NIGHT FLOAT CASE #12

[sozme]

NF CASE #12
Postoperative Fast HR

Night float quote of the week from one of my former senior residents:

"It's the same thing everywhere - you're there all by yourself, people crashin' and crumping, no one's there to help you, and you just gotta make **** happen."
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Links to previous cases:
Case 1 Case 2 Case 3
Case 4 Case 5 Case 6
Case 7 Case 8 Case 9
Case 10
Case 11
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49-year-old male 3 days s/p bariatric surgery.

PA covering general surgery floor calls you at 2:00am:

"Yeah this guy's heart rate is outta control, like 140 to 160. The EKG says it is sinus though. He's having some chest pain though. I gave him some nitro and it didn't help. Labs are normal. Can you come look at him?"

You check his labs real quick (ordered 30 minutes ago and just resulted):
- Electrolytes including ionized magnesium and calcium: All normal and K+ is 4.0
- Hemoglobin: 10.2 (was 9.8 yesterday, 10.1 day before)
- POC troponin: Undetectable
- nT-pro-BNP: Normal

You go see him. He is diaphoretic and clutching his chest.

His BP Is 151/102; SpO2 is 100%.

You glance at the EKG:

3 nurses and 2 techs are in the room freaking out, PA is nowhere to be found. What do?

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UPDATE 1
UPDATE 2
UPDATE 3
RESOLUTION

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[Gurby]

NF CASE #12
Postoperative Fast HR

Night float quote of the week from one of my former senior residents:

"It's the same thing everywhere - you're there all by yourself, people crashin' and crumping, no one's there to help you, and you just gotta make **** happen."
====================================================================
Links to previous cases:
Case 1 Case 2 Case 3
Case 4 Case 5 Case 6
Case 7 Case 8 Case 9
Case 10 Case 11
====================================================================

49-year-old male 1 day s/p bariatric surgery.

PA covering general surgery floor calls you at 2:00am:

"Yeah this guy's heart rate is outta control, like 140 to 160. The EKG says it is sinus though. He's having some chest pain though. I gave him some nitro and it didn't help. Labs are normal. Can you come look at him?"

You check his labs real quick (ordered 30 minutes ago and just resulted):
- Electrolytes including ionized magnesium and calcium: All normal and K+ is 4.0
- Hemoglobin: 10.2 (was 9.8 yesterday, 10.1 day before)
- POC troponin: Undetectable
- nT-pro-BNP: Normal

You go see him. He is diaphoretic and clutching his chest.

His BP Is 151/102; SpO2 is 100%.

You glance at the EKG:

View attachment 235022

3 nurses and 2 techs are in the room freaking out, PA is nowhere to be found. What do?

I'm only an M1, but I'm pretty sure the first step is to call your attending.

Beyond that... mitochondria are the powerhouse of the cell...?

 

[mehc012]

That EKG upload is kind of blurry. Any chance there's an extra p hidden in those choppy looking Ts?

 

[cbrons]

I'm only an M1, but I'm pretty sure the first step is to call your attending.

That's not the point of the exercise.

A general medicine or surgery attending is likely to be of little to no help from home at 2am.

There comes a point in your career where you have to actually know enough stuff to do more than answer a Uworld question

The prompt above is an example of an extremely basic cross-cover issue many will encounter during residency and you are going to be expected to know how to stabilize these situations without "calling your attending"

Hint: There's a few basic stuff you do everytime you encounter any tachyarrhythmia in the hospital, some of them were already done in the prompt above

 

[CherryRedDracul]

Do we have an old EKG to compare with?

 

[Cuongoff]

idk i suck at medicine but he's tachy, diaphoretic, doesn't say he's complaining of SOB tho. But since he's s/p sx maybe repeat EKG, cta r/o pe, call cardio for cath for NSTEMI if negative?

(please don't rip me apart guys)

 

[Major]

I’ll take a shot even though I still haven’t finished M1 year.

Repeat ECG, get D-Dimer, CXR, order subsequent Tropinins and CKMBs, get aspirin into him, get him down to cath-laB w/ Cardio consult.

 

[Gurby]

I’ll take a shot even though I still haven’t finished M1 year.

