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Friday, April 23, 2010

Trust Your Heart Monitor?

We got a call during our morning check out for a 26 year old female having chest pain. I'm pretty sure that everyone on my crew was thinking the same thing...BS.

As we pulled up to the apartment building we were greeted by close to a dozen kids all excited to see the fire truck stop at their place. We walked upstairs and past the kids to apartment C. The front room was totally bare with the exception of 3 pregnant women. One of them pointed towards the back bedroom.

As I walked in I found my patient laying down in bed. As reached for her wrist I asked her what was going on. While talking to her I noticed that I couldn't feel a pulse. My engineer quickly got her on the heart monitor and started working on a blood pressure. I assumed it would be low since I could get a pulse at her wrist. My patient told me that she woke up with this chest pain and that it had happened once before. It was a tightness in her chest that didn't radiate. She wasn't able to rate her pain but it appeared to be in moderate distress. No history of recent illness or recent stress. The pain did not increase on palpation or inspiration.

She was supposed to be on some medications but didn't have them. Last time she felt this way she was transported to the hospital where they gave her something to make the pain stop. The patient was also experiencing shortness of breath and general weakness.
The rate is wrong but this rhythm strips show basically what I saw.

On the heart monitor she appeared to be in SVT at a rate of about 230. Her systolic blood pressure was in the low 70's. Shocking. As I started an IV my engineer shot a 12 lead. AMR showed up just as I finished starting the IV. I gave a report and my engineer finished up the 12 lead. My heart monitor was telling me that my patient was in atrial flutter not SVT. It didn't look that way to me. Since we don't carry anything in my county that would work on atrial flutter part of me wanted to go ahead and give the Adenosine and see what it would do.
Once again the rate is wrong but this is what the monitor was telling me it saw.

And for the record, I did have the patient try a couple of Valsalva maneuver but those didn't work.

I ended up trusting the heart monitor. I recently read a book about the mistakes we make in medicine. It talked about a study in which a cardiologist went head to head against a machine in determining which patients were having an MI. While the computer was not correct all the time it did better than the cardiologist...and faster. I have to assume that my heart monitor was able to read things in the 12 lead that I just couldn't pick up on with the naked eye which made it determine it was a-flutter and not SVT.

I should have followed up on this patient and found out what they did for her in the ER.

So just curious, would you have given the Adenosine?


brian said...

It would be interesting to find out what the docs came up with...

Bostonian in NY said...

There's a study floating around somewhere that had a few cardiologists read the same series of EKGs, with some of the EKGs appearing twice to show if the docs were consistent in their reads. It showed that the docs agreed with each other and themselves about 50% of the time! Ah, the art of medicine...

Duffman said...

I would not have given adenosine. This is unstable Narrow Complex Tach/SVT. You should have immediately cardioverted......unless thats not in your protocol.

She is obviously hemodynamically unstable (decompensated cardiogenic shock). This means that she has been sustaining this rate for a while and now her heart is unable to properly perfuse the tissues. Assuming her BP is accurate (even then you couldnt get a radial which would indicate that her BP is less than 90)The issue here is that she is in IMMEDIATE danger of going into vtach, vfib or asystole, this is a critical finding and MUST be reversed

If this had been me, I would have assessed radial pulse, then carotid (screw manual BP at this point, peripheral pulses are good enough for me, remember your ITLS assessment) My guess is that she would have had a weak carotid. Defib pads on patient, 12 lead by partner, attempt IV until 12 lead results. Once I saw the narrow complex, Id cardiovert at 100 immediately (with or without sedation)

Firefighter/Paramedic said...

Duffman, I almost went down that route. Looking back on it, maybe I should have. Live and hopefully learn.

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