This is a very sick woman and I'd get her going asap. First thing i'd do before I left scene is grab her meds. You said she's been off the HTN RX because her BP was getting too low? That could be part of the problem today. Check her lung sounds (i=Is she SOB? Do I hear rales?). I'd look at the stool too. Is is bright red? Black? Foul or unusual odor? She could be bleeding out internally. If she hasn't eaten in 2-3 days and those are her vitals that is another red flag. I'd be cognizant of dehydration and malnutrition. Has she been vomiting as well? If so, what color is the emesis? Palpate the abd (make sure there's no pulsating masses or abnormal distention). Another great thing to grab would be her grips/pushes and have her smile for the differential diagnosis to r/o stroke. Then check her pedal and brachial (since radial probably won't be felt) to make sure they're present and equal. As far as treatment I'd do this:
1) Place her in shock position
2) Oxygen 15 LPM via NRB
3) Cardiac monitor (Have my partner perform a 12-lead)
4) Bilat. large bore IV (grab a bs as well)
5) NS fluid bolus (That could very well correct her HR and her BP)
6) I'd be careful with adenosine. She's unstable and this appears to be
a hypovolemia and not a conduction issue. Cardioversion (Versed
beforehand for pre-cardioversion)may be the better option although
that probably won't do much either.
7) Perform another 12-lead if I'm able to get the HR to slow down. This
could very well be an MI as well.
8) Get her to the hospital asap. She needs the higher level of care.
***I had a call very similar to this. 30-ish y/o female fell suddenly had been sob for several days. By the time we got there she was lethargic and unable to speak due to her breathing. VS: 230 HR SVT, BP 70/P, RR 60 rapid and shallow. LS were absent in the bases with rales heard in the upper lobes bilat. I ended up popping bilat. large bore IV's in her, bagging, and cardioverting her 3 times which didn't do anything. I wanted to put her on CPAP but she did not meet the criteria according to my protocols. Well when we get her to the hospital the doc put her on their CPAP and she was fixed within 10 minutes; full sentences and everything. Never had an SVT call like it since.***
She's awake, talking moving around and you want to jump to zapping her??
Fluids, watch her for fluid overload, consider adenosine maybe...
Using the 220-age rule she's barely into the SVT range...
^This was the point of the thread, figure out why the patient has the signs and symptoms that she does and treat the cause of them.
She was alert x3, responding appropriately I'm not sure why you call her unstable, yes the vital signs aren't the best but I would consider her borderline stable.
She wasn't in respiratory distress whatsoever, she was at 94%, and respirations where 14, the O2 at 15LPM seems like a bit much and I think this is one of those situations where it would've hurt her instead of helping.
Her BSG was normal, don't remember the exact number.
Second 12 lead was sinus-tach at about 130
May I ask why?
She needs an ALS workup and transport to definitive care but she doesn't need you running around like a chicken with your head cut off. Despite popular belief, there's very few things where seconds truly count.
The call you referenced is much more severe than the one originally described in this thread.
She's dehydrated. Severely. She doesn't need medications or electricity. She needs fluids and electrolytes. 150-170 isn't that fast for a 56 year old. It's fast and needs to be addressed but she's not going to crump on you. Take the numbers you're getting and combine them with your patient's presentation and decide on the best treatment path.
So you want to give a severely hypotensive patient versed to cardiovert her? Versed isn't as scary as medic school makes it out to be but if she's stable enough for you to mess around with getting a line and drawing narcs she's stable enough for you to start a fluid challenge and consider chemical cardioversion before lighting her up like the morning sky.
You said you'd be wary of adenosine because "she's unstable and hypovolemic, cardioversion is a better option". How is cardioversion even an option in this instance? What is cardioverting a hypovolemic patient going to do for them other than hurt? Replace the volume, see what that does then reconsider your plan of action...