Repeat ECG, get D-Dimer, CXR, order subsequent Tropinins and CKMBs, get aspirin into him, get him down to cath-laB w/ Cardio consult.

(M1 so this is wild speculation)
ASA makes me nervous. The nitro didn't help his pain, his EKG looks unconcerning wrt ischemia to my eyes, troponin negative.... Aside from "chest pain = it could be cardiac!", I don't see why you guys are so fixated on getting him to a cath lab.

Isn't it more likely this something directly related to his surgery? Possible that he's bleeding internally or has a leak or something, in which case I have to imagine ASA is bad news - though maybe potential benefits outweigh the risk?

Specifically what bariatric surgery did he have done? What is the physical exam like? Can we do a FAST at the bedside?

 

[agnes5]

I don't think this is sinus tach... Rarely does sinus tach have a HR of 150 (or at least that's what I've been told by numerous attendings). This might actually be aflutter with a rate of 150 (especially given the post-surgical history), though the EKG appears to have clear T waves in some of the leads.

Might also worry about PE in a post-op patient with chest patient and is now tachy.

 

[Gurby]

I don't think this is sinus tach... Rarely does sinus tach have a HR of 150 (or at least that's what I've been told by numerous attendings). This might actually be aflutter with a rate of 150 (especially given the post-surgical history), though the EKG appears to have clear T waves in some of the leads.

Good call! I remember memorizing that any time the HR = 150 exactly, consider 2:1 AFlutter. That PR interval does look real short, maybe the P wave actually initiating the QRS is actually buried in the T wave.

If this is rate-induced ischemia though, shouldn't we see that reflected in the EKG?

That diastolic pressure seems wonky, and coupled with the low voltage, is a little concerning for pericardial effusion? But then again he's obese so maybe both the voltage and diastolic pressure are WNL for him .... (also why the heck would he have pericardial effusion...?)

 

[Major]

(M1 so this is wild speculation)
ASA makes me nervous. The nitro didn't help his pain, his EKG looks unconcerning wrt ischemia to my eyes, troponin negative.... Aside from "chest pain = it could be cardiac!", I don't see why you guys are so fixated on getting him to a cath lab.

Isn't it more likely this something directly related to his surgery? Possible that he's bleeding internally or has a leak or something, in which case I have to imagine ASA is bad news - though maybe potential benefits outweigh the risk?

Specifically what bariatric surgery did he have done? What is the physical exam like? Can we do a FAST at the bedside?

PE was also floating around in my head. So we could get stat D-Dimer, CT w/ contrast of PA.

What else to rule out PE?

Also, Pericardial Effusion/ Cardiac Tamponade is floating around in my head.

 

[Entadus]

I'm assuming pt is afebrile with a normal RR? Can the pt describe his pain? How's his breathing?

Auscultate the heart, assessing for an S3, or muffled heart sounds (pericardial effusion?)
Auscultate the lung fields as well (does this guy have a pneumothorax?)
Inspect the surgical wound -- how's it looking? Any dehiscence or sign of infection?
Check the legs for evidence of PE(edit: DVT)

Stat CXR - assess for pneumothorax, aortic dissection

He's oxygenating well, so despite the chest pain with sinus tach, my suspicion for PE is low at this point. Going to hold off on ordering the CT Angio for a few minutes.
No EKG changes suggestive of ischemia, and first troponin was negative. Can repeat the troponin if the pain continues, but at this point low suspicion for MI

Going to try calming the patient (calming down the room) and administering some carotid massage/vagal maneuvers to try and lower pt's HR. Not going to give more nitro. If his HR stays over 150 and continues to be symptomatic, I'll give Adenosine IV 6mg push. What's on the pt's med list?? Does he take any beta blocker/cardiac meds at home, and what about his in-house meds? Cardiac hx?

What's the pt's pain med regimen (he's post-op day 1, correct?)

 

[nlax30]

I'm assuming pt is afebrile with a normal RR? Can the pt describe his pain? How's his breathing?

