Case Study: Sepsis and Tachycardia (with EKGs)

[Doczilla]

I'm going to jump into the mix here. I don't think you were wrong to give the adenosine. Given our hindsight, yes it looks like sepsis, and a lot of the evidence is pointing that way. Your gut feeling on the heart rate is that it was too high for the clinical situation. I don't see anything wrong with giving the adenosine here to help diagnose the rhythm. I have done this on several occasions to see the underlying atrial activity to confirm my rhythm interpretation of a deliriously high heart rate. Let's keep in mind that our ability to diagnose rhythms at extraordinarily high heart rates in not great. It looks like sinus tach, but at that rate could very well be atrial flutter with rapid conduction. While giving the adenosine is not without risk, it comes with very small risk, smaller than that posed by missing a malignant arrhythmia that is putting the patient in shock and leading to cardiac failure. If you give the adenosine and find that it's sinus tach, then you can go from there, and you have strengthened your diagnosis and may proceed to treat the sepsis and presumed hypovolemia with confidence. If you missed a primary arrhythmia as a presenting problem, you would start dumping in fluid and would rapidly push him into CHF.

'zilla

[AZCEP]

With the scenario listed, this patient is near unstable. Close enough in fact to consider synchronized cardioversion. Because this rhythm appears to be sinus tachycardia, adenosine is not indicated. Nor is it indicated for atrial flutter. The history combined with the ECG should show us that a rate control medication is not something to consider. Particularly one with the limited usefulness of adenosine.

Yes, hindsight is a wonderful thing, but using adenosine when it is not indicated should not be supported.

[Doczilla]

With the scenario listed, this patient is near unstable. Close enough in fact to consider synchronized cardioversion. Because this rhythm appears to be sinus tachycardia, adenosine is not indicated. Nor is it indicated for atrial flutter. The history combined with the ECG should show us that a rate control medication is not something to consider. Particularly one with the limited usefulness of adenosine.

Yes, hindsight is a wonderful thing, but using adenosine when it is not indicated should not be supported.

I'm advocating the adenosine for diagnostic purposes. Adenosine is not a rate control medication either. It is useful for 2 things: terminating a re-entry tachycardia, and assisting in diagnosis of an undifferentiated tachycardia, the latter of which this patient has.

'zilla

[fiznat]

Just curious. What prompted the priority transport? From what I can gather, the patient was on that fine line of stability? Not completely stable, but not exactly circling the drain?

If there is anything that goes without debate in this thread, I imagine it is probably the priority of the transport to the hospital. This patient absolutely was circling the drain, as you say. Hypotensive beyond measure, unresponsive, tachypenic, tachycardic... what else could you ask for? If nothing else, the fact that the patient coded 4 times in the ED should speak volumes as to how critical this patient really was. Priority one, no question about it.

Some people don't like to go pri 1 to hospitals with acute MIs because they worry (among other things maybe) that the anxiety of lights + sirens can possibly stress the patient out, increasing cardiac demand and therefore the damage to the heart. Its a matter of opinion, I suppose. This response, however, I don't really think is debatable.

[Dustdevil]

Some people don't like to go pri 1 to hospitals with acute MIs because they worry (among other things maybe) that the anxiety of lights + sirens can possibly stress the patient out, increasing cardiac demand and therefore the damage to the heart.

That is the least of my concerns. I am more worried that the anxiety of lights + sirens can possibly stress my driver out, increasing adrenaline rush and decreasing his/her attentiveness and causing me and my patient an unsafe ride for maybe 60 seconds of saved time.

This response, however, I don't really think is debatable.

You are correct that it is not debatable. However, it appears that you are trying to debate it anyhow, which is a sign of your inexperience. I have faith you'll grow out of that, though, so I'm not overly concerned. But multiple studies show that it simply is not worth it to be bombing through intersections and blowing people off the road to save a minute or two of time enroute to the hospital with a non-surgical patient, no matter how critical they are. They fact that your patient coded four or forty times is irrelevant. Arriving twenty minutes earlier would not have stopped that.

Except under the most unusual traffic circumstances, this patient would not have gotten lights and siren out of me.

[fiznat]

However, it appears that you are trying to debate it anyhow, which is a sign of your inexperience.

Come on man....

[Dustdevil]

Hey, I'm not bashing you. We all did it. I was a rookie once too. I took every opportunity to bomb intersections and drive like an arse, not just because it was "cool," but because when my patient was circling the drain, I was in a hurry to unload him off of my hands. It's a natural instinct. It's damn scary being "the one" who is in charge of that patient's life for the next ten minutes with so very little to work with. But with experience, you mellow out a little bit. You learn to do the best you can with what you have. And you see enough patients that you realise that you realise that those few minutes you might save simply do not make a difference to the patient's outcome. I won't lie to you and say that I grew out of that very quickly myself. I'm just trying to let you know earlier than I did that this is not the best way to go.

The best thing you can do for your patient is not to drive faster, but to be a better medic.

[ccmedoc]

The best thing you can do for your patient is not to drive faster, but to be a better medic.

Absolutely, getting to the hospital in one piece is a huge priority...wouldn't you agree. We all know how people drive when the lights and siren come on, and an erratic driver in the drivers seat of the ambulance increases your chance of injuring yourself needlessly..When newer medics get spooked, they pucker up and drive faster. I heard some say theres no problem they can't out-drive :shock: . Other than the off chance surgical emergency, priority or lights and siren transports should be few and far between..Risk/Benefit ratio is not so good.. This patient----no lights and siren

I'm advocating the adenosine for diagnostic purposes. Adenosine is not a rate control medication either. It is useful for 2 things: terminating a re-entry tachycardia, and assisting in diagnosis of an undifferentiated tachycardia, the latter of which this patient has.

I do agree with the use of adenosine for diagnostic purposes, but as it was stated before, this patient was unstable enough for cardioversion if rate was suspected as the primary contributor to the presentation. I think other measures could have been taken in lieu of the adenosine in this instance. Another line in prep for the administration of additional fluid boluses and pressors,for instance (IO Included).. These considerations come with experience with sick patients and the system he is working in..

This response, however, I don't really think is debatable.

This is probably not the most debatable part of this case..No lights and sirens... :roll:

[ExplorerShane]

I have a quick question, may be stupid to you guys but I have no clue, what exactly is Tachycardia?

[brentoli]

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