# "Heart keeps skipping a beat"



## Explorer127 (May 17, 2009)

57 y/o female pt
Only past medical history is lupus.
No allergies
Only med pt is on is Advil...
Last oral intake--nothing out of the ordinary..
Events Prior--Once again, nothing that could provoke symptoms.

Pt states that she often feels heart skip a beat once or twice every day.

However, today it happened every 3-5 minutes for about 30 minutes every hour. States that often when it happens, she feels dizzy and everything around her "turns red." This continued for a few hours.

Pulse 88
BP  136/80 (her normal) 
Whenver I take her pulse, it would be pretty regular, suddenly stop (the skipped beat) then continue and be somewhat tachy, then go back to normal.


Never got to find out what happened---any ideas?


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## Sasha (May 17, 2009)

Explorer127 said:


> 57 y/o female pt
> Only past medical history is lupus.
> No allergies
> Only med pt is on is Advil...
> ...




Sounds like she's was getting PVCs.

Did you hook her up to a 4 lead by chance? 12 lead?


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## Explorer127 (May 17, 2009)

No EKG was obtained b/c ALS was not available.


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## VentMedic (May 17, 2009)

Several things can be going on with many different etiologies.

She may actually have experienced an MI recently that has yet to be diagnosed which can now be causing electrical distrubances. 

She may also have an undiagnosed cardiomyopathy which could now be symptomatic.

*



Only past medical history is lupus.

Click to expand...

* 
*This is VERY significant for history as it affects many systems including the kidneys or renal system. *

She could have an electrolyte imbalance cause electrical disturbances.

Did she have a history of smoking? She could now have an undiagnosed COPD which may already be presenting with cor pulmonale and rhythm disturbanes such as WAP or MAT. 

Her dizziness may be from the irregularity in perfusion from the missed beats.

Did you listen for heart sounds?

An EKG? That would be the only way to know exactly what the rhythm is. She may also need to wear a Holter Monitor for 24 - 48 hours to determine rhythm disturbances or to be admiitted to a telemetry unit in the hospital for continous monitoring.

The missed beats could be PVCs, PACs, runs of PSVT, VT or tachy-brady associated with SSS which would get her a pacemaker.


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## Kentia (May 17, 2009)

Are EMT's there not allowed to do 4 lead or even 12 leads? it is standard practice here, whether ALS is there or not (most often they are though). If ALS is not able to come, we still attach a 12 and send it from the montior (heartstart MRX which has wireless capabilitys) to the recieving facility for interp.


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## VentMedic (May 17, 2009)

Let me give you a link for the abbreviations I used.

http://www.wtv-zone.com/MARCEY/EKG/cardiacrhytable.html

SSS is Sick Sinus Syndrome.

http://www.aafp.org/afp/20030415/1725.html


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## VentMedic (May 17, 2009)

Kentia said:


> Are EMT's there not allowed to do 4 lead or even 12 leads? it is standard practice here, whether ALS is there or not (most often they are though). If ALS is not able to come, we still attach a 12 and send it from the montior (heartstart MRX which has wireless capabilitys) to the recieving facility for interp.


 
And then what?


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## amberdt03 (May 17, 2009)

i have the same problem. my heart skips beats multiple times daily, never got it checked out till i started having chest pain. my doc said my 12 lead was regularly irregular. all my labs came back normal. i thought that it was my thyroid acting up cause the time before that my thyroid levels were high. had to get an echo done and my doc said that my mitral valve is regurgitating and that i have some fluid build up around my heart.


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## amberdt03 (May 17, 2009)

VentMedic said:


> And then what?



they sit there and twittle their thumbs. lol.


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## mycrofft (May 17, 2009)

*I get skips too, don't get target fixated.*

The pt sensing "skipped beats" is hardly diagnostic, it is historic. She could be arrythmic at other times and not know it.  EKG is needed, but other areas cannot be ruled out, e.g., atrial fib and tossing clots, the pt senses these missed beats due to s/s of intracranial circ issues, etc. "Everything turning red" can be either too much intracranial pressure or too little venous outflow from the cranium (a "red-out") or too little perfusion (maybe even some sort of vaso-vagal episode). I'll bet she also heard a roaring sound in her ears.

As always, obviously needs to be worked up in a hospital, cut to the chase and get 'er in.


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## JPINFV (May 17, 2009)

/me sighs. 

Vent, don't you know, it's never lupus...


/house reference.
//had to be done.


