest, I think I’m having a panic attack”.

*Event hx:* Arrived at uni for an exam. While walking pts heart starts racing and the pt assumed she was nervous about the exam. It then got worse, with the new onset of chest tightness. Pt has had panic attacks before and it feels pretty similar. 

The sensation in her the middle of her chest is described as a tightness. Her heart started racing 30 minutes prior followed by chest tightness beginning 10 mins ago. She also complains of mild SOB and dizziness. Nil N&V. The discomfort is rated on a pain scale as 3/10.

Whilst taking vitals the pt has many questions, is talking quickly and becomes quite upset about the idea of cannulation. Denies ETOH or drugs and seems quite honest. 

*Vitals*
Pulse: 170 (Regular & strong)
BP: 125/85
RR: 26 (No excessive effort or accessory muscle use).
GCS: 15
Temp: 36.8
Spo2 on RA: 97
Medications: prn xanax, but she does not have it with her and has not taken any today.

*Med Hx:* Suffers from “panic attacks” and is under the care of her GP.  
Recent stressors are all uni related. She is currently in the middle of an exam period, and she was up all night studying and drinking energy drinks.
She lives at home with her brother and her parents in a pretty standard upper middleclass house and reports no abnormally stressful life events other than university where she studies a double degree in arts and business. 

*Family Hx:* Brother has mild down syndrome. Isn't aware of any of her parents medical problems, but nothing obvious to her.

*Physical:* No change to feeling of discomfort on movement, palpation and inspiration. Pt’s skin is warm, clammy and pale. You note nothing else unusual on the physical exam. 

I'm sorry about the ECG but I couldn't get a good picture on my iPhone. Its lead II. The ECG's actual rate in the pic is 183 for some reason, but take it to be 170.







This job caused me some concern when we debriefed with the sessional afterward, I'll talk about why after people have a bit of a play with it.


----------



## SanDiegoEmt7 (Sep 22, 2010)

Caffeine overdose from consumption of numerous strong energy drinks.  Would account for tachycardia, rapid speech and thoughts, etc. Couple that with her nervousness for her exam and her predisposition to panic.

How many beverages did she consume and over what period of time?

As for the EKG, I'm teaching myself cardiology right now so I can't definitively say.  ST elevation?

Maybe she truly is having a MI, or Prinzmetal's angina/ cardiac syndrome X.

Did she get nitro? If yes, was there any relief of CP following its administration?

Is she taking birth control (estrogen containing), is she overweight, does she smoke?

Also DDx for Pulmonary embolism:  Increased pain on inspiration? Any cough?


----------



## Melclin (Sep 22, 2010)

I think it was three cans (about 200mls each I suppose) and it was in the early hours of the morning. Its now about 11:45am. 


I can't see any ST-elevation. 

No nitro was given.

No birth control. Patient weighs maybe 60kgs. Non-smoker.

No change in pain on inspiration. No cough.


For any lurkers, jump in. This isn't a quiz, I actually want people to answer some of my own questions, but I don't want anybody's suggested management to be biased by me asking those questions straight off the bat.


----------



## clibb (Sep 22, 2010)

SVT which people will get from coffee. Will also explain SOB and dizziness. With the amount of caffeine people consume without any snacks or food, it doesn't surprise me she's in SVT.


----------



## 46Young (Sep 22, 2010)

Did you try to get her to vagal down enough to see if it was sinus tach or not?


----------



## 46Young (Sep 22, 2010)

SanDiegoEmt7 said:


> As for the EKG, I'm teaching myself cardiology right now so I can't definitively say.  ST elevation?



An ECG can be read in either monitor or diagnostic mode. Elevations and such can only be definitively read in diagnostic mode. The next time you go to work, hook yourself up and see the difference in the two modes. Also check out the rhythm generator as well. I've seen obvious ST evelations in the inferior leads on the pt in monitor mode and then see nothing whatsoever on the diagnostic mode. Hope this helps.


----------



## medic417 (Sep 22, 2010)

Did you run a 12 lead?  

Any response to vagal?

Is she compliant with medications?

Were the beverages just soda pop or were they the mega caffeine energy drinks?  

