47 y/o female syncopal episode

[rhan101277]

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?

 

[usalsfyre]

54 systolic off of an automated cuff or manually?

 

[Dwindlin]

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.

 

[Handsome Robb]

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

 

[usalsfyre]

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.

 

[Handsome Robb]

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:

 

[usalsfyre]

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...

 

[Handsome Robb]

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.

 

[DrankTheKoolaid]

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 ).

 

[usalsfyre]

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.

 

[usalsfyre]

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.

 

[Dwindlin]

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.

 

[Medic87]

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?

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

 

[Dwindlin]

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.

 

[usalsfyre]

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

Entirely appropriate if the rates CAUSING the hypotension.

 

[usalsfyre]

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?

 

[Handsome Robb]

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.

 

[Handsome Robb]

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.

 

[DrankTheKoolaid]

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.

 

[usalsfyre]

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.