Case Study: Sepsis and Tachycardia (with EKGs)

[1EMT-P]

I would have given the patient a 500 ML bolus of NS first and then re-assessed the patient. If the lung sounds were clear after the first bolus then I would have given a second 500 ML bolus.

[fiznat]

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.

Wait a minute. Correct me if I am wrong here (I may very well be), but just because there are p waves doesn't mean that the rhythm is coming from the sinus node. All it means is that the rhythm has a single atrial focus. I admit that the morphology of the p waves is pretty consistent, but that would also be true if the rhythm was from a single, irritable ectopic focus. It is simply not true that "there is no other interpretation that this could be." I'm not seeing anything there that tells me that the rhythm is NOT an ectopic atrial tachycardia. In fact, the rate might even suggest it. It could be sinus, too, but I felt that the rate was too fast and I took a shot.

Dont worry about the perceived harshness-- its all good. I expect that from you guys, especially if I screwed up! :wink:

I would have given the patient a 500 ML bolus of NS first and then re-assessed the patient. If the lung sounds were clear after the first bolus then I would have given a second 500 ML bolus.

That would be nice if I had a half hour with the patient. I had 10 minutes, and probably only 5-6 minutes of actual time to run fluids in once I got the line and everything else all set up. The IV was wide open. Theres your bolus.

[chbare]

Your rationale is correct regarding the fact that p waves can originate from areas other than the SA node; however, is this really the case with the patient in the scenario above? Is this really the patient's primary problem? There is a significant amount of evidence that supports the hypothesis that the tachycardia is related to the patients underlying condition. You will have to convince us that using adenosine to rule out other problems was in fact the most appropriate course of therapy with this patient.

Take care,

chbare.

[fiznat]

There is a significant amount of evidence that supports the hypothesis that the tachycardia is related to the patients underlying condition. You will have to convince us that using adenosine to rule out other problems was in fact the most appropriate course of therapy with this patient.

Yeah, and there it is.

Like I've said a few times now, I never really thought that this patient had a primary cardiac problem. I used adenocard because I felt strongly that a rate of 180-190 was too fast to be compensatory or singly mediated by infection, and the patient was profoundly hypotensive. I had already done everything else that I could have to help with pressure (fluids wide open, trendelenburg), and I had maybe two minutes to do something else. The choices were (I think we agree): intubate, 2nd IV, or drugs. I went with drugs because I felt intubation would be difficult if not impossible (and the BVM was working nicely), and the patient was a very tough stick-- I didnt think I'd be able to get another line, leaning over the patient to his right arm in the moving, lights + sirens ambulance. Adenosine was diagnostic, yes, but could also have turned out to be an effective treatment. In the unlikely event that this rhythm was originating from an irritated ectopic focus, I might have been able to break the rate and help contribute to a more reasonable blood pressure. Given the amount of time I had, and the complications with my other options, I felt it was the best thing to do at the time.

[AZCEP]

What does ectopic atrial tachycardia look like if this is what you think this rhythm could be?

It is irregular, and the p-waves have different morphology from beat to beat. Yes, we are making an assumption that this is sinus, but with the strip provided it is the best interpretation you will get.

Regular rhythm, identical p-waves in front of each QRS, normal PR interval for each of them. This is sinus. The likelihood of it originating regularly from an ectopic atrial focus is slim, at best.

Adenosine was not the indicated treatment for this patient. Second IV or not, using a rate control medication on a patient that is trying to compensate for widespread vasodilation is not recommended anywhere. Your second IV should have been in the biggest vein you could find, including an IO site. This patient needed fluids and pressors.

[fiznat]

What does ectopic atrial tachycardia look like if this is what you think this rhythm could be?

It is irregular, and the p-waves have different morphology from beat to beat. Yes, we are making an assumption that this is sinus, but with the strip provided it is the best interpretation you will get.

I think you're thinking of multifocal atrial tachycardia (MAT), not simply ectopic atrial tachycardia, which can be from a single focus and therefore maintain a regular rhythm and a single p-wave morphology. You are right, though, that this rhythm is probably fairly rare (although I am unsure of the real statistics), and my patient's rhythm was more likely sinus. You are probably also right that adenosine was not indicated.

Given all that, though, at the time I felt that it was worth a try. If the rhythm was truly compensatory, the adenosine would do nothing. If it was ectopic, there is a chance the drug could have helped. I am not putting the patient at risk, but simply attempting a treatment that may or may not work.

Will I do it next time? Probably not.

[mediccjh]

fiznat,

The fact that you brought it to us for our discussion, and your willingness to learn, shows that The Force is strong with you.

Your patient is septic. 220-age=highest sinus tachycardia possible.

If it was an SVT, chances are your patient woulda been cool/pale/diaphoretic. Remember that in immunocompromised patients, a fever may not be necessarily present in infection.

[p3medic]

[quote="fiznat

If the rhythm was truly compensatory, the adenosine would do nothing. If it was ectopic, there is a chance the drug could have helped. I am not putting the patient at risk, but simply attempting a treatment that may or may not work.

Will I do it next time? Probably not.

[DwayneEMTP]

fiznat, You're my hero.

Two things about you stand out.

1) It takes major brass testes to march yourself out here naked time and time again. Often I think "man, he could have said that a little different, it would have still been the truth, but he would have looked better!" But you never do that! You just march out, warts and all...If this site can give people nothing else, just one simple tool, it's to see the educational value in that. You've inspired me in many ways, I hope I am brave enough to do the same when the time comes.

2) I can't remember (though I didn't run back your history here) a single thread that you've been involved in that wasn't completely focuse on improving yourself, and the rest of us, as a medics and professionals. Thread after thread shows you to be kind, focused, and to always have your eye on the ball. Amazing.

Plus (bonus point) I hope you notice that only the smartest people on the board reply to your posts...that speaks volumes to me...thanks for what you do.

I return you to your previously scheduled thread...

Dwayne

[p3medic]

You know, Dwayne is spot on. For some reason, medics tend to be very sensitive about having someone critique there medicine. Doctors do rounds, and residents get put on the spot time and time again, its the way you learn. There is no one "right"way to treat a patient, and there is plenty of room for debate. Anyone who has been doing this job for more than 10 minutes has made mistakes, and in hind sight may have done things differently. We have very little time in some instances to make very big decision, with very limited information and no access to labs, imageing, etc...Good for you for putting yourself out there, most wouldn't have the "balls" to do the same.