Jetpearl Number 8

[jetproppilot]

You need a cuppla cardiology buddy's cellphone numbers in your phone. Alotta our decisions concerning lets-go-or-lets-cancel involves the heart. Atrial fibrillation, for example, that hasn't been previously documented is not uncommon, among other worries you have, cardiovascularly speaking. It's nice, convenient, and efficient to be able to pull out your DROID, call your cardiology buddy, and get his opinion. More often than not the dude will say "hey dude I'm here, I'll run up, OK?"

Wanna my buddies on a perilous call nite not long ago had just exited the gate of doctor's parking in his 911 when I called.

DUDE TURNED AROUND.

I was thankful.

PROBLEM SOLVED.

Think of yourself as THE WOLF FROM PULP FICTION

of the operating room.

You're here to SOLVE PROBLEMS.

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[cfdavid]

Hey Jet, I've often wondered about that. The billing issue that is.

That is, when you call a consultant for an issue such as you mentioned, and he does in fact turn around, and come by to eval. the patient's history, meds, and ECG, surely he/she will bill for it, correct?? It's not just a "favor" I'm assuming. Buddy or no buddy. I hate to sound naive, but just want to know how it's actually handled.

cf

 

[jetproppilot]

Hey Jet, I've often wondered about that. The billing issue that is.

That is, when you call a consultant for an issue such as you mentioned, and he does in fact turn around, and come by to eval. the patient's history, meds, and ECG, surely he/she will bill for it, correct?? It's not just a "favor" I'm assuming. Buddy or no buddy. I hate to sound naive, but just want to know how it's actually handled.

cf

Some of its billed, CF.

Dude turning around his 911 surely billed.

Theres alotta "consults" tho that go unbilled.

Even with us.

I've given advice to calling physician buddies that went unbilled.

A doctor speaking with a buddy doctor on the phone for some pragmatic advice is just that.

Theres a mutual understanding...

that thats where it stops.

Want a formal consult?

Call for one.

Wait.

Delay.

Need some pragmatic advice about how to handle something you need help with? That you can handle with said help?

Call a buddy.

Yeah, we're physicians. We're also human. Unless you're an a s s h o le you realize you can't know everything. You call for help when needed.

Call a buddy.

 

[Noyac]

Some of its billed, CF.

Dude turning around his 911 surely billed.

Theres alotta "consults" tho that go unbilled.

Even with us.

I've given advice to calling physician buddies that went unbilled.

A doctor speaking with a buddy doctor on the phone for some pragmatic advice is just that.

Theres a mutual understanding...

that thats where it stops.

Want a formal consult?

Call for one.

Wait.

Delay.

Need some pragmatic advice about how to handle something you need help with? That you can handle with said help?

Call a buddy.

Yeah, we're physicians. We're also human. Unless you're an a s s h o le you realize you can't know everything. You call for help when needed.

Call a buddy.

As far s i'm concerned, this is your best "pearl" yet Jet. I remember doing an EGD on 90 yo chick (yeah i said chick, she was hot for 90) when she went into SVT. I couldn't break the damn thing. I tried neo, Adenosine, esmolol, Ca channel blocker (actually never gave this), Digoxin. I know that's a lot of drugs and you can critic all you want. But this chick was tach'in away at 190 bpm. So i grabbed my phone and called the first cards guy I could think of. He said I'll be right there. It was after 5pm. And sure enough, the minute he walked thru the door she converted. But the moral is, call them and they will usually come right over. I find that most cards guy's are fairly impressed with anesthesiologist's and are very eager to help out. In most situations i really dig the cards guys.

So when Jet says "Call a Buddy" well, that's ideal. The guy I called isn't a buddy but still a person I know well and when a peer calls your cell phone for help most everyone will drop everything to help.

 

[fakin' the funk]

Forgive my naivete...

But I'd not heard of phenylephrine for conversion of SVT to NSR.

I'm conjecturing here, but is it that it has reflexive vagotonic action on the AV/SA nodes and should slow the rate and/or convert? What's the suggested dose?

 

[rsgillmd]

Forgive my naivete...

But I'd not heard of phenylephrine for conversion of SVT to NSR.

I'm conjecturing here, but is it that it has reflexive vagotonic action on the AV/SA nodes and should slow the rate and/or convert? What's the suggested dose?

I forget the suggested dose, but I do recall reading about it and it was quite high. I would probably start at a 100 mcg and work my way up. Remember, anything you give through the IV you can't get back.

 

[Gern Blansten]

Forgive my naivete...

But I'd not heard of phenylephrine for conversion of SVT to NSR.

