Cardiology Scenario

[Lone Star]

This is a senario that was presented to me in my cardiology homework. I thought I'd throw it out here, just to see how others would handle it and see if they could explain WHY they chose the treatments that they did.

I was initially going to put this out as a running scenario, but decided to just post it in its entirety.

You and your partner are called to the scene of a rural residence where you find a 57 year old male who is complaining of chest pain. The patient reports a history of recent surgery which was performed to repair a fractured pelvis. Approximately 2 hours ago he began to experience “tightening of his chest,” chest discomfort and shortness of breath. He now reports that he feels nauseated.

1. What would be your primary assessment considerations with this patient?

Your partner records the patient’s vital signs as follows” BP, 180/120; heart rate, 140; and respirations, 32. When you connect the patient to the ECG, you see a wide complex tachycardia (uncertain type). When you contact the base hospital, your medical direction physician instructs you to follow the ACLS algorithm for wide-complex tachycardia and to keep him informed of the patient’s status.

2. Prior to initiating drug therapy, what questions would you ask the patient?

3. What is the most important step in the initial management of this patient?

4. Five minutes into your management of this patient, his BP drops to 130/74 and he exhibits a decreased level of consciousness. What would you do next?

[scratrat]

1. ABC's? Is that what you're looking for? I'm going with PE and/or embolus to the heart itself.

2. Allergies, PMH, present medications, previous episodes

3. Oxygen

4. That depends....did I give a medication? Is the rhythm unchanged? If I've done nothing so far, he's getting cardioverted. If I've given a medication AND the rhythm remains unchaged, I'm cardioverting.

[Asysin2leads]

I'm not sure how in depth this scenario wants you to get, but I would say the biggest concern would be if the wide complex tachycardia was atrial fibrillation with aberrancy. Post surgical patients can be at risk for hypercoagulability, which while I don't think would increase the risk of atrial fibrillation does raise the risk of clot formation. I'm also not sure if they are trying to throw you with the BP and the patient's mental state... I would think something other than a cardiac cause for the decrease in mental status if he is maintaining a normotensive pressure. While by ACLS guidelines this patient is unstable because of his decrease in mental status, I would still suggest starting an antidysrhythmic and hunting for an alternate cause for the decrease in mental status rather than going to synchronized cardioversion because of the increased risk of blood clot formation if the rhythm turns out to be a-fib with aberrancy. That's my real life answer. As for textbook answers, I would say thus:

1. Primary assessment concerns are what they always are. Airway, breathing, circulation, make sure he has an airway and a good O2 flow and SPO2.

2. Questions to ask the patient: Are you allergic and/or hypersensitive to amiodarone? Is he on a Beta-blocker, Calcium Channel Blocker, or Digoxin, who's effects may be enhanced by the drug? Does he have Wolf-Parkinson-White Syndrome?

3. The most important step? I don't know... history? I guess?

4. See my above answer for real life. Textbook answer is probably to regurgitate the ACLS algorithm for an unstable patient with a wide complex tachycardia, and move to synchronized cardioversion at 100 J, although the algorithm for the stable patient does mention moving to a calcium channel or beta blocker if you suspect atrial fibrillation with aberrancy, unless, of course he does have WPW and A-fib and then you don't want to use diltiazem. So to wrap it up, if the decrease in mental status is caused by the arrhythmia, then move to synchronized cardioversion, unless it isn't, in which case, move to amiodarone, unless its actually atrial fibrillation with aberrancy, in which you should move to a calcium channel blocker, unless he also has WPW, in which case you shouldn't. That should clear things up.

[Lone Star]

And this is exactly why cardiology is going to be the reason I fail out of medic school! Its disheartening to think of all I've been through to get to this point, only to get washed out by a damn squiggly line....

I understand what each segment represents (which is definately a step up from where I used to be), I understand that changes in the 'averages' usually has significant implications. The problem appears to be when all the segments are put together repeatedly that it all falls apart.

I dont know if I've got enough fight left to try this 'one more time' if I fail............

[Kiwiology]

1. What would be your primary assessment considerations with this patient?

I was thinking pulmonary embolisim to be honest.

With a hx of recent surgery it could also be very fast AF with ventricular conduction as surgical patients seem to get AF alot

I'd like to know if this bloke has any history of cardiac disease

2. Prior to initiating drug therapy, what questions would you ask the patient?

Again you have to consider "real life" vs "textbook" here; the real life answer is I wouldn't give him any medications, the textbook answer is probably allgeries etc

3. What is the most important step in the initial management of this patient?

To terminate the tachydysrhythmia

4. Five minutes into your management of this patient, his BP drops to 130/74 and he exhibits a decreased level of consciousness. What would you do next?

Cardiovert him, the more compromised they are and the more likely the rhythm is to be VT the more important it is to cardiovert.

These are funny questions mate and your instructor is most certinaly looking for answers which do not fit into what I am going to tell you to do because the "textbook" answers probably dont make sense out in the real world of clinical medicine. There are a bunch of reasons this bloke might have a wide complex tachycardia, the recent surgery makes me suspect of AF with ventricular conduction, however he might have a history of ten massive bloody MIs and a nunngered ticker so its hard to say, for us that's not really important, he has a very fast wide complex tacyardia and an altered LOC which we can extrapolate (correctly or not) to that is causing his problem, without us fixing it up it WILL cause him further problems like you know, death.

[usmc_chris]

2 things I'd really like to know before giving ANY pharmaceutical or electrical treatment, unless the pt is decompensating rapidly - BG and what he 12-lead looks like. Your partner can hook up the 12-lead while you go for the line. Is there any history of renal failure or diabetes? When you factor in the possibility of electrolyte imbalances, especially hyperkalemia, I've seen sinus tachycardia that looked an awful lot like VT in one lead only - the P wave unidentifiable in the downslope of the T wave in an isolated lead.

[Vorenus]

1. What would be your primary assessment considerations with this patient?

I was thinking pulmonary embolisim to be honest.

Same here, possible pulmonary embolism was the first thing that crossed my mind, too.

[Just Plain Ruff]

And this is exactly why cardiology is going to be the reason I fail out of medic school! Its disheartening to think of all I've been through to get to this point, only to get washed out by a damn squiggly line....

I understand what each segment represents (which is definately a step up from where I used to be), I understand that changes in the 'averages' usually has significant implications. The problem appears to be when all the segments are put together repeatedly that it all falls apart.

I dont know if I've got enough fight left to try this 'one more time' if I fail............

i'm thinking the PE route as well.

but on a more personal note:

DAMNIT LONE, You will not fail, I know you and I know that you will make sure that doesn't happen.

Remember, you have friends here on this site that want nothing more than to see you succeed and get that gold crown called a medic license.

If you need help I'm sure there are ton's of people here, myself included that would welcome a phone call from you to help you out. Or just to listen to you bitch and moan(ya girlie man).

When you need help, reach out. make a phone call.

Edited September 7, 2011 by Ruffems

[Kiwiology]

Damn it to the bowels of bloody hell mate, I've known you for ages and you're a top notch bloke, not like one of those shav scrote ambo who I hate, bloody dickheads they are

I will not let you fail, I marked some wankers assignments the other week and they were absolute bloody rubbish he called junctional rhythm first degree block and he's a bloody Paramedic (ILS) now ....you know how to get ahold of me, I'm sitting on my arse for the next little bit, let me help you

[Asysin2leads]

Yeah Lone, don't let this one throw you. The wide complex tachycardia of unknown origin is a tricky one, and the AMS vs. normotensive BP is another curve ball.