Tachycardia

Question 1

A 31-year-old woman presents to the Emergency Department 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
Patient has an acute presentation of tachycardia. Provisionally think this is related to SVT (most common AVNRT), however would want to rule out red flag DDx including ACS, PE, AF, and VT.

Goals

• conduct thorough H/E/I to identify underlying aetiology of tachycardia
• initiate appropriate emergent management to stabilise the patient
• institute appropriate long-term management

Question 2

Tachycardia - Assessment

Answer 2

Assessment
- Given patient is symptomatic with palpitations, would utilise an A to E approach to initial assessment

A - patent, maintaining
B - RR, sats
C - ECG - diagnose SVT vs ACS vs other arrhythmia, indicate PE.
- 2xIVC
- take bloods: FBC, UEC, VBG
- bedside CXR (resp pathology)
- toxicology screen (if suspected)
D - GCS
E - Exposure (patches, IVDU)
F - Fluids, electrolytes
G - glucose

• call for senior assistance
• if SVT on ECG, then initiate management pathway

Question 3

SVT - Management

Answer 3

Management

• Conduct A to E and implement appropriate stabilising measures as necessary
• ultimately depends if patient is haemodynamically stable

Stable:

• Valsalva manouevres
• Adenosine 6mg initially to differentiate rhythm
• Then Verapamil of B Blocker to restore sinus rhythm(only if confirmed SVT, confer with senior colleague before administering)

Unstable

• Use synchronised DC cardio version
• requires procedural sedation, need to organise ED team to facilitate

Definitive
- cardiac ablation (in EP studies, diagnostic and therapeutic)

Ongoing prophylaxis

• b blockers
• flueicanide if no structural cardiac disease

Question 4

Tachycardia - History

Answer 4

History

• sx: palpitations, light-headedness/syncope, SOB, diaphoresis, etc
• REDF: chest pain (radiation etc), fevers,
• PMHx: cardiac disease
• Medications
• Substance use history
• SNAP

Question 5

Tachycardia - Examination

Answer 5

Examination

• General obs + vital signs
• Cardiorespiratory examination

Question 6

Tachycardia - Investigations

Answer 6

Investigations
- Key/diagnostic: ECG +/- adenosine

• Bedside: ECG, CXR, VBG,
• Bloods: serial trops, FBC, UEC, LFT, TFT, BNP, toxicology screen
• Imaging: ECHO (structural causes),
• Other: 24-hr holter monitor, EP study