I'm conjecturing here, but is it that it has reflexive vagotonic action on the AV/SA nodes and should slow the rate and/or convert? What's the suggested dose?

Perhaps by "neo" he meant neostigmine. In the distant past, neostigmine or edrophonium had been used to disrupt SVT as an off label use. As far as I know, newer anti arrhythmics have made this practice fairly obsolete. I have never seen it used for this, but it does not seem out of the question that it might work. Wouldn't be near the top of my list though. I googled it and found a couple of obscure references to it being used a bit in the past.
We certainly know that it can cause bradycardia.

 

[Jay K]

Nice pearl. I haven't yet started taking down personal cell numbers from physician colleagues, but one of my partners definitely has EVERYBODY's number in his phone. It's a good practice and another reason to be collegial and friendly to your colleagues in other fields. A handy pearl I'm gonna start using myself.

 

[AbbyNormal]

Think of yourself as THE WOLF FROM PULP FICTION of the operating room.

You're here to SOLVE PROBLEMS.

 

[DrDre']

Noyac most likely meant phenylephrine. It was used a lot before we had adenosine for PSVT. It also is used intramuscular for priapism relief - I know. I have to use it weekly

It is the reflex bradycardia that is the functional effect from phenylephrine.

Neostigmine would certainly cause a bradycardia, maybe even asystole if you were lucky. I certainly would not use this until last line and would have atropine and epi syringes at the ready. I would cardiovert before I would ever use neostigmine for this indication.

Perhaps by "neo" he meant neostigmine. In the distant past, neostigmine or edrophonium had been used to disrupt SVT as an off label use. As far as I know, newer anti arrhythmics have made this practice fairly obsolete. I have never seen it used for this, but it does not seem out of the question that it might work. Wouldn't be near the top of my list though. I googled it and found a couple of obscure references to it being used a bit in the past.
We certainly know that it can cause bradycardia.

 

[kmurp]

It was neostigmine. I'm old enough to remember (Tensilon too).
In our practice, we just page the cardiologist on call- no need for cell phone numbers. It helps if you don't abuse them with last minute "clearances" too much. Just call when really needed.

 

[hoyden]

As far s i'm concerned, this is your best "pearl" yet Jet. I remember doing an EGD on 90 yo chick (yeah i said chick, she was hot for 90) when she went into SVT. I couldn't break the damn thing. I tried neo, Adenosine, esmolol, Ca channel blocker (actually never gave this), Digoxin. I know that's a lot of drugs and you can critic all you want. But this chick was tach'in away at 190 bpm. So i grabbed my phone and called the first cards guy I could think of. He said I'll be right there. It was after 5pm. And sure enough, the minute he walked thru the door she converted. But the moral is, call them and they will usually come right over. I find that most cards guy's are fairly impressed with anesthesiologist's and are very eager to help out. In most situations i really dig the cards guys.

So when Jet says "Call a Buddy" well, that's ideal. The guy I called isn't a buddy but still a person I know well and when a peer calls your cell phone for help most everyone will drop everything to help.

Did you ever try massaging the carotids? Worked for me twice - once in residency for a 40-something y.o. guy with SVTs and no previous cardiac Hx and with a 90 yo. fragile lady which was about to undergo an ORIF of her hip.

 

[Noyac]

Did you ever try massaging the carotids? Worked for me twice - once in residency for a 40-something y.o. guy with SVTs and no previous cardiac Hx and with a 90 yo. fragile lady which was about to undergo an ORIF of her hip.

That's what the cards guy said to do. Luckily it converted and i never had to rub her neck.

It was probably the neostigmine that converted her.

Actually, I was refering to phenylephrine when I said neo.

 

[SexPanther]

Did you ever try massaging the carotids? Worked for me twice - once in residency for a 40-something y.o. guy with SVTs and no previous cardiac Hx and with a 90 yo. fragile lady which was about to undergo an ORIF of her hip.

I had a dude in the PACU a couple of mos. ago who had several episodes of hemodynamically stable SVT. I was able to break it each time with a lil' loving to the carotid. Told him if he did it again I would hit both carotids up via rear naked choke - no more problems after that.

 

[Apollyon]

90 yo. fragile lady which was about to undergo an ORIF of her hip.

As I recall all those years ago from a doc that was teaching us in paramedic school: "Your smile will go right away when you rub the carotid, and that patient's face droops right in front of you".

Carotid sinus massage in a 90 y/o is a pretty gutsy move.

 

[jetproppilot]

.

 

[IlDestriero]

Thats why we make large bank.

Bilateral occular pressure. It worked for me in the past, and no CVA!

 

[Apollyon]

Thats why we make large bank.

As I learned in military college, "There's a fine line between balls and stupidity!"

