Atrial Flutter

[1EMT-P]

I was talking with a Paramedic who told me that he respond to a primary care clinic 30 minutes away from the hospital for a 50 year old white male patient who is 1 month S/P CABG. The patient went in for a routine appointment for palpitations. Upon arrival you find the patient on an exam table, on 2 liters of oxygen with saline lock in place & Dynamap in place. The patients vs were as follows HR 130, BP 110/50, RR 20, SPo2 95%, T 98.7. SAMPLE History was as follows: Hx of Palpitations. Allergies: NKA, Medications: Lopressor 100MG, Aspirin 325MG, Zocor 40MG, Lasix 40MG, Nitro SL, Plavix 75MG & Multi Vit. Past Hx.: CAD & HTN. Last intake breakfast. Events leading up to patient was resting at home. Enroute the patient was placed on 4 liters of oxygen, an IV of NS was started an additional 12 lead was obtained HR was 130 Atrial Flutter vs SVT, The Medical Command Physician ordered Adenosine 6MG IV x1 & the patients rate slowed to 113 with Atrial Flutter 3:1. If this was your patient what would you do?

[Jwade]

I was talking with a Paramedic who told me that he respond to a primary care clinic 30 minutes away from the hospital for a 50 year old white male patient who is 1 month S/P CABG. The patient went in for a routine appointment for palpitations. Upon arrival you find the patient on an exam table, on 2 liters of oxygen with saline lock in place & Dynamap in place. The patients vs were as follows HR 130, BP 110/50, RR 20, SPo2 95%, T 98.7. SAMPLE History was as follows: Hx of Palpitations. Allergies: NKA, Medications: Lopressor 100MG, Aspirin 325MG, Zocor 40MG, Lasix 40MG, Nitro SL, Plavix 75MG & Multi Vit. Past Hx.: CAD & HTN. Last intake breakfast. Events leading up to patient was resting at home. Enroute the patient was placed on 4 liters of oxygen, an IV of NS was started an additional 12 lead was obtained HR was 130 Atrial Flutter vs SVT, The Medical Command Physician ordered Adenosine 6MG IV x1 & the patients rate slowed to 113 with Atrial Flutter 3:1. If this was your patient what would you do?

First, without looking at the 12 lead myself, this anecdotal evidence is pretty useless IMO. Is the Atrial Flutter versus SVT what the 12 lead printed out as interpretation, or was this interpreted by the paramedic? There can be a huge difference in what the 12 lead says at the top, and what is actually going on.

Aside, from having a tachy HR and mild tachy RR, he " sounds " pretty stable. Did anyone think to call his cardiologist or cardiac surgeon before transfer?

Respectfully,

JW

[nypamedic43]

I would no have. We have protocol for adenosine for SVT. In the long run, with this patient, the adnosine only slowed him down by 27 beats. The other thing that bothers me is the adenosine for an atrial rhythm. Because of the clotting issue of the atria, if its a new onset, I would have questioned the Doc as to his reasons why the adenosine. If anything I would have cardioverted but, as I said before, the rate isnt horribly high. Was the patient short of breath? nauseated? lightheaded? Without seeing a strip, it's hard for me to say what I would do....but I wouldnt ask for adenosine with an atrial rhythm.

[Niftymedi911]

Sounds pretty Asymptomatic to me, I wouldn't of treated it. Sometimes less is more. The question is simple, why would you even be treating that???? B/P is stable, negative chest pain. And for another thing you don't know how trul his condition as been going on. It's called the 48 hr rule. If it is fast enough for that long period of time, you have no business slowing the rate down. You might just already go ahead and make the neuro/cardiac ICU appointment for the patient. Fast rhythms of the heart that are confined to the atria (e.g., atrial fibrillation, atrial flutter) or ventricles (e.g., monomorphic ventricular tachycardia) and do not involve the AV node as part of the re-entrant circuit are not typically converted by adenosine. However, the ventricular response rate is temporarily slowed with adenosine in such cases.

[piranah]

IMO I would say less is more, the pt is hemodynamically stable with that pressure and even that rate 130 doesn't really bother me..CP,SOB? I'm curious to what the pressure was post Adenosine. I would have monitored this pt closely for any changes.was he still experiencing the palp. after the adenosine? If the pt is asymptomatic just supportive care....

[JakeEMTP]

It depends. Is he symptomatic or asymptomatic post Adenosine? How does he present? What does he look like? If he's just sitting on the stretcher chillin', I'd monitor him. Before Adenosine though, I'd would have tried a vagal maneuver. A HR of 130 doesn't set of alarms since he has a cardiac hx of palpitations and a Cath. As the above posters have stated, w/o a strip it is hard to tell what we would do. But anyways, I wouldn't give Adenosine for a HR of 130 and the pt. presented as stated.

[Kiwiology]

Little oxygen, say 3-4l on a NC, and take the patient to the hospital.

No other treatment as it's not clinically indicated.

[Tom B.]

I was talking with a Paramedic who told me that he respond to a primary care clinic 30 minutes away from the hospital for a 50 year old white male patient who is 1 month S/P CABG. The patient went in for a routine appointment for palpitations. Upon arrival you find the patient on an exam table, on 2 liters of oxygen with saline lock in place & Dynamap in place. The patients vs were as follows HR 130, BP 110/50, RR 20, SPo2 95%, T 98.7. SAMPLE History was as follows: Hx of Palpitations. Allergies: NKA, Medications: Lopressor 100MG, Aspirin 325MG, Zocor 40MG, Lasix 40MG, Nitro SL, Plavix 75MG & Multi Vit. Past Hx.: CAD & HTN. Last intake breakfast. Events leading up to patient was resting at home. Enroute the patient was placed on 4 liters of oxygen, an IV of NS was started an additional 12 lead was obtained HR was 130 Atrial Flutter vs SVT, The Medical Command Physician ordered Adenosine 6MG IV x1 & the patients rate slowed to 113 with Atrial Flutter 3:1. If this was your patient what would you do?

In the first place, a heart rate of 130 with a BP of 110/50 should be left alone.

Secondly, I would question the diagnosis of atrial flutter. 2:1 flutter generally presents with a heart rate of about 150. While it's possible for 2:1 flutter to be 130, that would make the flutter rate 260 which would make 3:1 flutter about 86.

SVT is an umbrella term that includes all non-ventricular tachycardias, including sinus tachycardia, atrial fibrillation, and atrial flutter. Adenosine is specifically intended for reentrant tachycardias like AVNRT. If you give adenosine and it reveals flutter waves, you need to switch to another drug like diltiazem. That's if it's really necessary to treat the arrhythmia in the prehospital setting, which is debatable. After all, if it was hemodynamically unstable you'd be cardioverting.

One has to wonder sometimes whether we do things because it's good for our patients or because it's good for our egos!

Tom

[Kiwiology]

One has to wonder sometimes whether we do things because it's good for our patients or because it's good for our egos!

My thoughts exactly!

[armymedic571]

I am going to have to agree with the don't treat theory....But, I am curious as to those who say that the pt was Asymptomatic? Are palpatations a symptom? That was the chief complaint that was used to summon EMS. So.....you really can't say that the pt was asymptomatic. Remember, what the patient, MS, Nurse considers an emergency may not fit your criteria, but that is not the point.

Once again, I would not have treated this pt. I don't think this should be symptomatic vs asymptomatic, but stable vs unstable.

Also---> why would you give adenosine to a 50 y/o with a HR of 130???? Sinus Tachycardia is not SVT. I think we need to start teaching some people how to sit on their drug boxes......

Edited January 5, 2010 by armymedic571