Auscultate the heart, assessing for an S3, or muffled heart sounds (pericardial effusion?)
Auscultate the lung fields as well (does this guy have a pneumothorax?)
Inspect the surgical wound -- how's it looking? Any dehiscence or sign of infection?
Check the legs for evidence of PE

Stat CXR - assess for pneumothorax, aortic dissection

He's oxygenating well, so despite the chest pain with sinus tach, my suspicion for PE is low at this point. Going to hold off on ordering the CT Angio for a few minutes.
No EKG changes suggestive of ischemia, and first troponin was negative. Can repeat the troponin if the pain continues, but at this point low suspicion for MI

Going to try calming the patient (calming down the room) and administering some carotid massage/vagal maneuvers to try and lower pt's HR. Not going to give more nitro. If his HR stays over 150 and continues to be symptomatic, I'll give Adenosine IV 6mg push. What's on the pt's med list?? Does he take any beta blocker/cardiac meds at home, and what about his in-house meds? Cardiac hx?

What's the pt's pain med regimen (he's post-op day 1, correct?)

I like the approach here.

For the others, obviously you need to go see the patient.

Even while on your way to see him you should be starting to frame the problem in your mind.... "Post op chest pain and tachycardia" and mentally have a DDX in mind.

His BP and SpO2 are currently stable so unless you walk in the room and visually he appears like he is spiraling the drain you have some time to gather some more data.

Do a focused exam, certainly paying attention to the Chest/heart/lungs and surgical site.

 

[nlax30]

In regards to the tachycardia itself.... I would want to know if he was on telemetry or not before this occurred. If so, what would you want to know or look at?

 

[Glowes]

After ruling out the things that are immediately going to kill you (MI, PE, postoperative hemorrhage) sustained sinus tachycardia in a postoperative bariatric patient is a leak until proven otherwise.

His EKG looks like sinus tach, troponin is negative, his hemoglobin is stable and he is satting well on room air.

What I would order/do:
CXR - you are operating near the diaphragm and hiatus so need to make sure there is not a pneumo or effusion
Evaluate fluid status - is he under resuscitated? If yes, then fluids.
Make sure pain well controlled.
I would repeat EKG/trop and full set of labs in the morning.
If no improvement by AM order CT abdomen/pelvis with PO and IV contrast to evaluate for leak or bleed. (If he had any respiratory symptoms I would include the chest as well to eval for PE)
If persistently tachy and all other bad things have been ruled out I would give metoprolol (or call cardiology)

 

[nlax30]

I agree with ruling out acute life threatening things first.

Would want more details on the chest pain characteristics. Negative initial troponin doesn’t really mean anything here if it’s all acute. While I don’t think we need to whisk him off to the cath my decision would be made on EKG changes, response to nitro and his clinical course. I don’t see acute ischemic EKG changes at this point and he had no response to nitro.

PE also would be on my list. Though if he’s saturating well with normal/high BP I’m less worried about a whooping acute saddle PE.

Post surgical site issues/bled is also on the list. Would defer to surgical team/colleagues regarding what sort of imaging based on what surgery was performed but I would certainly perform a careful exam in that area.

And then back to the EKG. We still have debate on what the actual rhythm is.

What clues would telemetry tell us?

What maneuvers/therapies could we use to try and figure out what the rhythm is?

 

[sozme]

Do we have an old EKG to compare with?

 

[FindMeOnTheLinks]

did anybody listen to this dudes heart and lungs or take his temperature?

 

[doc05]

Kids - remember that a d-dimer is always positive in a postop patient. Also remember that you don't do emergent caths for nstemi.

 

[nlax30]

Kids - remember that a d-dimer is always positive in a postop patient. Also remember that you don't do emergent caths for nstemi.

Well, it's not a hard and fast 'no' to that question. There are certainly instances where I would want to send, and have sent either an NSTEMI or UA emergently to the cath lab.

 

[sozme]

Update #1

OK I will add a couple things to the OP

Temperature is 37 degrees C. RR is 18.


Patient is awake, alert, and oriented. Responds to questions appropriately. Phonating audibly. Denies any shortness of breath.
Lung sounds clear bilaterally.
S1 S2 normal. Fast rate. No obvious murmurs. No JVD.
Abdomen protuberant. Soft, tender over incision site. No rebound guarding or rigidity. Hypoactive bowel sounds.
2+ pitting edema of distal bilateral lower extremity.
Pain is described as "feels like something sitting on my chest." 7-8/10.