Where the heck did a CVA assessment come into play? I'm all for being thorough but nothing here says stroke to me at all. Maybe I'm missing something but you can do a pretty solid neurological assessment by just interacting with a patient. She complained of generalized weakness, not unilateral weakness....
.
Agreed with most of this, however a medial CVA would cause general weakness, but it would've also caused other symptoms which is why we didn't suspect it, dysphagia, aphagia, ect.
Booo! Booooo! It is only "PSVT" if you watched it start and stop. That term is a bad term anyways. "Narrow complex tachycardia" and "wide complex tachycardia" are better. SVT isn't a rhythm and apparently only exists to confuse people.
If by "150-170" you meant a ranging heart rate? Only three narrow complex tachycardias meet that definition:
- Sinus tachycardia
- Atrial fibrillation
- Atrial tachycardia (but not a huge range)
- Atrial flutter with variable conduction and "150-170" is the rate displayed by the cardiac monitor's moving average (unlikely)
If by "150-170" you meant, "somewhere exactly between those two", I would add the following are differentials separated by rhythm interpretation and not by rate (ordered by likelihood given patient's age):
- Sinus tachycardia
- AVNRT
- AVRT
- Atrial flutter (2:1)
- Atrial tachycardia
- Junctional tachycardia
It would go up and down between 150-170, once we reassessed after the fluids her heart rate was at 125-135 (as in i'm not sure what it was, but it was somewhere around there).
CVA with these s/s seems very unlikely. Why couldn't she get up ORIGINALLY, did she get dizzy? (later on,probably). Any ortho issue which kept her from getting to the toilet, getting water and food, etc., like broken hip or a blown knee?
Saw a similar situation in a man who fell (had Parkinson's) and wedged between tub and toilet for three days, his barking dog summoned help (neighbors called landlord). Similar findings.
No ortho, only history was hypertension, she said she couldn't get up because she had been getting weaker over time.
It also says directly in our protocols Adenosine is for stable SVT. This patient is without a doubt unstable when you look at her BP.
A BP alone is not the only thing that would determine if a patient is stable or unstable, as many EMT/Medic instructors have said, treat the patient not the monitor(sorry I know some people don't like this saying.)
That's not exactly true.
Adenosine is for tachycardias likely to be due to reentry mechanisms, whether they are stable or unstable makes no matter for its efficacy. Adenosine will not "fix" a stable sinus tachycardia nor a stable atrial tachycardia nor a stable atrial flutter or atrial fibrillation.
I've had stable patients with blood pressures in the 60's. They were in septic shock, but answered all questions appropriately and without hesitation. They most assuredly did not need cardioversion or adenosine for their tachycardias.
You must understand that cardioversion is for patients unstable DUE to their tachycardia. If their tachycardia is a compensatory response then cardioversion (whether chemical or electrical) is CONTRAINDICATED.
Atrial fibrillation with RVR is not always the cause of a patient's hemodynamic instability. Hypovolemic patient with a GI bleed and AF w/ RVR @ 140-170 will not respond to cardioversion no matter how many times you do it. They also meet the definition of unstable...
Sinus tachycardia is never* the cause of a patient's hemodynamic instability. (* you may only replace 'never' with another word if you actually can name the forms of sinus tachycardia that may cause hemodynamic instability)
Treatment of tachycardias is not rate based nor blood pressure based nor stable versus unstable.
Treatment of tachycardias is based on the appropriate rhythm interpretation in light of the patient's clinical presentation. This is not contradictory with ACLS or Paramedic curriculum or any protocols.
I'll add that if you are electing to cardiovert a narrow complex tachycardia that is not atrial fibrillation with RVR or atrial flutter, you need to take a step back and seriously evaluate what you are doing. Narrow complex tachycardias other than those two are almost always well tolerated even for prolonged periods of time. You would be well served to have already gone down the list of fluids, valsalva, adenosine, and a really hard look at H's and T's...
I agree and fluids would be part of the H's & T's, and it's how we figured out what was wrong with her.