Had she had any arguments with family/friends prior to the events?


----------



## EMS49393 (Sep 22, 2010)

Did you get a 12-lead?  This looks like SVT, but a 12-lead is necessary for a truly diagnostic look.  This a strip in monitoring mode.

Caffeine and even smoking can cause SVT in otherwise healthy young people.  So can cocaine, amphetamines, and extreme panic.  

A 12-lead is important to help rule-out any aberrancy conduction issues that rear their ugly heads in the age group this young lady falls in.  WPW usually starts appearing in the older teenager, early 20's year old person.  Certain anti-arrhythmics are contraindicated with these aberrancy conduction problems so it's generally a good idea to have some idea of what you are really looking at should it come to a need for conversion of the otherwise alert and conscious patient that would really mind electricity.

In this patients instance, the text book will tell you she is unstable secondary to chest pain and shortness of breath.  Given your information, I would deem her stable at this interval because her blood pressure is holding, her SPO2 is holding (how are her lung sounds?), she is not altered, and appears to be compensating on her own pretty well.  Once you start throwing drugs at patients, you run the risk of shutting down their own compensatory mechanisms.  

I would get a 12-lead, have a nice sized, fairly proximal IV in place, continue to monitor, have O2 at the ready, and have her attempt to vagal.  If you feel this to be truly SVT and not WPW or LGL syndrome, and she does not convert with vagal maneuvers, you may elect based on her condition to assist in her conversion, either electrically or pharmacologically.   In her case, I'd probably start with drugs, specifically adenosine.  I'm super cautious with adenosine, even with it's extremely short half-life, and I have a lot of things in place before I administer the drug.  I have my initial 12-lead, and I will print a strip from the point that I administer the drug until they convert.  I understand that a cardiologist can actually see quite a bit when that conversion process is documented via a nice long strip.  I also like to have the combo-pads in place before I administer the drug, just in case something goes awry.  If they convert for you, you're likely looking at a PSVT situation.  The other symptoms should resolve after the heart rate is under control.

If you elect to treat with electricity and your patient would greatly mind the electricity, I would hope you would be kind to them and pre-medicate them with something that would render them relatively care-free and pain-free.  I like a little versed (if the BP is high enough) and some fentanyl.  

This is all based on the limited information presented in your case, and would be subject to change should I actually be able to assess this patient for myself.  

Before the inquisition begins, I readily admit that I am an overly cautious paramedic and tend to really overkill on precautions when I do things to patients.  Some people are more comfortable just throwing things at patients with little forethought or caution.  My overly analytical brain will not let me work that way.


----------



## johnrsemt (Sep 22, 2010)

You can DX SVT without a 12 lead;   as long as it is regular.  Irregular is A-fib

   Our Med Director used to teach not to go with a set rate,  but it was 220 - age:  so a 20 year old would be in SVT with a HR of 200.
    Use Adenocard to DX it,  when it slows down, you can see if it was SVT  (regular rhythm)  or A-Fib.     just don't document that you used the Adenocard to Diagnose it.  (his wording not mine).


----------



## gicts (Sep 22, 2010)

Looks like SVT due to stress, sleep deprivation, and caffeine (on an empty stomach too?) . I'd try to reassure her, try vagals, and place a line in en route. No need to push drugs unless she worsens.

Because it sounds like perhaps it was (or could have been) something else, I'd ask about dehydration or allergies. Was an abdominal assessment done?




SanDiegoEmt7 said:


> Caffeine overdose from consumption of numerous strong energy drinks.  Would account for tachycardia, rapid speech and thoughts, etc. Couple that with her nervousness for her exam and her predisposition to panic.
> 
> How many beverages did she consume and over what period of time?
> 
> ...



By ST elevation do you mean enlarged T wave? Also, why the nitro? Good question about the BC.


----------



## FLEMTP (Sep 22, 2010)

I have a better idea before ya'll jump into using medications like adenosine. 

how about some calming reassurance and some good ol' normal saline? if her rate comes down, it was anxiety, and dehydration.

She said she takes xanax every day.. but did not take it today.. seems pretty simple to me. 