Bilateral occular pressure. It worked for me in the past, and no CVA!

As per the old ACLS book (the one in black and white, before they dumbed it down), you can also provide "rectal stimulation".

(As they stated then, there were "bizarre" methods for increasing parasympathetic discharge, and eyeball pressure and rectal stimulation were two stated. The origin of these two, though, make them less bizarre - the eyes were noted by ophthalmologists, and the butt stim by infants getting rectal temperature.)

 

[rsgillmd]

Did you ever try massaging the carotids? Worked for me twice - once in residency for a 40-something y.o. guy with SVTs and no previous cardiac Hx and with a 90 yo. fragile lady which was about to undergo an ORIF of her hip.

I'd be more afraid of dislodging a carotid plaque in a 90 year old. I'd rather just cardiovert. Yes I realize it could be rapid A-fib posing as SVT and I could dislodge a clot with cardioversion, but that seems a safer bet than carotid massage. Now if you've got an otherwise healthy 90 year old (I haven't run into many) that's a different story.

I tried carotid massage when I was a PGY-1 on a young person, and again on a young to midle aged guy as a CA-1, but it didn't work either time.

 

[rsgillmd]

Oops! Just saw Apollyon's post.

 

[fakin' the funk]

Oops! Just saw Apollyon's post.

I've seen a cardiologist break stable sustained VT on a tele unit (which the patient went into when we at bedside on rounds) by asking the awake, alert patient to Valsalva (cough). Not really sure why it worked, but it was cool.

 

[Apollyon]

I've seen a cardiologist break stable sustained VT on a tele unit (which the patient went into when we at bedside on rounds) by asking the awake, alert patient to Valsalva (cough). Not really sure why it worked, but it was cool.

They're all ways of increasing parasympathetic tone. Straining against a closed glottis (the Valsalva) puts physical pressure on the vagus nerve, which can terminate aberrant rhythms. It's the same reason old people die on the toilet - they strain against a closed glottis, trying to push out the turd, and vagal into asystole. This is the one patient where "why not shock them - what could it hurt?" does NOT work. These patients would benefit from atropine, but a defib will affirmatively kill them (or render them unresuscitatable). The cold water/ice water to the face, rectal stimulation, carotid sinus massage, and pressure on the eyeballs also all do this.

 

[proman]

They're all ways of increasing parasympathetic tone. Straining against a closed glottis (the Valsalva) puts physical pressure on the vagus nerve, which can terminate aberrant rhythms.

I'm not sure I've ever heard of explanation. Here's a more likely mechanism:

There are several phases in this cardiovascular reaction. At the initiation of the Valsalva maneuver, arterial pressure is abruptly elevated for several beats due to the intrathoracic pressure transmitted to the thoracic aorta. The sustained elevation in intrathoracic pressure leads to a fall in venous return and a fall in blood pressure, which evokes a compensatory reflex increase in heart rate and peripheral vasoconstriction. (During this period, the red face and distended peripheral veins are indicative of high peripheral venous pressures.) At the cessation of the maneuver, there is an abrupt fall in pressure for a couple of beats due to the reduction of intrathoracic pressure. Venous blood then moves rapidly into the central venous pool; stroke volume, cardiac output, and arterial pressure increase rapidly; and a reflex bradycardia occurs.

Mohrman DE, Heller LJ, "Chapter 10. Cardiovascular Responses to Physiological Stresses" (Chapter). Mohrman DE, Heller LJ: Cardiovascular Physiology, 6e:

 

[Apollyon]

I'm not sure I've ever heard of explanation.

Thank you for that. I did not have data on my side - it was told to me by a doc in the 90s (my response).

 

[hoyden]

I'd be more afraid of dislodging a carotid plaque in a 90 year old. I'd rather just cardiovert. Yes I realize it could be rapid A-fib posing as SVT and I could dislodge a clot with cardioversion, but that seems a safer bet than carotid massage. Now if you've got an otherwise healthy 90 year old (I haven't run into many) that's a different story.

I tried carotid massage when I was a PGY-1 on a young person, and again on a young to midle aged guy as a CA-1, but it didn't work either time.

You probably ( and Apollyon as well) think that it was hardcore massage you need to your stiff neck

It was a very light and gentle touch - and it is not that easy to dislodge the plaque. Even in a 90 y.o.

 

[Apollyon]

It was a very light and gentle touch - and it is not that easy to dislodge the plaque. Even in a 90 y.o.

I've never done carotid sinus massage, but how I was instructed was that it was NOT a "light and gentle" touch - that you really had to put some pressure on it. With a rigid plaque, it just takes one impulse to crack it, with little emboli (or the whole iceberg) calving off and flowing away into the brain.

