NIGHT FLOAT CASE #12

[Microshaft]

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given how elusive OP was, I was totally expecting some non-cardiac plot twist at the end

 

[Major]

Thanks for the case OP! That was pretty fun.

 

[sozme]

 

[boshtrich]

RESOLUTION​

(Will update this specific post as more responses/valuable insight becomes available)

This is a patient 3-days post-bariatric surgery. The specific kind of surgery e.g. REY vs. GBL isn't as relevant; sure there could be some operative complication here, but the primary goal of the exercise is to deal with the emergency first, namely the fast HR and possible on-going ischemia. You were given enough information to realize that the tachydysrhythmia wasn't due to acute blood loss anemia, hence the answer to stabilization isn't to give blood or IV fluids.

Again, picture yourself in this scenario as a resident overnight. You only have the information presented. You are at bedside. There's 7 or 8 other people in room waiting for you to tell them what to do. You have a patient with relatively stable vital signs except for a regular narrow complex tachycardia in the 150s complaining of severe chest pain. You actually have to ***do*** something here.

One of the important steps you could've made here was to identify the rhythm itself, as that offers insight into what effective (or safe) interventions could be. But if you are ever doubt about the actual rhythm, here is a good rule to remember:

When in doubt: Pace a slow rhythm. Shock a fast rhythm (try not to shock sinus tachycardia - but it will likely be OK if you do).

Initial actions for this case:

• Stat team basics
  [Things you should ask for when you are paged]
  • Ask for latest set of vital signs
  • Ask for continuous telemetry and pulse oximetry
  • Ensure placement of 2 large-bore IVs
  • Order stat 12-lead EKG
• Determine patient stability
  • Look at vital signs
  • Assess for the presence of serious symptoms
    [Presence of any of the below suggest instability]
    • Chest pain?
      [Usually represents demand ischemia from the fast HR itself]
    • Dyspnea?
      [If lungs are “wet” – possibly acute decompensated heart failure from dysrhythmia-induced pulmonary edema]
    • Decreased level of consciousness
      [Represents poor cerebral perfusion]
    • Signs of shock (hypotension, cold and clammy skin)
  • Determine if above symptoms/signs are due to rapid HR or if rapid HR (and above symptoms/signs) are due to something else
    [E.g. sinus tachycardia: Sepsis, hemorrhage, pulmonary embolism, cardiac tamponade, dehydration]
  • 
    
  • Review EKG to determine rhythm (or at least determine if it is wide or narrow
• o Wide or narrow
  
  o P-waves present?
  
  o Regularity (regular vs. regularly irregular vs. irregularly irregular)
  
  o Rate?
  
  o Rate changes: sudden or gradual?
  [Gradually decreases with IV fluids – e.g. sinus tachycardia, always 150? – atrial flutter]

Appropriate intervention:

In this case, I likely would have cardioverted this patient emergently. That being said, there have been some good arguments for a rate-control strategy (which might be what most residents are more comfortable with overnight). If you go the rate-control route, you need to be ready to cardiovert if that doesn't work out (in this case, if patient's chest pain continues or BP bottoms out, etc.).

Rate-control options

View attachment 235232

Electrical cardioversion: requires procedural sedation in this case (because patient is stable).

Post-stabilization testing
Some people have said this patient requires a "stat CTPE" because he has new-onset atrial flutter and chest pain. I'm not sure that's necessary. If you cardiovert him and he no longer has any chest pain, then that obviates the need to look for a PE. I also am not aware of any research showing that new onset SVT in post surgical patients is associated with PE. Given that he has been on prophylactic Lovenox for 24-hours, I also wonder how much that lowers his pre-test probability for PE. But you've read other arguments for testing him, so you should make-up your own decision. I will say that sending him to the scanner before stabilizing his HR and chest pain issue is probably a bad idea.

I do believe a post-stabilization troponin, electrolyte panel, and transthoracic echocardiogram are reasonable tests. The troponin for the chest pain, the electrolytes because he had a dysrhythmia, and the echo because of the newly diagnosed atrial flutter (which is a standard test for this indication).

Concluding notes

Here is my very simplified algorithm for what I would do if I was dealing with a tachyarrhythmia that I couldn't identify (more than willing to change this based on any helpful input from our experts in this thread

Simplified Adult Tachydysrhythmia Algorithm
(Assumes you do NOT know the exact rhythm you are dealing with)​

View attachment 235230
View attachment 235231



**In case you are wondering, the Modified Valsalva maneuver is the only kind of vagal maneuver i do in these circumstances. Carotid massage is potentially dangerous. Regular Valsalva rarely works. I try to keep my memorization to interventions that are high effectiveness and relatively safe (Modified Valsalva's only contraindication that I know of is in pregnant women, in whom it may induce premature labor).

Remaining questions for research:
1. To what extent does prophylactic-dose LMWH reduce one's chance of developing a VTE while in the hospital?
2. What is the association between new-onset SVT and PE in medical patients (and surgical patients)?

I'd still argue against emergently cardioverting this patient. You don't know how long he's been in flutter. We're already POD #3, for all we know from the stem, he could've been in flutter since the time of surgery, giving him more than adequate time to form a clot in the LAA. Emergent cardioversion is indicated for patients who are hemodynamically unstable. While his chest pain is certainly concerning, nothing about his vitals screams hemodynamically unstable to me. In my opinion, I would rate control with IV beta blocker until the morning, and then have a talk with the primary suregery team and cardiology about why he's in flutter and whether TEE/cardioversion is indicated. I agree that PE still has to be on your mind, even with normal sats and patient being on Lovenox. Tachycardia with sluggish RV can often be the first sign of PE. For those who plan to be involved in any sort of critical care, it's also worth learning some basic TTE skills. It's pretty easy to learn the basic views and throw a probe on a patient and get an idea of what's going on with their heart. If you do a quick echo and his RV is dilated and hypokinetic, management changes drastically compared to if they had normal biventricular function. Echo also helps you rule out some random stuff like a new pericardial effusion causing tamponade (probably not a concern in this patient, but a good thing to keep in the back of your mind), a dynamic LVOT obstuction like SAM in a tachycardic patient, and can give you an idea of volume status and vascular tone.

 

[Radetzky]

The important thing to note from this case is to address the source of physiological compromise first. In this case it is the tachyarrythmia. The case as presented does not suggest the guy is compromised from a PE. Additionally putting an obese guy into a ct scanner with a heart rate of 150 and chest pain is asking for trouble.

Once you have rate controlled/cardioverted you have time to reassess the situation and decide whether you need to look deeper for an underlying cause. If his chest pain and tachycardia resolved, then the clinical picture as presented is not suggestive of either PE or leak- development of an isolated atrial tachyarrythmia is not strong evidence for either, assuming clinically he remains as previously described. This is where the ability to observe your patients becomes paramount. Of course if the chest pain persists or the picture changes then it is a different story.

Say you scan him and find a small subsegmental clot. What then? Was it the cause of all his problems? If you scanned all d3 obese pts you would likely find a not insignificant number of these whose clinical significance is uncertain.

Finding a dilated RV on echo would not be helpful. How do you know it's not cor pulmonare from Undiagnosed OSA or OHS? Assuming the pain/tachycardia settles with treatment of the arrhythmia this guys clinical picture is not consistent with submassive PE, especially if his serial troponins are negative.