SVT

Question 1

A 31 year old woman presents to the ED complaining of palpitations and feeling faint. She looks pale and when you take her pulse it is 180 beats per minute. How would you assess and manage her?

Answer 1

Impression
Likely SVT.

DDx to consider
- regular: AVRT (WPW), AVNRT, junctional tachycardia, focal atrial tachycardia, sinus tachy, atrial flutter
- irregular: AF, multifocal atrial tachycardia
- ventricular tachy/fibrillation
Other medical causes;
- hyperthyroid, sepsis, pain, PE, volume depletion, ACS, anxiety, electrolyte derangements

Goals

• rapid assessment utilising A to E approach, identify aetiology of tachycardia
• utilise valsalva, adenosine to arrest arrhythmia, ;

Question 2

SVT - Assessment

Answer 2

Assessment
- Take A to E assessment, call for senior help
A - Patent, maintaining
B - RR/SP02, supplemental as required
C - ECG monitoring, HR/BP. Assess pulses, auscultate chest for murmurs. Gain IV access and initial bloods (VBG, FBC, UEC, Trops). May require adenosine to diagnose tachyarrhythmia. Attempt valsalva/ modified valsalva manoeuvres. Then Adenosine, for DCCV if HD unstable.
D - GCS

Question 3

SVT - History

Answer 3

History

• PC: timing, onset, progression
• sx: chest pain, palpitations, diaphoresis, LOC//light-headedness, SOB
• RISKS: fam hx, known structural heart disease, CVD risk factors,
• PMHx: pregnancy, WPW, hyperthyroidism, psych history
• Drugs: stimulants
• Medications: vasodilators, anticholinergics, ß-Blocker withdrawal, etc

Question 4

SVT - Examination

Answer 4

Examination

• General appearance + vitals
• Cardioresp examination: PR, murmus, signs of heart failure (creps, peripheral oedema)

Question 5

SVT - Investigations

Answer 5

Investigations
Diagnostic
- ECG: 12 leads, looking for rate, regularity. Narrow vs broad complex, additional features (Delta waves, etc)

Bedside: CXR, UA for drug screen
Bloods: FBC, trops, UEC, LFT, TFTs, ß-HCG (pregnancy), CMP
Imaging: Echo for structural heart disease

Question 6

SVT - Management

Answer 6

Management

• cardio consult
• definitive depends on underlying aetiology

SVT
- continuous ECG monitoring, utilise tacahyarrhythmia pathway
If regular and narrow complex;
- valsalva and modified valsalva manoeuvres
- adenosine IV push: 6mg then 12, 12
o contraindicated if patient has asthma
- synchronised DC cardio version if unstable
If irregular;
- rate control with ß-Blockers or Digoxin IV, consider amiodarone

If broad complex tachycardia

• torsades: then administer magnesium sulphate
• amiodarone if VT

Supportive

• fluids
• electrolyte replacement
• analgesia