Why is it that most people are just so ready to jump into pushing drugs?

I had a patient the other day that was in a sinus tach... on the 4 lead it looked MARGINALLY wide... but it did not have the typical morphology of v-tach. My partner, who is a Paramedic by licensure working as an EMT in our system, saw it and was like.. "um.. monitor! look at the monitor! Do you want the amiodarone?" I glanced over, saw it was sinus tach with what was probably a mild Bundle branch block, and said, nah, just a 12 lead is cool. 

The patient had a complaint of mild epigastric pain after eating meat he thought was possibly rancid, but he cooked it to kill whatever. He was smoking a cigarette upon our arrival and ambulated to the truck.

Not exactly something requiring a drug, or panic, but there are quite a few paramedics that seem to jump right into both.. 

i'll never understand it.


----------



## Veneficus (Sep 22, 2010)

FLEMTP said:


> I have a better idea before ya'll jump into using medications like adenosine.
> 
> how about some calming reassurance and some good ol' normal saline? if her rate comes down, it was anxiety, and dehydration.
> 
> ...



I understand it, but it doesn't make it any less stupid.

Because a large portion of those providing paramedic education/service present it in an almost military style of "You will do this when you see... or you are wrong, and the patient is going to die, the protocol will be breached you will lose your license, and get sued for an amount of money you will never earn in your life..."

Thinking is not on the menu, reacting is. 

You also have to remember you work for one of the best services anywhere. A large population of systems in the US don't want paramedics to actually think. Few actually provide their employees with professional educational opportunities or try to constantly increase the capabilities an thereby value of their employees. I  bet we could name >95% of them just from reputation.

We both see it all the time I am sure, it is still madness. You even see it here on the ACLS threads and the like. "because the protocol says..." "Because my instructor said..." "Because there are solicitors waiting around every corner, reviewing every run report waiting to catch a paramedic in anyway deviating from cookbook so they can litigate for all the poor :censored::censored::censored::censored::censored::censored::censored:'s  worldly possessions."


----------



## EMS49393 (Sep 22, 2010)

FLEMTP said:


> I have a better idea before ya'll jump into using medications like adenosine.
> 
> how about some calming reassurance and some good ol' normal saline? if her rate comes down, it was anxiety, and dehydration.
> 
> ...



I'm sure this was directed at me, which is fine, however you failed to read my post in its entirety or you simply found the fault you wanted to find and are now tearing it apart. 

I do not advocate pushing drugs if a patient is compensating on their own, which judging by the very limited information given, she clearly was.  I do advocate making certain you take every precaution if you feel you have to administer a medication, including taking the time to run a 12-lead ECG in this instance.  

I think she's nervous, period.  I think they over prescribe drugs like Xanax.  I also think it's an interesting scenario given the patients age and presentation.  She may not be nervous, she may have a genuine cardiac issue that presents in her age group.  She may have a PE or even a partial spontaneous pneumo.  There's a multitude of things that could be wrong with this girl and I do not think it's a bad thing to consider every possibility and not just go with "she's some chick that didn't take her daily Xanax."

It's about discussion and learning.  Or it's about egos.  Wait, it's EMS, it must be about the egos.  How silly for me to forget.


----------



## FLEMTP (Sep 22, 2010)

Veneficus said:


> I understand it, but it doesn't make it any less stupid.
> 
> Because a large portion of those providing paramedic education/service present it in an almost military style of "You will do this when you see... or you are wrong, and the patient is going to die, the protocol will be breached you will lose your license, and get sued for an amount of money you will never earn in your life..."
> 
> ...




Well.. i'll say you are right. I just couldn't imagine working some where that i wasn't allowed to think for myself, examine the patient, and treat the patient based on my exam, irregardless of what the "protocols" say. 

I feel like my hands are tied as it is ... being a paramedic. Id love to be able to obtain lab values, radiological exams, and have the ability to treat a patient on a longer term basis than 20 or so minutes. 

I guess im going to have to suck it up and go to PA school.In the meantime im going to keep working at trying to get Paramedic Practitioners brought into EMS.


----------



## MrBrown (Sep 22, 2010)

She's just a bit upset nothing to worry about, transport not required.

