what do you think?

Tal

Tal

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I just started my internship in the EMS here in israel and had a patient that I didnt know how to approach.

a 73 years old woman came to a health clinic complaining on palpitation. the doc's at the clinic told us the lady had a 160 bpm that pass after a short rest.
in the ECG the doc's did we saw a sinustachy with ST depression at the anterior wall, and negative T waves at the inferior wall, no chest pains appeared.

when we arrived, the lady was calm, saying "I feel fine". our ECG showed a NSR of 70 bpm, without any signs showed at the ECG the doctor did befor our arrival.

what would you do, and why?

I didnt know how to carry on the treatment, but the paramedic gave 300mg Aspirin, and 4000iu Heparin.
 
Well unless symptoms were to recur, IMHO it'd just be supportive care. O2, EKG with 12's, IV, ASA, emotional support and obtaining meticulous cardiac hx. We don't carry heparin.

Come to think of it, lets say the symptoms did recur. IMHO again, it'd have to be a sustained run refractory to vagal maneuvers, for me to consider pharmacological intervention beyond above stated.

What was your 12 lead showing? Did it agree with the physicians? I personally wouldn't get too concerned with the anterior ST depression (nor the non reciprocal t-wave inversions). There are plenty of benign reasons behind ST depression, many of which are not ischemic.
 
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well treat your patient not your ECG. but being a monday morning quarterback. V.O.M.I.T. vitals, O2, Monitor, IV, transport. if the signs an symptoms come back treat accordingly.
 
vquintessence said:
Well unless symptoms were to recur, IMHO it'd just be supportive care. O2, EKG with 12's, IV, ASA, emotional support and obtaining meticulous cardiac hx. We don't carry heparin.

Come to think of it, lets say the symptoms did recur. IMHO again, it'd have to be a sustained run refractory to vagal maneuvers, for me to consider pharmacological intervention beyond above stated.

What was your 12 lead showing? Did it agree with the physicians? I personally wouldn't get too concerned with the anterior ST depression (nor the non reciprocal t-wave inversions). There are plenty of benign reasons behind ST depression, many of which are not ischemic.
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that's the thing. our ECG was so clean its the one appear at the books under: normal ECG.
 
I have noticed before that with a ST sometimes there appears to be ST changes when there really isn't. I do not know why or if I am just crazy but maybe that's what they saw.
 
motomedic said:
well treat your patient not your ECG. but being a monday morning quarterback. V.O.M.I.T. vitals, O2, Monitor, IV, transport. if the signs an symptoms come back treat accordingly.
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Take a good history and perhaps ASA in adition to VOMIT. If her symptoms improved with rest there's not much to treat in the pre-hospital setting.
 
Tal said:
I just started my internship in the EMS here in israel and had a patient that I didnt know how to approach.

a 73 years old woman came to a health clinic complaining on palpitation. the doc's at the clinic told us the lady had a 160 bpm that pass after a short rest.
in the ECG the doc's did we saw a sinustachy with ST depression at the anterior wall, and negative T waves at the inferior wall, no chest pains appeared.

when we arrived, the lady was calm, saying "I feel fine". our ECG showed a NSR of 70 bpm, without any signs showed at the ECG the doctor did befor our arrival.

what would you do, and why?

I didnt know how to carry on the treatment, but the paramedic gave 300mg Aspirin, and 4000iu Heparin.
Click to expand...
I'm not that worried about the ST depression an inverted T at that rate. I'm more concerned about the rate. If a vasovagal technique slows that down and the ECG shows NSR without any ectopy, I'm happy with that. I would imagine that her heart was getting a little ischemic while kicking along at 160, and that might one reason why you were told about what was observed prior to your arrival.

Get a good History, list of meds, Allergies, Tx done by the Doc... My Tx at most: O2 2LPM, ECG, IV TKO and/or Saline Lock. Watch the patient closely and have a nice, pleasant conversation during transport. No complaint of Chest Pain/discomfort, no SOB = IV Saline Lock and ECG, vitals q 5 enroute. I'll have the NTG and ASA handy... but I'm thinking the ECG changes were rate related. Monitor for recurrence, and capture it to a strip...

Nothing to get too excited about... yet.
 
If you're not too concerned and it's gone away with the patient denying pain, why even administer O2?
 
Akulahawk said:
I'm not that worried about the ST depression an inverted T at that rate. I'm more concerned about the rate. If a vasovagal technique slows that down and the ECG shows NSR without any ectopy, I'm happy with that. I would imagine that her heart was getting a little ischemic while kicking along at 160, and that might one reason why you were told about what was observed prior to your arrival.

Get a good History, list of meds, Allergies, Tx done by the Doc... My Tx at most: O2 2LPM, ECG, IV TKO and/or Saline Lock. Watch the patient closely and have a nice, pleasant conversation during transport. No complaint of Chest Pain/discomfort, no SOB = IV Saline Lock and ECG, vitals q 5 enroute. I'll have the NTG and ASA handy... but I'm thinking the ECG changes were rate related. Monitor for recurrence, and capture it to a strip...

Nothing to get too excited about... yet.
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JPINFV said:
If you're not too concerned and it's gone away with the patient denying pain, why even administer O2?
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I was typing that on the way out the door... no CP/SOB and no immediately identifiable need for O2... just keep it handy. Just do the IV/SL and ECG. Basically, treat as BLS with ECG. The IV/SL is for med/fluid access but is more prophylactic/"just in case" than anything else.

Our local protocols state for us to provide O2, ECG, IV NS TKO, Valsalva, transport (for Stable SVT). That's if they're found by us in that a Stable SVT. If we find them in NSR with the history and no other complaints... and they have ECG/IV/O2 going... I'm going to continue that therapy.

This is a patient that (as described) doesn't get me very worked up about yet. The history of SVT that can be broken with vagus stimulation has my antennae perked up a bit, but... nothing going on at the moment just has me keeping an eye on this.
 
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It's not just directed to you, but everyone else on here that has stated oxygen. Oxygen is one of the most overused drugs we have. Sure, it's hard to have oxygen do harm for a patient, but you can say the same thing about a lot of other drugs and interventions.
 
One of the more interesting things I've come across in the past couple years is that for some things (primarily chest pain), the argument isn't so much High Flow/Low Flow as it is Low Flow vs. No Flow O2. Interesting premise. That topic popped up on an EMS list serv a couple years ago.
 
never hold back oxygen..even if it does nothing for the SVT its a natural anxiolytic...she may be nervous,scared... it will help i have seen it time and time again...i would assess if the vitals are stable and she has no complaints (asymptomatic)...is the rhythm regular,possible afib? there is no reason to treat an asymptomatic tachycardia besides supportive care.......you could try a vagul but otherwise i agree with everyone....IV,monitor,O2,reassess and treat what comes...now if she got any higher then i might consider pharmacology but until she shows any symptoms...ill lay low..:)
 
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