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Post by pbruss on Jul 18, 2014 10:21:37 GMT -5
39 yo female presents with acute onset of "palpitations" started 1 hour PTA. PMHx of HTN on lopressor, Smokes, fam Hx of DM and CAD. says she feels like her heart is racing and has associated chest pressure that radiates to jaw, SOB, and nausea. It is a busy shift at Toledo so EKG and blood was drawn in triage, EKG signed by the doc for the other zone. She was in teh waiting for 30 min but the lab called with a trop of 0.1 so she was brrough right back. On exam AAOx3 in no disrtess, rates ches pressure 4/10, tachycardic but rest of exam and ROS within normal limits. attached is her EKG done in triage and her previous EKG from 2010. If you could pick only one medication to give her what would it be and why? Attachments:
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Post by Bjs04f on Jul 18, 2014 17:03:47 GMT -5
Cardizem. Narrow complex tachycardia, with signs of demand ischemia, could be svt, could be aflutter. SO thinking is adenosine is ok for svt but alot of people power through it as it doesnt always terminat, but backup is cardizem. So skip adenosine use 2nd line for svt, and first line for afib/flutter. Gives best chance at rate control, allowing a repeat ekg to show any underlying rhythm not seen at this rate.
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Post by pbruss on Jul 19, 2014 10:17:05 GMT -5
Spot on. Its not very fast for svt,probably because she is on motoprolol. The machine, and the other doc, saw what looked like sinus tach with 1st degree block by mistaking the t waves for p waves. I went with 6 of adenosine which put her back in sinus and stopped her chest pain.
After conversion she is symptom free and in sinus rate of 70.
What would you do with her next? DC or admit and what is your reasoning behind plan of care?
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Post by DD on Jul 19, 2014 11:39:21 GMT -5
I would admit if no prior stress/cath/echo. She has some major risk factors there.
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Post by pbruss on Jul 19, 2014 23:46:09 GMT -5
EXACTLY. the cardiologist tried to blow it off but technically she just failed a stress test. he heart rate was high, but not crazy high, and it had been for a relatively short time (1-2 hours). how many old people do you see who sit with rates in 160's for a day or too and have normal trops? her symptoms of anginal type pain with sob and positive trop with relatively mild rate induced stress indicates some advanced CAD that could lead to infarction and needs a cath.
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Post by kemple on Jul 23, 2014 8:42:50 GMT -5
Good teaching point about patient's failing their own stress test. For some reason cardiologists think if it didn't happen in a nuc med lab it doesn't count.
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