What exactly about this job is bothering you mate?


----------



## Veneficus (Sep 22, 2010)

EMS49393 said:


> I think they over prescribe drugs like Xanax.



Could I respectfully inquire how you came to that decision, and given the current state of western society what alternative treatment you would advocate?

(I do agree, and have some ideas, but I am interested in your thoughts)



EMS49393 said:


> She may not be nervous, she may have a genuine cardiac issue that presents in her age group.



Fair enough. (with no prior cardiac hx but a prior psych hx and her current med, I don't think anyone could fault you for entertaining this thought, but I also don't think it likely.)



EMS49393 said:


> She may have a PE or even a partial spontaneous pneumo.



I think these are getting a little out in left field.



EMS49393 said:


> There's a multitude of things that could be wrong with this girl and I do not think it's a bad thing to consider every possibility and not just go with "she's some chick that didn't take her daily Xanax."



Very true, but if you start to treat for anxiety, an it resolves, then considerable resources and grief for the patient can be reduced.

If she is stable, why not give it a go?


----------



## firetender (Sep 22, 2010)

*Couldn't resist!*



46Young said:


> Did you try to get her to vagal down enough to see if it was sinus tach or not?



I'm sure...

"Hey Lady," he calls to the back of the ambulance _*as he's DRIVING*_, "bear down like you're gonna poop!"


----------



## SanDiegoEmt7 (Sep 22, 2010)

46Young said:


> An ECG can be read in either monitor or diagnostic mode. Elevations and such can only be definitively read in diagnostic mode. The next time you go to work, hook yourself up and see the difference in the two modes. Also check out the rhythm generator as well. I've seen obvious ST evelations in the inferior leads on the pt in monitor mode and then see nothing whatsoever on the diagnostic mode. Hope this helps.



Thanks, I will check it out



gicts said:


> Looks like SVT due to stress, sleep deprivation, and caffeine (on an empty stomach too?) .
> 
> By ST elevation do you mean enlarged T wave? Also, why the nitro? Good question about the BC.



This is my poor ECG skills! I haven't covered SVT yet, although I should have recognized it


----------



## EMS49393 (Sep 22, 2010)

Veneficus said:


> Could I respectfully inquire how you came to that decision, and given the current state of western society what alternative treatment you would advocate?
> 
> (I do agree, and have some ideas, but I am interested in your thoughts)
> 
> ...


----------



## FLEMTP (Sep 22, 2010)

EMS49393 I wasnt picking apart your post.. im sorry if you took it that way. I was speaking in a generality. I see many many many many paramedics who throw a drug at damn near any problem someone has. There is a time and a place for pharmacology, and then there is a time and a place to hold off. I've heard more than once.. from a very well respected ER physician, that if you LISTEN to your patient, they will TELL you EXACTLY whats wrong with them. 

Most paramedics are no longer clinicians, they are cooks, and they are told they're going to bake a cake. sometimes its a chest pain cake, sometimes its a Breathing problem cake, but either way, they can't make it without following the recipe. 

I try to be like the little old lady that grabs a pinch of this and a pinch of that, and throws the cake in the oven without needing to set a timer, or check the temp every 5 minutes. 

It just saddens me that most people jump into the ACLS routine for SVT whenever they see a narrow complex rate above 150ish. SVT comes in many flavors, and sizes, and sometimes it might look like SVT and not even be close. 

So please, dont take offense to my post, i wasnt trying to tear anyone apart.. I like to get people to open the top to the box they live in, step out, and look around a little. You'd be surprised at what you'll find.


----------



## EMS49393 (Sep 22, 2010)

FLEMTP: Thank you for that post.  I appreciate where you are coming from since I've seen nothing but cookbook medics since I left Missouri.  I just can't bring myself to do a lot of screwing around with this and that intervention when a patient is compensating.  They might be "textbook" unstable, but are they really unstable?  In many instances they are not so critically unstable that they can't wait for very definitive interventions beyond what we are able to provide or the additional diagnostics available to determine their exact needs.  

