Interesting patient... svt into VT?

[pinipig523]

So I had a patient today... she said that she felt "weird"... I listened to her and she would switch between a tachycardic rhythm and then would become NSR again. So I had the techs do an EKG.... it was NSR.

Then I looked at the tele - and I noted that she would cycle between what appeared to be SVT and NSR. Then she became sustained SVT. We didn't have adenosine nearby so I had the patient valsalva down - then I looked up... I noted a change from narrow complex regular SVT to wide complex SVT or VTACH!

So I was like... whoa whoa whoa... no more valsalva!!

And then she went back to NSR.

I wasn't sure what to do - do I give amio or procainamide? Do I give diltiazem or lopressor to keep her from going into SVT?

Anyway - I think it was SVT w/ aberrancy, probably a little bit of an accessory pathway and maybe she went antidromic when she was valsalva-ing and she flew into a wide complex rhythm!

Best thing to do was procainamide IMO. I had to argue with the cardiologist who wanted me to give diltiazem.

Btw.... the patient also had this weird mid back pain - I did a CT angio - and we found a descending dissection. We flew her out.

Geez.

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[jdh71]

So I had a patient today... she said that she felt "weird"... I listened to her and she would switch between a tachycardic rhythm and then would become NSR again. So I had the techs do an EKG.... it was NSR.

Then I looked at the tele - and I noted that she would cycle between what appeared to be SVT and NSR. Then she became sustained SVT. We didn't have adenosine nearby so I had the patient valsalva down - then I looked up... I noted a change from narrow complex regular SVT to wide complex SVT or VTACH!

So I was like... whoa whoa whoa... no more valsalva!!

And then she went back to NSR.

I wasn't sure what to do - do I give amio or procainamide? Do I give diltiazem or lopressor to keep her from going into SVT?

Anyway - I think it was SVT w/ aberrancy, probably a little bit of an accessory pathway and maybe she went antidromic when she was valsalva-ing and she flew into a wide complex rhythm!

Best thing to do was procainamide IMO. I had to argue with the cardiologist who wanted me to give diltiazem.

Btw.... the patient also had this weird mid back pain - I did a CT angio - and we found a descending dissection. We flew her out.

Geez.

If this would have happened on one of my unit patients I personally would have used amio - I think it treats both the SVT and VT reasonably. I've also used it a lot because lots of the guys I've trained with used it, so I'm more comfortable with it than some of the other antiarrhythmics.

Must have been an interesting case for a new attending 😀 I can't quite imagine yet what it'll be like to see these kinds of things on my own.

Those aberrancy rhythms sure can look a lot like VT!

 

[joeDO2]

Interesting. I had a patient with a similar presentation. Gave adenosine slowed the rate and then revealed prominent delta wave... gave amiodarone (no procainamide available) with a good result. Why did the cardiologist want diltiazem? Seems like that wouldn't be the best especially an accessory pathway was being considered.

 

[PAGuy77]

Will amio address the accessory pathway if there is one? I don't agree with Cardizem, now youre dependant on that accessory Pathway! But I'm new to all this so what do I know.

So patophysiologywise.... Valsalva blocks the AV node, so this patient going into Vtach from an accessory pathway? Any other explanation for this?

 

[PAGuy77]

Did the EKG show any signs of BBB while pt was in NSR?

 

[pinipig523]

Did the EKG show any signs of BBB while pt was in NSR?

Yes, there was RBBB on initial EKG.

And then the patient went into SVT... then a completely different appearing wide complex tach, regular.

 

[PAGuy77]

Wow, so SVT c aberrancy is def a posibility, but why go into vtach with valsalva. He must have had an acessory pathway. Very cool case. Know if he ever went to EP?

 

[dchristismi]

Descending dissection? I could see an ascending dissection do that - dissect into the coronaries, and provoke arrhythmia, but descending? Hm. Hit the baroreceptors?

There's no way this is an isolated cardiac arrhythmia. Dissections are weird beasts. How old is this pt? Any follow up from your receiving hospital? This is the sort of case I'd make my follow nurse call on.

Not to mention the "oh, and I'm having some back pain" and it turns out to be a dissection. It's cases like this that give me the heebie jeebies! The last dissection I saw was a lady who felt a "pop" a month prior while opening a window, and her XR showed a compression fx right where she hurt. When she required much more pain medication that she should have we got the CT and a variety of expletives followed. I never in a million years would have guessed that. It is better to be lucky than good some times.

 

[Cerberus]

I've had decent results using Amio in both SVT and V-tach. I had a recent SVT which would not break regardless of what I threw at it (including 3 jolts of electricity as the patient was mildly hypotensive). The patient would go back into sinus for a few seconds following adenosine or cardioversion but then go right back into a narrow complex rhythm w/ rate around 220. After the third shock I gave a bolus of amio and his rate dropped to around 150. Cardio didn't want to start an amio drip and ended up putting her on a cardizem drip which last I saw before going home was maxed out and doing very little to control the rate. Still not sure why the SVT was so refractory - lytes/labs were normal.

 

[Cerberus]

Descending dissection? I could see an ascending dissection do that - dissect into the coronaries, and provoke arrhythmia, but descending? Hm. Hit the baroreceptors?

There's no way this is an isolated cardiac arrhythmia. Dissections are weird beasts. How old is this pt? Any follow up from your receiving hospital? This is the sort of case I'd make my follow nurse call on.

Not to mention the "oh, and I'm having some back pain" and it turns out to be a dissection. It's cases like this that give me the heebie jeebies! The last dissection I saw was a lady who felt a "pop" a month prior while opening a window, and her XR showed a compression fx right where she hurt. When she required much more pain medication that she should have we got the CT and a variety of expletives followed. I never in a million years would have guessed that. It is better to be lucky than good some times.

I've seen 7-8 dissections in my short career and only one of them had the classic "tearing back pain" (a few did have some degree of back pain though). The scariest had a CC of unilateral lower ext neurodeficit and pain which had resolved prior to being seen. On exam he was hypotensive and had minimally decreased pulses on the side of the deficit but otherwise unremarkable exam. I ended up scanning for dissection because the story didn't add up and he was persistently hypotensive - scan showed a Type A all the way to the common illiacs. Pt died shortly after I sent them to the OR but never once complained of back or chest pain😱😱