If it worked for you, then huzzah! "If it's working, keep doing it." (Loeb's First Law of Medicine)

 

[hoyden]

I've never done carotid sinus massage, but how I was instructed was that it was NOT a "light and gentle" touch - that you really had to put some pressure on it. With a rigid plaque, it just takes one impulse to crack it, with little emboli (or the whole iceberg) calving off and flowing away into the brain.

If it worked for you, then huzzah! "If it's working, keep doing it." (Loeb's First Law of Medicine)

Luckily enough it does not happen that often ))))

 

[cleansocks]

On call reading through jetpearls! =).

A surgeon a couple weeks ago asked me to "please valsalva the patient." Being a new CA-1 I had no idea what they meant and by the time I called to ask my attending how to perform such a trick, they no longer needed it. Anyone know what they wanted? The case was abruptly ending and I forgot to follow up. I think it might've been a urology case.

On a side note, if "valsalva'ing" a patient is possible, does anyone use this for "stable" SVT's in the OR? And another thing - since altered mental status is a criterion for "instability," are SVT's in asleep patients ever considered stable since it is impossible to assess mental status?

 

[pgg]

On call reading through jetpearls! =).

A surgeon a couple weeks ago asked me to "please valsalva the patient." Being a new CA-1 I had no idea what they meant and by the time I called to ask my attending how to perform such a trick, they no longer needed it. Anyone know what they wanted? The case was abruptly ending and I forgot to follow up. I think it might've been a urology case.

Take them off the vent. Close the APL to 30-40. Squeeze the bag. That's it.

On a side note, if "valsalva'ing" a patient is possible, does anyone use this for "stable" SVT's in the OR? And another thing - since altered mental status is a criterion for "instability," are SVT's in asleep patients ever considered stable since it is impossible to assess mental status?

Never occurred to me to try that. You can measure BP in anesthetized people.

 

[Bertelman]

On call reading through jetpearls! =).

A surgeon a couple weeks ago asked me to "please valsalva the patient." Being a new CA-1 I had no idea what they meant and by the time I called to ask my attending how to perform such a trick, they no longer needed it. Anyone know what they wanted? The case was abruptly ending and I forgot to follow up. I think it might've been a urology case.

On a side note, if "valsalva'ing" a patient is possible, does anyone use this for "stable" SVT's in the OR? And another thing - since altered mental status is a criterion for "instability," are SVT's in asleep patients ever considered stable since it is impossible to assess mental status?

They wanted you to put the pt. on spont vent, crank the APL to 40 or so, and hold positive pressure. Depending on the procedure, you will maintain anywhere from 20-40 cm H20.

I wouldn't rely on this to control an SVT.

Prolonged SVT with stable b.p. would be considered "stable" in the OR. Since you can't assess mental status, you ignore it.

 

[cleansocks]

They wanted you to put the pt. on spont vent, crank the APL to 40 or so, and hold positive pressure. Depending on the procedure, you will maintain anywhere from 20-40 cm H20.

I wouldn't rely on this to control an SVT.

Prolonged SVT with stable b.p. would be considered "stable" in the OR. Since you can't assess mental status, you ignore it.

I see... I thought this might be what they wanted and did do something like that but only for 5 seconds or so. Why do they ask for it? To help transmit pressure to the bladder or something?

I wonder how this technique compares with someone actually bearing down against a closed glottis. Anyone know how much intrathoracic pressure that generates vs this which I guess generates up to 40?

 

[cleansocks]

You can measure BP in anesthetized people.

Academics might say about patients on the floor: "declining blood pressure is a late sign of clinical deterioration. Better earlier signs that should prompt more aggressive measures are chest pain, SOB, altered mental status." But since we have fast acting drugs to counteract the arrythmia already drawn and ready to go I guess it makes sense we can rely on BP even if it's a later sign.

 

[Bertelman]

I see... I thought this might be what they wanted and did do something like that but only for 5 seconds or so. Why do they ask for it? To help transmit pressure to the bladder or something?

I wonder how this technique compares with someone actually bearing down against a closed glottis. Anyone know how much intrathoracic pressure that generates vs this which I guess generates up to 40?

I don't know why they asked for it. What kind of surgery was it?

During lung resections, they use it to check the stump sutures. During neck dissections, they use it to check for tracheal leaks. The list goes on.

 

[Idiopathic]

Sometimes they check for urological sphincter tone (i.e. No leaking at intrathoracic pressure of 50 i think). Id imagine a forceful cough raises the intrathoracic pressure to around 60 or so? I'd imagine it would be hard to valsalva much higher before passing out