We carried Retavase in Missouri for the STEMI patient.  Although they were trialing thrombolytics at the hospital for ischemic CVA's, I certainly wouldn't dream of administering that drug to a stroke patient, no matter how much I felt the stroke to be ischemic in nature.  My CT machine has been down for years in my ambulance, and all the repair orders have been neglected.  My point is, just pushing something because you can, or you think you should is dangerous without proper education, diagnostics, and consideration.   

I really get tired of hearing the phrase "I did it because the protocol told me to."  They are guidelines and are not always appropriate for every patient encountered.  This young lady with chest pain is a prime example.  There are no cardiac protocols in PA that truly fit this patient.  There is a chest pain protocol and a narrow complex tachycardia protocol, but neither of them really fit this scenario.  She's likely not having an MI (unless she's been abusing cocaine) so going down the ACS protocol is just ridiculous.  She does have a "narrow complex tachycardia" but she is really relatively stable, so I just can't see baking the cake through that algorithm and screwing with her compensatory mechanisms.  I can see monitoring her closely, and helping her to calm down (likely being her problem).

Despite my unpopular stance, I'm going to continue to swear up and down that the major problem with EMS in this country is the lack of needing a degree to work.  You just can't make a truly informed decision without education, period.


----------



## Aidey (Sep 23, 2010)

FLEMTP said:


> I have a better idea before ya'll jump into using medications like adenosine.
> 
> how about some calming reassurance and some good ol' normal saline? if her rate comes down, it was anxiety, and dehydration.
> 
> ...





Veneficus said:


> I understand it, but it doesn't make it any less stupid.
> 
> Because a large portion of those providing paramedic education/service present it in an almost military style of "You will do this when you see... or you are wrong, and the patient is going to die, the protocol will be breached you will lose your license, and get sued for an amount of money you will never earn in your life..."
> 
> ...



I agree with both of you. After speaking with several people about cases they had like this, I have come to the conclusion that we SUCK at telling SVT from ST, and adenosine should be taken out of the protocol in my area. If they are unstable then they should be cardioverted. If they are stable, then leave the drugs alone! 

I heard someone declare a HR of 180 in a 3 yo /c a fever was SVT. I had a fire medic want to give adenosine to a 93 yo woman /c a HR ranging between 130-190. Hmmm, irregular...rate over the ST threshold...93 years old...how many people even need to look at the strip to know what it is? 

And for those who truly are in SVT, it is not an uncommon idopathic event in young adults, especially young women. It resolves on its own, and doesn't need emergency treatment. I have had episodes of SVT myself, and I have also managed to get my HR up into the 180s-190s when working out. Was there chest pain and SOB associated with both? Yup, but it is a totally different sensation. 

Chest pain in fast ST isn't really unexpected. The way it was explained to me is that the heart is a muscle, when it is beating 160 times a minute the muscle is working hard. When you work your arm and leg muscles hard what happens? They hurt (Duh. The duh was actually included by the doc giving the lecture). 

And then we've got WPW...adenosine = v-fib. If you don't know what WPW stands for, what it is, how do identify it and why adenosine is bad, you don't know enough to be giving anyone adenosine. 

To the OP, what was the issue you had with the run?


----------



## Melclin (Sep 23, 2010)

*Overwhelmingly satisfying.*

First of all: There was no twelve lead available. No vagal maneuvers tried. No particular stressors other than uni of late. I've heard of the difference between monitoring mode and diagnostic mode before, but its not something we talk about at uni and I've never seen it used on the road. Maybe the service monitors are different than at uni but as far as we're concerned there is one mode. :unsure:

Now, both my partner and I interpreted the rhythm to be sinus tach. We both felt that what this girl needed was to be calmed down. Her history of anxiety, plus stressors plus caffeine and not much sleep = anxiety attack. I felt coaching her breathing and utilizing some relaxation/bio-feedback techniques were warranted. Ventmedic's voice was floating around in my head saying "hyperventilation syndrommmmeeeee, hyperventilaaaatttitonnn syndrommmme" "don't fob off the anxious tachypneic pt"), but I still felt on the balance of probabilities this was not an emergent job, and it was worth spending some time calming the patient, taking her home to get her xanax if it wasn't far and giving that a shot (she was quite sure it was an anxiety attack), maybe giving her doctor a ring getting some advice and organizing for an checkup/doctors cert for the exam. 

