Case Study:
A 35-year-old female suddenly develops palpitations and chest discomfort while white-water rafting. Paramedics arrive and record a HR of 190 bpm. She is immediately transported to the local emergency department where you are working. On exam she appears anxious and has a regular HR at a rate of 75 bpm. An ECG, basic labs, and a urine toxicologic screen are ordered. An hour later the toxicologic screen and basic labs come back negative. You are about to discharge her with a diagnosis of acute anxiety attack when you realize that you haven’t seen her ECG yet…
Soon after, you see paramedics rolling a gurney with an older male into another room. They give you the quick report that the patient is having intermittent shortness of breath and chest discomfort. You look at the vital signs on the run sheet and are reassured to see that his blood pressure is 140/80 with an O2 sat of 98% on room air. You ask the nurse to place the patient on a monitor while you take care of a few other things. Minutes later, you are paged overhead to his room and the nurse tells you, “His heart rate is 180/min and he really doesn’t look good.” The patient is diaphoretic and his BP is now 100/50. You ask the patient how he is feeling and he mumbles a response that is barely comprehensible. The monitor shows a narrow complex tachycardia. An ECG is obtained and no P waves are discernible. You’re on the fence; can you convert this SVT with adenosine or should you cardiovert?
Conclusion of the above case study…
You prepared the discharge paperwork for the anxious 35-year-old female and asked the nurse to send her home with primary care physician follow-up. The patient was walking towards the exit when the nurse handed you the ECG you requested for this patient. The ECG demonstrated what you had expected: sinus rhythm. However,the QRS complex caught your eye and you noted a delta wave. Luckily, the patient hadn’t left the ED yet. After an informed discussion with the patient regarding her new diagnosis of WPW syndrome, she was discharged home with a follow-up cardiology appointment within the next week and instructions to follow-up with an electrophysiologic specialist.
You used synchronized cardioversion to treat the SVT in the older male presenting with intermittent chest pain and shortness of breath. You thought about using adenosine, but his declining mental status was concerning enough to classify his SVT as unstable. He converted to sinus rhythm with a rate of 90 bpm. Looking back at his records from prior visits, you realized his blood pressure had always been around 170/90. It seems very clear now that his blood pressure of 100/50 today was producing mental status changes and you were glad that you made the call to cardiovert rather than use adenosine.
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