Case Study: Sepsis and Tachycardia (with EKGs)

[fiznat]

Dispatched:

Intercept with BLS crew for shortness of breath. The patient is a 45 y/o male:

Hx: "Brain Cysts," HIV+, Unknown other (family not the best reporters)

Rx: Family remembers only Morphine and Ativan

All: NKDA

The patient presents unresponsive, GCS 4 (1 point for occasional moans). Family says (through the BLS crew, I intercepted enroute) that this mental status is baseline x 1 week. I have a hard time believing that, but thats the story. They called 911 "because it looked like he was having troube breathing."

VS:

RR: 48

HR: 190

BP: Unobtainable. Maybe a radial pulse, hard to tell.

SPO2: Wont read (?hypotension/perfusion issue)

ETCO2: 10, with good waveform

Lung sounds with diffuse rhonchi, no JVD/distal edema. Skin is warm/pink/dry at the core but mottled and somewhat cyanotic to the extremities. Pupils are sluggish to react, 3mm, with a disconjugurate gaze to the upper left (unknown baseline). Rapid trauma assess negative for DCAPBTLS. Blood Glucose is 146.

EKG:

SVT at 175-190 without ectopy, generalized ischemia.

My treatment:

I direct assisted vents with BVM+OPA+O2. Reassessment of the lungs finds good expansion on each vent from the BVM, ETCO2 trending upward as the tachypenia is slowed down.

IV with NS wide open

Trendelenburg position

I made a decision here to give Adenosine 6mg. I felt that the heart rate was too fast to be compensatory, and that reduced refilling time could be accounting for at least some of the hypotension. I realized that this patient was probably not having a primary cardiac problem, but I felt that the rate was something that needed to be addressed.

6mg didnt touch the guy-- no changes on the EKG or otherwise. We arrived at the ED before I had time to draw up 12mg.

**

In the hospital the patient was intubated with RSI, and promptly coded 4 times, recuscitated each time from the various (VF, VT, PEA, asystole) rhythms. When I turned in my paperwork the patient had a blood pressure in the 70s systolic, and they were mixing up an epi drip in the hopes that it would bump the pressure up. I havnt been able to follow up since, but it didnt look good.

Discussion:

The crossroads here was really the decision to go with adenosine. I was working with a primary clinical impression of septic shock, but believed that the heart rate was way too fast to be helping. I felt I did what I was able to.

I could also have spent my time attempting to intubate, but the patient was biting on the OPA and the BVM vents seemed to be working just fine. I didnt think it would be successful and at the moment, the airway was secure.

I suppose I could have also spent the time attempting a 2nd IV.

I would like to hear what you guys think.

[p3medic]

Giving adenosine to a sinus tach is probably not what I would have done. What are you looking to achieve? If you think its an ectopic rythm, then sure, try and break it, but if your idea is to slow it down to improve filling time, adenosine is not the drug to do that. Adenosine has a half life of around 10 seconds (someone will correct me with the actual half life) so even if you slow this down, your only slowing it for about 10 seconds and then the sinus tach will resume. Sustained rate control is not the role of adenosine, and in this particular patient, volume resus seems to be the best course of action, imho.

[fiznat]

The assumption is that the rhythm was ectopic. I know that the LP12 printout says "sinus tach" on it, but that readout is often incorrect, and with an unknown rhythm onset I really had very little to distinguish between sinus tach and ectopic SVT. If for nothing else, the adenocard may have helped make that differentiation.

Attempting to break the rhythm was not my only treatment. As I mentioned above, I was running fluids as well, along with the airway stuff.

[chbare]

I agree. I am not sure adenosine would have been the best choice with this patient. When looking at tachycardias, one must consider the cause and correct if possible. If you thought his unstable condition was in fact because of his heart rate, cardioversion would have been a therapy to consider. I understand your thinking regarding ventricular filling time as it relates to decreased cardiac output with extreme cases of tachycardia; however, I think this patients tachycardia was part of a bigger picture.

I applaud the fact that you are willing to put yourself on the stand in front of your peers and take both the praise and criticism. I do not see this as a recurring theme with EMS providers. Many people are too prideful and self absorbed to even think about attempting to learn from their actions, bad or good. In addition, you seem quite willing to own up to your decisions right or wrong. (Not that I am telling you that what you did was incorrect, this is simply how I viewed the situation given the information.)

Take care,

chbare.

[fiznat]

I think this patients tachycardia was part of a bigger picture.

I agree. ...Although at the same time I felt that the rate was possibly a problem in and of itself. Sure, it may be part of some other pathology, but that doesn't make the rate benign. Like I said before, I worried that it was contributing to the hypotension. I couldnt/wouldnt assume that it was the only cause.

I agree that cardioversion was indicated considering the patient's condition, but to be honest I sissied out on it a little bit-- mostly because I knew in the back of my mind that the tachycardia was probably not the primary problem. I decided to do a brief trial of medication first and see how that worked out. Meanwhile, I did the fluid boluses and maintained the airway.

As far as putting myself out there, thank you. I am new, I admit, and there is a lot I have yet to learn. The same is probably true of many members here. Hopefully we can all learn from these calls.

[Medic26]

In paramedic school we learned that basicly anything > than a rate of 150 was SVT if you could not see P-waves. I have since learned a formula that is 220 - age = sinus tachy. This means that this 45 y/o man could achieve a sinus tachy of roughly 185 under certian circumstances. With the ronchi and supressed immune system I would have given the fluid challenge a chance to take effect, after all sepsis requires several litters of fluid to correct if that was a possibility you had considered early on. I feel your pain for the lack of information on BLS report, we see this all to often as well with a few of the agencies we assist.

[Medic26]

I wouldn't let it bother you too much, its only one of several possible causes. Given the history of this onset and symptoms you found right away its just a possible cause, we have all been there after a call or several for that matter scratching our heads wondering what we should have done different.

[chbare]

I understand your thinking. I would not have gone the route of adenosine with this patient; however, that is not to say you were in the wrong. Medicine is pretty complex in this way, you can arrive at a plan to treat people by taking many paths. No one path may be more or less beneficial than the others. I imagine you are starting to see this outside of school. Providers can differ in the way they look at their patients and their treatment modalities may differ as well. However, we agree on the major points: His airway and breathing was addressed and he was receiving a fluid challenge.

Take care,

chbare.

[CBEMT]

I feel your pain for the lack of information on BLS report, we see this all to often as well with a few of the agencies we assist.

The BLS report wasn't the problem here. The family just didn't know anything. BLS can't invent information.

[AZCEP]

You have a patient with a clearly discernible sinus tachycardia. Even if you do not use the machine's interpretation, which is a good move, your own eyes should tell you that there are P-waves preceding each QRS complex. There is no other interpretation that this could be. It is sinus, the rate is due to a compensatory mechanism.

Adenosine is not indicated for this situation. Pressors and enormous amounts of fluid replacement are needed. Not rate control.

I apologize for the harshness that is probably coming out of this post, but I've had to run through this same progression a number of times recently. :roll: It would seem that some providers are missing a couple of days of class.