If we couldn't drop the heart rate at all, and the sensation in her chest continued, then maybe some IN fentanyl to calm her/treat the discomfort and transport non-emergently to the nearest public ED for a looksie. 

What actually happened instead was that the instructor corrected our ECG interpretation to SVT and continued to prompt my partner into: cannulation, IV morphine (to which the patient became nauseated and received metaclopramide), activation of MICA backup, and emergent transport to a cardiac center. 

She felt that the not at the top of what I thought was a T/P combination was actually a retrograde P wave in the middle of a large T wave and that it was dead-set SVT. She seemed to want to emphasize the instability of the patient (she seemed fine to me) based primarily on the the SVT and the pale skin (the pt was wearing a lot of make up but I thought it was just that the actress happened to be wearing make up). She was quite sure that this girl would be chemically cardioverted. She also said that an anxiety attack would not provoke a rate of a 170, to which I intuitively disagreed, but had no evidence with which to support the idea.


----------



## Aidey (Sep 23, 2010)

^^^ And that ladies and gentleman is EXACTLY why we need to reconsider adenosine use pre-hospitally. I know it wasn't given in this case, but it is the overall issue of people not being able to tell what is SVT from what isn't.


----------



## EMS49393 (Sep 23, 2010)

Melclin said:


> She also said that an anxiety attack would not provoke a rate of a 170, to which I intuitively disagreed, but had no evidence with which to support the idea.



I have no evidence to support this either, however I've personally had my heart rate that high over too much caffeine an anxiety, so the blanket statement that it will not provoke a rate of 170 doesn't hold water with me. 

Now that you've presented the remainder of the story, I have to agree with your line of intervention versus the instructors line.  Unfortunately, the instructors appear to always be correct.


----------



## slb862 (Sep 23, 2010)

*too much caffeine*

My very first call as a Paramedic was very similar:

40ish yo guy out jogging, developed CP.  

BP-normal 120's/80's
P-elevated (170's)
R-28
Cardiac Monitor-ST, no ectopy
NKDA
PMH: none healthy
12 lead: ST
Sweating, denies N/V and no radiation.
Pt. states out drinking last night, not a heavy drinker, but got sloshed. (states he smoked a pack of cigarettes, states he doesn't smoke) Woke up this am, slammed 4 diet cokes, went out for a morning jog.  
Classic caffeine "overdose", on top of being dehydrated.

He survived, and felt better after a liter of NS.


----------



## clibb (Sep 23, 2010)

Melclin said:


> Now, both my partner and I interpreted the rhythm to be sinus tach.



How can you confuse that with Sinus Tach? There are no P waves.


----------



## Veneficus (Sep 23, 2010)

EMS49393 said:


> I'm interested in your views.  I've read several of your posts and find them intelligent and well written.   It's actually refreshing since the main reason I hate my career is the lack of required education and subsequent progress.  I enjoy a good dialogue.



It is not benzos that really worry me. Both Benzos and barbiturates have been used for centuries and despite the side effects, the mechanisms and understanding of them are well established.

But it doesn't mean it should be the first choice.

I think a lot of the psychiatric diagnosis do not qualify as pathology. Obviously there are people with such severe psychosis that they require pharmacological or intervention.

The problem I see is that most psychiatric illnesses are actually coping mechanisms. When a physiologic coping mechanism gets out of control, that is where medicine needs to come into play. Examples abound in other organ systems. Liver fibrosis, ectopic myocardial contractions, certain immune responses, etc. 

If your problem is you are depressed because you lost your job, can't pay your bills, aren't very successful with romance, etc. then certain levels of anxiety and/or depression are physiologic. Until it actually has a strongly negative effect or a person's biochemistry is so altered they cannot recover from the compensatory mechanism is where medicine should come into play. 

In earlier western society and in many nonwestern societies, it is a family or other social support group that has the largest positive effect on resolving the issues. 

Take for example indiginous tribes in South America. Some guy loses his house in a flood. He is depressed, homeless, doesn't have an insurance plan to compensate him for losing everything. 