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## AnthonyM83 (May 17, 2009)

JPINFV said:


> /me sighs.
> 
> Vent, don't you know, it's never lupus...
> 
> ...


Course, it's always disseminated intravascular coagulapathy, right?


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## daedalus (May 17, 2009)

AnthonyM83 said:


> Course, it's always disseminated intravascular coagulapathy, right?



No its not lupus or DIC. And its not Wegners ether, in case you were wondering. 

JP, get a stress test
Anthony, go ultrasound her heart and look for valve problems
Vent, bleed the patient and spin the blood, find out if she has been eating her bananas. 

I am going to sit here and watch my soap.


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## Sasha (May 17, 2009)

daedalus said:


> No its not lupus or DIC. And its not Wegners ether, in case you were wondering.
> 
> JP, get a stress test
> Anthony, go ultrasound her heart and look for valve problems
> ...



Hmph.

10chars


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## VentMedic (May 17, 2009)

Sasha said:


> Hmph.
> 
> 10chars


 
And you can biopsy the brain.

Isn't that done in every House episode?


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## mycrofft (May 18, 2009)

*You missed House's versin of a "subspace field":*

"Paraneoplastic syndrome".

OP, any followup for us?


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## AnthonyM83 (May 18, 2009)

While you're at it, get her an MRI, since I know you're going to do it behind my back, anyway. And order the experimental treatment...make up some false lab reports for her.


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## Sasha (May 18, 2009)

AnthonyM83 said:


> While you're at it, get her an MRI, since I know you're going to do it behind my back, anyway. And order the experimental treatment...make up some false lab reports for her.



But what about Cuddy?


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## daedalus (May 18, 2009)

Sasha said:


> But what about Cuddy?



It came to me, from our PMs, that you are clearly Dr. Cameron
^_^

But thats ok.


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## daedalus (May 18, 2009)

By the way, systemic lupus causes tachycardia, chest pain, and dyspnea in up to 50% of cases. Periods of tachycardia can certainly seem like SSS, SVT or skipped beats (palpitations). Women are more likely than men to get lupus (autoimmune). And as Vent has said, a significant sequelae of SLE is renal failure. Remember that kidney problems wreak havoc on electrolyte and fluid balance. 

Lupus would definitely be in your ddx for this patient as the cause of her symptoms. Along with old/new MI, electrolyte issues, etc etc.


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## AnthonyM83 (May 18, 2009)

Sasha said:


> But what about Cuddy?


I'll handle Cuddy. She wants me anyway, so I'll deal with her. Just get me some lab values and CBC's. I'll handle her.


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## Sasha (May 18, 2009)

daedalus said:


> It came to me, from our PMs, that you are clearly Dr. Cameron
> ^_^
> 
> But thats ok.



It has come to me, from our PMs, that you clearly are---nevermind, I'll keep that to myself.


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## mycrofft (May 18, 2009)

*Daedelus has something.*

A tachyarrythmia, or even too damn many espressos, can reveal a weak AV node which may sneak in a missed beat once in a while but when you switch it from "foxtrot" to "lambada", it can't keep up.
Doesn't sound safe to drive to me.


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## daedalus (May 18, 2009)

VentMedic said:


> And you can biopsy the brain.
> 
> Isn't that done in every House episode?



You mean we do not usually do that in the hospital?
Ill have to take my Bx punch out of the ambulance before I get into trouble....


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## mycrofft (May 19, 2009)

*Just use your "Gage and DeSoto EMERGENCY window punch"*

Or my Binford Obsidian 3000 head trochar:


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## DT4EMS (May 19, 2009)

mycrofft said:


> Or my Binford Obsidian 3000 head trochar:



Sorry to hijack the thread........ But that is a bute!!

What kind of stone is that made from?


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## Sasha (May 19, 2009)

DT4EMS said:


> Sorry to hijack the thread........ But that is a bute!!
> 
> What kind of stone is that made from?





> Or my Binford *Obsidian* 3000 head trochar:



I'd guess obsidian? 

Edit:

Oooohhh... You probably meant the handle...

Whoops.


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## DT4EMS (May 19, 2009)

Sasha said:


> I'd guess obsidian?
> 
> Edit:
> 
> ...



No...no......... that was a dumb-dumb on my part. I didn't know what "obsidian" was. Now I know....... thanks to Google. It is from Volcanic rock that turns to some sort of glass.

I just really, really liked the look of that blade!


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