Denies any abdominal pain. Denies any shortness-of-breath.

Med list includes:

- Nitroglycerin sublingual 0.4mg q5min x 3 PRN
- Enoxaparin 60mg q12h (started 24-hours ago, received yesterday nights PM and this AM dose)
- Morphine 4mg IV q1h PRN severe pain
- Tylenol 650 q6h scheduled
- Oxycodone 5mg q3h PRN moderate pain
- Atorvastatin 80mg QDAY
- Symbicort inhaler BID
- DuoNeb PRN
- Lantus 30mg QHS
- Sliding scale lispro

PMH includes:
- Asthma
- Morbid obesity
- Type II diabetes

You quickly check the EMR for the operative note

He had a Rou-en-Y done. Reported surgical blood loss was listed as minimal.

 

[cbrons]

First things first.... is this patient stable?

It's usually taught that the first thing you do in this situation is determine stable vs. unstable, and somehow by working through that dichotomy you can get an easy answer on what to do next. "Unstable" patients with supraventricular tachycardia of any kind = shock them (though you shouldn't shock sinus tachycardia, nothing super bad is going to happen if you do). That being said, shocking an unstable SVT patient isn't always a useful thing to do, but if the patient is super unstable, and you really aren't sure what rhythm you are dealing with, then you are obligated to shock them.

People might say this patient is stable because his vitals are otherwise normal. I would say the chest pain is very concerning, and makes them unstable. Fail to respond to nitroglycerin doesn't mean it isn't ischemic chest pain. In fact, it's probably demand ischemia from the fast HR itself, which I would tend to think might be less responsive to nitroglycerin (though I don't know if this is true or not).

So now that I've convinced myself they are unstable, I try to think about what to do about it.

If I was convinced this was "sinus tachycardia" as the computer says, and If I'm worried about ischemic chest pain, then I make sure they've gotten the max of nitro, and then move onto morphine, and possibly drips, etc.

I'm not convinced this is sinus tach though. I'm convinced this is another kind of rhythm that if you treat may actually alleviate this person's chest pain. If you can't tell based on the EKG, then the clue is that the patient is within 4 days postop. There's certain types of SVT which are common within that window.

What to do after recognizing what the actual rhythm is, I'm not sure what the best answer would be (drugs vs. electrical cardioversion). I lean more towards the latter.

 

[cbrons]

I’ll take a shot even though I still haven’t finished M1 year.

Repeat ECG, get D-Dimer, CXR, order subsequent Tropinins and CKMBs, get aspirin into him, get him down to cath-laB w/ Cardio consult.

D-dimer won't be helpful. It will most likely be high, and then you will be obligated to CTPA him despite having low suspicion for PE. THis person has been on adequate doses of prophylactic-dose Lovenox (I'm assuming his BMI is over 50, hence the 60mg BID) for over 24 hours. I think a PE is fairly unlikely. That being said, in this particular patient, if you did have a high suspicion for PE, you don't need a D-dimer to CTPA them.
CKMB isn't going to be helpful.
Aspirin isn't a wrong thing to do in this scenario.
Chest X-ray is fine, but remember that this person is unstable and isn't dyspneic. Probably not a bad idea, but I try not to order tests where I can't anticipate the findings. In a non-dyspneic patient with chest pain and a fast HR, my first thoughts don't include anything that would show-up on a chest X-ray. (Though you are certainly not wrong for ordering one).

 

[Major]

D-dimer won't be helpful. It will most likely be high, and then you will be obligated to CTPA him despite having low suspicion for PE. THis person has been on adequate doses of prophylactic-dose Lovenox (I'm assuming his BMI is over 50, hence the 60mg BID) for over 24 hours. I think a PE is fairly unlikely. That being said, in this particular patient, if you did have a high suspicion for PE, you don't need a D-dimer to CTPA them.
CKMB isn't going to be helpful.
Aspirin isn't a wrong thing to do in this scenario.
Chest X-ray is fine, but remember that this person is unstable and isn't dyspneic. Probably not a bad idea, but I try not to order tests where I can't anticipate the findings. In a non-dyspneic patient with chest pain and a fast HR, my first thoughts don't include anything that would show-up on a chest X-ray. (Though you are certainly not wrong for ordering one).