So the local shamen gies him a stimulant to chew, (similar to cocaine) performs an exorcism like ritual, and sudenly with the evil spirits gone, his life takes a dramatic upturn. 

Let us analyze this witchcraft a little deeper though. 

His problems are attributed to an outside supernatural source, therby absolving him of a feeling of guilt or fault. He is given some temporary (one time use) pharm therapy, and the public ritual calls public attention to his plight. Now being absolved, in celebration other villagers help him build a new house, bring him gifts and have a feast to sole his immediate food and neccesary possession problems, and then he is suddenly an attractive mate or hunter, etc. 

All of it stems from a form of highly ritualized social support. The root of the problem is addressed. 

If he was just given his stimulant, none of his issues would be addressed and as soon as the stimulant wore off, he would require some more in order to prevent relapse. Eventually he will be so doped up, he will then be a burden on society around him or abandoned. 

With the exception of the most serious levels of disorder, modern therapy is basically overcompensating the defense mechanisms by altering biochemical pathways without addressing the root issues so that normal brain function can return. 

Most modern western societies have lost the social support mechanisms for a variety of reasons too numerous to describe in a post here. 

We have tried to replace those mechanisms with various pharmacological agents or "counciling." What that equates to is what I describe "help light" (counciling) which can have a real impact in minor cases, or a "nuclear option" (pharm) that is often considerably more than a person needs to get back to normal compensation levels. 

It turns into an imprecise game of playing with a chemistry set without addressing the root causes. It is the same as treating a dysfunctional liver caused by heart failure without doing anything for the heart.

Pharm therapy without counciling or social support just basically makes people "high" by stimulating or inhibiting various chemical processes. You certainly don't need to pay a doctor for that. Your local street pharmacist can do the same for much less. 

The trouble is there is negative stigma about social support programs as well as many psychological services not affordable or covered by insurance/effectively funded by the social systems. we simply cannot replace social support networks (the hyperspecialization of modern western society actually makes social support more neccesary as individuals no longer have the broad range of knowledge and skills to properly cope with many adversities.) Primates require social interaction for health. People are Primates.

Again, the pharm therapy does work and in certain patients is certainly indicated and beneficial. But there is a culture of trying to use pharm therapy as a simple easy to use magic cure. 

"Don't use a cannon to kill a mosquito."


----------



## Smash (Sep 23, 2010)

Further to the above, recent years have seen a flood of Ritalin being prescribed for children with "ADHD" or "ADD". Whilst some may indeed actually have such a disorder, there is a growing realization that the majority of behavioral problems can be attributed to other causes such as sleep deprivation (I'm always astounded at the number of residences we attend late at night or early in the morning to find children up and about at an hour that I wish knead in bed!) or just plain old needing a bit of discipline. 
However, we seem, as a society, to be interested in two things above all others: the quick fix and abrogation of any kind of personal responsibility. 

This is not intended to diminish the impact that mental illness has on individuals or on healthcare/society, but it does seem we are keen to throw drugs at things that could be managed more appropriately with other means.


----------



## Melclin (Sep 23, 2010)

clibb said:


> How can you confuse that with Sinus Tach? There are no P waves.



There is a p wave. The argument was whether the notch in the middle of the complex in between the two QRSs is a retrograde p wave in the middle of a t wave, or that the notch is the begining of the natural decline of the t wave and that it is followed by a normal p wave. 

To further confuse matters I've since seen the actual written version of the standard scenario and it says the patient is "monitored in Sinus Tachycardia".


----------



## Aidey (Sep 24, 2010)

clibb said:


> How can you confuse that with Sinus Tach? There are no P waves.



I'm 100% sure that if we were able to slow that down, more obvious P waves would show up.


