Anne Palmer
last written: July 2011, David LaPierre
last reviewed:
introduction
Anne is a 72 year-old healthy woman who is admitted to the surgery floor after falling and breaking her hip. She is awaiting open reduction and internal fixation for tomorrow.
She settles nicely, but soon rings the nurse saying she is feeling her heart racing. She is also short of breath.
The nurse calls you, and while you are coming checks her vitals. She finds HR 188, BP 102/66, and oxygen saturation 88%.
What are your immediate steps?
Manage ABCs:
- give oxygen
- secure IV access (if not otherwise attained) and begin fluid recuscitation as required
- monitor cardiac rhythm and vitals
Anne is shaken by this, but does not have any chest pain.
What do you do next?
As Anne is stable (no shock, chest pain, or altered mental status), immediate cardioversion is not warranted.
Obtain a 12-lead ECG.
The rhythm strip shows a regular, narrow-complex tachycardia.
How do you begin treatment?
Attempt vagal maneuvers if not contraindicated (ie, known carotid disease).
If unsuccessful, give adenosine 6mg rapid IV push.
If unsuccessful, give a dose of 12 mg rapid push; this may be repeated once.
This is unsuccessful; Anne's HR remains 170.
What further treatment options do you consider?
It is possible that Anne has atrial flutter, ectopic atrial tachycardia, or junctional tachycardia.
Proceeding with caution, and with expert consultation as possible, consider:
- diltiazem IV, 0.25mg/kg over 2 min
- beta-blockers (being cautious with pulmonary disease or CHF)
What contribution causes may also be possible?
Consider the H's and T's:
- hypovolemia
- hypoxia
- hydrogen ions (acidosis)
- hypo-/hyperkalemia
- hypoglycemia
- hypothermia
- toxins
- tamponade
- tension pneumothorax
- thrombosis, coronary or pulmonary
- trauma (hypovolemia)
Anne responds to IV diltiazem. She is started on PO diltiazem to maintain her heart rate. She is scheduled to see the internist prior to surgery.
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