Makes sense! Thanks for the teaching points!

 

[Crayola227]

(M1 so this is wild speculation)
ASA makes me nervous. The nitro didn't help his pain, his EKG looks unconcerning wrt ischemia to my eyes, troponin negative.... Aside from "chest pain = it could be cardiac!", I don't see why you guys are so fixated on getting him to a cath lab.

Isn't it more likely this something directly related to his surgery? Possible that he's bleeding internally or has a leak or something, in which case I have to imagine ASA is bad news - though maybe potential benefits outweigh the risk?

Specifically what bariatric surgery did he have done? What is the physical exam like? Can we do a FAST at the bedside?

a few thoughts.... always rule out an inferior MI before giving nitro

also, as much as you might worry about bleeding post-op, which is great to keep in mind (risk is low in bariatric surgery anyway) you should ALWAYS worry about PE or other clots

surgery is a traumatic insult to the body that causes a hypercoagulable state, and being under anesthesia is the sort of stasis you basically don't even get from someone in a hospital bed who is asleep and can roll around in bed (one reason we roll around in bed) - Virchow's triad baby

being on a vent vs breathing independently is a poor way to move around air and blood in the lungs, comparatively

this is why surgery and ventilation are set ups for clots and PNA

lastly, while ASA is great for ischemic stroke and MI, it's not such a strong blood thinner that you really need to stress giving it in situations where you are concerned for them, even post or pre-op

better to give it in these situations where you are concerned for life-threatening clot, than withhold because of the small but real bleeding risk

in general, outcomes from management of bleeds are better than outcomes of adequately or inadequately treated ischemic events

this is why we go for the risk/benefit trade off with warfarin in so many instances

easier to pour blood & fluids into someone than restore blood flow in a clotted artery

 

[nlax30]

Waiting for someone to tackle the EKG/rhythm in more depth.

 

[FindMeOnTheLinks]

Waiting for someone to tackle the EKG/rhythm in more depth.

It is very difficult to read the EKG due to the quality and I haven't really looked at EKG since my medicine rotation a whole year ago, but I think I'm seeing a shortened PR interval suggestive of a pre-excitation syndrome

 

[Crayola227]

also, repeat after me, ddimer is WORTHLESS in a post-op patient, even in a minor procedure with little bleeding

the chances that it will be elevated when the patient has no clot, is high

in that setting, if your suspicion is high enough for ddimer (high pretest rather than low) then you go straight to CT angio

why not doppler? because if your suspicion is quite high for PE and your picture suggests it, you could have a PE with no DVT

repeat after me, patients can have PE with no DVT for a lot of reasons

I'm not saying this guy needs a CT angio, but if you're that worried for PE depending on your picture, you skip the so-called "rule out" or screening tests

really ddimers and dopplers are cheap ways to try to determine who should get a CT angio, negative results are only reassuring when suspicion is low, and mean squat when suspicion is high

you have to understand how pre-test probably and sensitivity/specificity play into your choice of doing these tests for DVT/PE

ddimer & doppler is a RULE OUT - your suspicion is low, and you would like this info to reassure you that you do not need doppler or CT angio

this is partly what you should always ask yourself, "how does the result of this test affect management?"

so before you get a ddimer, you have to ask yourself if an elevated result can be trusted, post-op it can't
same with a doppler, if the result is negative for DVT, do you still do CT angio?
if it's positive in someone post-op with chest pain, you are going to angio no matter what, so in the scenario where even a negative doppler you still worry for PE w/o DVT, you again can skip doppler

I've seen a lot of PEs with no DVT, so you have to keep that in mind when you are assessing risk of PE

I'll try to post a great pocketcare algorithm on this

 

[deleted245139]

Just hopping in to point out the polarity change in lead III (newly inverted)

 

[Gurby]

Just hopping in to point out the polarity change in lead III (newly inverted)

There is also a much longer PR interval in the old EKG!