----------



## FLEMTP (Sep 24, 2010)

Melclin said:


> First of all: There was no twelve lead available. No vagal maneuvers tried. No particular stressors other than uni of late. I've heard of the difference between monitoring mode and diagnostic mode before, but its not something we talk about at uni and I've never seen it used on the road. Maybe the service monitors are different than at uni but as far as we're concerned there is one mode. :unsure:
> 
> Now, both my partner and I interpreted the rhythm to be sinus tach. We both felt that what this girl needed was to be calmed down. Her history of anxiety, plus stressors plus caffeine and not much sleep = anxiety attack. I felt coaching her breathing and utilizing some relaxation/bio-feedback techniques were warranted. Ventmedic's voice was floating around in my head saying "hyperventilation syndrommmmeeeee, hyperventilaaaatttitonnn syndrommmme" "don't fob off the anxious tachypneic pt"), but I still felt on the balance of probabilities this was not an emergent job, and it was worth spending some time calming the patient, taking her home to get her xanax if it wasn't far and giving that a shot (she was quite sure it was an anxiety attack), maybe giving her doctor a ring getting some advice and organizing for an checkup/doctors cert for the exam.
> 
> ...



My opinion is that your "instructor" is in need of some serious "instruction" of her own!


----------



## gicts (Sep 24, 2010)

What would the benefit of intranasal fentanyl be over IV in this situation?


----------



## EMS49393 (Sep 24, 2010)

gicts said:


> What would the benefit of intranasal fentanyl be over IV in this situation?



Iam suddenly confused. Why is this girl getting fentanyl?


----------



## Sam Adams (Sep 24, 2010)

I'm in agreement here, why the fent.?

Advanced Life Support wouldn't have even been dispatched to this call in these parts. She needs hugs, not drugs.


----------



## dixie_flatline (Sep 24, 2010)

Sam Adams said:


> She needs hugs, not drugs.



I lol'd


----------



## gicts (Sep 24, 2010)

EMS49393 said:


> Iam suddenly confused. Why is this girl getting fentanyl?



My guess is a poor decision of a sedative for anxiety in an over blown treatment choice for this scenario. Tis what the OP said the treatment was though if that is the question.


----------



## medic417 (Sep 24, 2010)

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.  

Just because the patient tells you a history of anxiety does not rule out the cardiac possibility.  By immediately saying its FHS ( Female Hysterics Syndrome ) you may be missing the big picture.  Perhaps the pale cool skin is improper perfusion caused by a cardiac event rather than just her hyperventilating and panicking.  Even if this was a panic attack has she now actually pushed herself over the edge and now is having a true cardiac episode.  

Age is not a determining factor to cardiac problems.  Do not put blinders on. 

Melclin have you been able to follow up at the hospital to see what the actual diagnosis was?


----------



## sir.shocksalot (Sep 24, 2010)

EMS49393 said:


> Iam suddenly confused. Why is this girl getting fentanyl?


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.)


----------



## Aidey (Sep 24, 2010)

medic417 said:


> 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.
> 
> Just because the patient tells you a history of anxiety does not rule out the cardiac possibility.  By immediately saying its FHS ( Female Hysterics Syndrome ) you may be missing the big picture.  Perhaps the pale cool skin is improper perfusion caused by a cardiac event rather than just her hyperventilating and panicking.  Even if this was a panic attack has she now actually pushed herself over the edge and now is having a true cardiac episode.
> 
> ...



I think this was a scenario, not an actual patient. 

I also don't think that everyone is dismissing this has FHS. I believe there is an anxiety component that is being exacerbated by some benzo withdrawal, caffeine overload, lack of sleep and minor dehydration.


----------



## socalmedic (Sep 24, 2010)

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 (Sep 27, 2010)

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 (Nov 1, 2010)

sir.shocksalot said:


> 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 (Nov 2, 2010)

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 (Nov 3, 2010)

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 (Nov 3, 2010)

*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 (Nov 3, 2010)

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


----------



## 18G (Nov 3, 2010)

"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 (Nov 3, 2010)

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 (Nov 3, 2010)

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 (Nov 3, 2010)

What *aside* from the rate?


----------



## 18G (Nov 3, 2010)

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 (Nov 3, 2010)

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


----------



## emtchick171 (Nov 3, 2010)

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 (Nov 3, 2010)

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 (Nov 4, 2010)

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 (Nov 4, 2010)

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 (Nov 4, 2010)

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 (Nov 4, 2010)

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..


----------