a few thoughts.... always rule out an inferior MI before giving nitro

also, as much as you might worry about bleeding post-op, which is great to keep in mind (risk is low in bariatric surgery anyway) you should ALWAYS worry about PE or other clots

surgery is a traumatic insult to the body that causes a hypercoagulable state, and being under anesthesia is the sort of stasis you basically don't even get from someone in a hospital bed who is asleep and can roll around in bed (one reason we roll around in bed) - Virchow's triad baby

being on a vent vs breathing independently is a poor way to move around air and blood in the lungs, comparatively

this is why surgery and ventilation are set ups for clots and PNA

lastly, while ASA is great for ischemic stroke and MI, it's not such a strong blood thinner that you really need to stress giving it in situations where you are concerned for them, even post or pre-op

better to give it in these situations where you are concerned for life-threatening clot, than withhold because of the small but real bleeding risk

in general, outcomes from management of bleeds are better than outcomes of adequately or inadequately treated ischemic events

this is why we go for the risk/benefit trade off with warfarin in so many instances

easier to pour blood & fluids into someone than restore blood flow in a clotted artery

Wow, this clears up so many things, thank you!

 

[Crayola227]

After ruling out the things that are immediately going to kill you (MI, PE, postoperative hemorrhage) sustained sinus tachycardia in a postoperative bariatric patient is a leak until proven otherwise.

His EKG looks like sinus tach, troponin is negative, his hemoglobin is stable and he is satting well on room air.

What I would order/do:
CXR - you are operating near the diaphragm and hiatus so need to make sure there is not a pneumo or effusion
Evaluate fluid status - is he under resuscitated? If yes, then fluids.
Make sure pain well controlled.
I would repeat EKG/trop and full set of labs in the morning.
If no improvement by AM order CT abdomen/pelvis with PO and IV contrast to evaluate for leak or bleed. (If he had any respiratory symptoms I would include the chest as well to eval for PE)
If persistently tachy and all other bad things have been ruled out I would give metoprolol (or call cardiology)

great point, in someone post-op in this area leak or other injury to the mediastinum is key to consider, I saw pneumomediastinum with subcutaneous emphysema post-op from just this procedure

repeat after me others in this thread, for chest pain one of the MOST important questions you can ask is QUALITY

I was taught the 3 following questions, answers to 2/3 c/w MI is sensitive for MI like some crazy percentage I can't recall, but should ALWAYS be asked for chest pain, period:

location (substernal), radiation (+/-, where to), quality (pressure, dyspnea)

granted there are atypical presentations, keep in mind, but the guideline above is still useful because even in women or the elderly, while they might not have substernal pain, it will still be consistent with radiation and quality

quality is most useful compared to the other two when trying to distinguish cardiac from somatic causes of pain

the vagus nerve is not a somatic nerve, it's visceral, so cardiac pain is never sharp in quality unless there are reasons for other structures nearby to be

given the nature of his surgery, I would EXPECT his esophagus and gastric area to be painful, and to have a sharp and/or BURNING quality

granted, sharp or burning in this area in the presence of crushing/pressure pain isn't reassuring, but when someone's chest pain is not radiating to areas c/w MI AND there is no pressure to it, then it's just the location that is concerning and absent other signs of MI (trop pos, EKG, etc) I am much less worried for cardiac cause

 

[sozme]

Update #2

Waiting for someone to tackle the EKG/rhythm in more depth.

Scroll to 10:14 for a discussion of this specific EKG


The lack of biphasic P-wave in V1 suggests this not sinus rhythm. This is atrial flutter with ventricular rate of close to 150, and atrial rate of just under 300. The computer is incorrect.

 

[Crayola227]

I would add that given the nature of his surgery, he absolutely could have vagus nerve firing that is giving this substernal pain a pressure quality

so that muddies the waters

given the rest of his picture, it would lean me towards complication directly related to his surgery vs cardiac, once you've done your due diligence for cardiac cause or PE, I would definitely feel good about kicking this back to the surgical team for what sort of imaging/eval they want for complications directly related to the surgery

in general, from a medicine standpoint, you should be able to manage all aspects of dealing with post-op things like MI, stroke, PE, pneumothorax, on and etc, but when you start thinking that this is surgical site, you need to get the surgeons, because they are the ones who know what they did, what might have gone wrong, how to determine that, and to treat

that is what you cannot be expected to know and shouldn't do on your own

whenever you are going to a specialist you will want to have done everything they would want to know/do that you *could* be expected to have anticipated, don't do more than that exposing patients to radiation or other tests, because that's ridiculous, potentially harmful and wasteful

it's a balance to find that medium and that's part of training, learning what is your scope and then doing it

 

[Xurros]

I would also hold any drugs that can cause further tachycardia like the nitro and the albuterol from the duonebs.

 

[AsianPersuasion]

Get a stat CXR.

 

[sozme]

Get a stat CXR.

Looking for what

 

[Major]

Looking for what

Pleural effusion...?

 

[RogueBanana]

I'm just an M1 but i'll take a swing:

First: Carotid Massage to try and slow that SVT. (Shoutout to Dr.P for teaching me that in anatomy)

GI surgery suggests possible Vagus nerve clip, but even then his HR would max at 110 at rest. Though he could be panicking.

Look for a bleed, push Metoprolol or equivalent and see if that doesn't slow him down.

 

[CliveStaples]

So this is a subtle EKG - but there's a good lesson to be learned here. Anybody with a tachycardia at around 150bpm needs to have Atrial Flutter on the differential diagnosis. You can't chalk all these up to sinus tach vs. SVT.

1) Always go see the patient and perform a physical exam.

2) Stable vs. Unstable. This patient is stable. Yes, chest pain/discomfort is concerning, but this patient is perfusing well and protecting his airway. You have time to think.

3) Get repeat EKGs or watch this rhythm on the monitor for a while. While it doesn't appear on this EKG, most cases of 2:1 Atrial Flutter will degenerate briefly into 3:1 at some point, and then the diagnosis becomes much more clear.

4) Treatment of Atrial Flutter is going to be just like that of Atrial Fibrillation. I prefer calcium channel blockers (i.e. Diltiazem drip) as a rate control method over beta blockers (Metoprolol push doses) but you may be in a setting on the floor where starting a drop is not possible, in which case stick with the metoprolol pushes. There's some school of thought towards giving chemical/electrical cardioversion instead of rate control in isolated afib/flutter like this case (especially if he was on a monitor and we can definitely see the onset of this rhythm, so thrombus and anticoagulation are not concerns) but that probably goes beyond the purpose of this exercise. Stick with rate control when in doubt.

 

[anbuitachi]

put an ultrasound on this guy to assess his lungs and heart. see if any walls are down. PE should be high up on the differential along with cardiac issues since this is guy is obese and just had surgery so he's high risk for clots.

 

[Crayola227]

not to reward the notion that -GASP!- anything chest related gets a stat CXR, but in this particular case given the nature of the surgery, all the structures that could be potential causes, a CXR is very very reasonable in this case compared to so many, so yes, for once, get the CXR. At my institution like $50 - 200 depending, something of a steal for such a useful diagnostic test with low risk/rad (useful when used right)

that's a note aside from the fact this guy's got a flutter

although, a lot of tachyarrythmias will emerge under certain types of stress, and it could just be that he's post-op, but it could be more sinister complications at the heart of this (pun not intended)

 

[operaman]

Yeah that was a very subtle ekg indeed!

For teaching purposes I would say that this presentation in my mind would be PE until proven otherwise. So many risk factors and the only data points not consistent with it are the 100% spo2 and tachycardia being a bit too fast, and half the time someone has put these folks on some nasal canula o2 before you even get there so that’s not terribly reliable.

Unless I saw some obvious 3:1 flutter hit the monitor while I’m standing there or his cxr showed a pneumo or dissection, this dude would have gotten a CTA. I’d rather be the tern that scanned the aflutter dude than the tern who tried to cardiovert or rate control the PE.

My personal algo for any floor issues with chest pain/pressure, sob, tachypnea, etc: pretty much everyone gets a CXR, CBC, EKG, troponin — sometimes also an ABG, and a blood glucose level. There isn’t a single acute issue I can’t disgnose or rule out with that panel other than a PE. It also gives me plenty of objective data to use when managing whatever issue I uncover, and they are all relatively inexpensive and very low risk.

 

[libertyyne]

M1 taking a stab. Seems like cardiac, pe VS hypovolemic shock.
What was the post op blood loss?
What type of bariatric procedure?
Any vomiting blood or bowel movements with blood or blood products?
What day is this post op? Were his home meds dced during the hospital stay?
Hematocrit?

 

[nlax30]

Granted it could be a subtle EKG for an intern though I’d argue it isn’t that subtle if you were to show this to a cardiologist or EP. If there’s a question on something like when you’re on the floors then call up and have a a cardiologist, EP or cardio/EP fellow take a look at the EKG. There are some pretty clear, subtle, signs that that’s an atrial flutter and not sinus tachycardia.

 

[Entadus]

M1 taking a stab. Seems like cardiac, pe VS hypovolemic shock.
What was the post op blood loss?
What type of bariatric procedure?
Any vomiting blood or bowel movements with blood or blood products?
What day is this post op? Were his home meds dced during the hospital stay?
Hematocrit?

Awesome participation, here's a couple learning points for ya:

-hypovolemic shock = not enough circulating blood volume to perfuse tissues/organs. This goes hand in hand with hypotension, however this pt's BP is not low (150's/100's). So this pt is not in shock and most likely not hypovolemic.

-Pt's Hb=10.2, which predicts a hematocrit ~ 30.6. These 2 numbers give the same information and so it's not necessary to know both. Remember, technically the hematocrit is a fraction of the blood volume occupied by RBC's, whereas the hemoglobin is only an indirect measure of circulating red blood cell mass(volume). But if you report one you need not report the other, it's redundant information for a clinician

 

[VA Hopeful Dr]

not to reward the notion that -GASP!- anything chest related gets a stat CXR, but in this particular case given the nature of the surgery, all the structures that could be potential causes, a CXR is very very reasonable in this case compared to so many, so yes, for once, get the CXR. At my institution like $50 - 200 depending, something of a steal for such a useful diagnostic test with low risk/rad (useful when used right)

that's a note aside from the fact this guy's got a flutter

although, a lot of tachyarrythmias will emerge under certain types of stress, and it could just be that he's post-op, but it could be more sinister complications at the heart of this (pun not intended)

That was my thought as well. After that type of surgery, a CXR has a good chance of showing free air if any of his new GI anastomoses came loose. Plus, all the usual stuff you can see with it.

 

[libertyyne]

Awesome participation, here's a couple learning points for ya:

-hypovolemic shock = not enough circulating blood volume to perfuse tissues/organs. This goes hand in hand with hypotension, however this pt's BP is not low (150's/100's). So this pt is not in shock and most likely not hypovolemic.

-Pt's Hb=10.2, which predicts a hematocrit ~ 30.6. These 2 numbers give the same information and so it's not necessary to know both. Remember, technically the hematocrit is a fraction of the blood volume occupied by RBC's, whereas the hemoglobin is only an indirect measure of circulating red blood cell mass(volume). But if you report one you need not report the other, it's redundant information for a clinician

Thanks for that clarification regarding Hb. That makes sense. I was going off of him possibly being in stage II -III where you will have increased diastolic BP and perhaps maintained Systolic with tachy.

 

[AsianPersuasion]

Looking for what

I'm suspecting pneumothorax and leaning more toward pleural effusion. I would need to know what kind of surgery he had done. He's still stable, so I would pain manage and consult card / the surgery team.

 

[doc05]

That was my thought as well. After that type of surgery, a CXR has a good chance of showing free air if any of his new GI anastomoses came loose. Plus, all the usual stuff you can see with it.

You will always have free air in a fresh post op, whether laparotomy or laparoscopy.

Shall I give the answer? Don't want to spoil it for the students...

 

[evilbooyaa]

Is this not a leak until proven otherwise? The a-flutter is secondary to what's going on internally?

Bariatric surgery - Meaning Roux en Y? Sleeve Gastrectomy? Look at the OP note. Risk of leak is not zero.

Also, I'm calling the surgery staff (resident, attending, whoever) to let them know about their patient.