No cardioversion due to risk of embolism?

XmasShopperRN, ASN, RN · May 12, 2013

That reminds me I've heard from intensivists in the past that if adenosine fails to convert SVT it's not true SVT. Anyone heard this before?[/quote']
SVT is a blanket diagnosis for all tachyarrhythmias (sinus tach, a fib, a flutter, etc.) The specific tachyarrhythmia can only be determined through a 12 lead EKG interpretation d/t rapid HR and indistinguishable P waves on a single lead. If a pt's tachyarrhythmia doesn't respond to cardioversion, the source of the tachyarrhythmia is most likely not electrical in nature, but instead d/t another cause such as sympathetic stimulation (dehydration, hyperthyroidism, etc.)
If the EKG revealed an atrial etiology, I would think the doc would be more concerned with the pt throwing a clot from her atrium d/t blood pooling, and less with an existing PE. IMO. Also, a HR in the 240's sounds atrial. While it sounds like the pt was symptomatic (i.e. chest pain), she doesn't sound hemodynamically unstable as she was still perfusing with the high BP.
I'm curious what the pt's labs looked like, namely thyroid studies. Also, was a d-dimer drawn? Although not completely specific, an elevated d-dimer could better help support the doc's concern that the pt's CP was d/t a PE and not just poor coronary perfusion d/t a decreased cardiac output.
Also, I'm curious why the doctor drew the line about cardioverting after only a single dose of adenosine for fear of the pt throwing a clot when the intended purpose of adenosine is to cardiovert chemically. I would think that maxing out on adenosine before determining the pt wasn't responding would make more sense, especially since only one dose was given, and who knows how long the pt's heart could've maintained at a rate in the 240's.

CodeteamB · May 12, 2013

Also, I'm curious why the doctor drew the line about cardioverting after only a single dose of adenosine for fear of the pt throwing a clot when the intended purpose of adenosine is to cardiovert chemically. I would think that maxing out on adenosine before determining the pt wasn't responding would make more sense, especially since only one dose was given, and who knows how long the pt's heart could've maintained at a rate in the 240's.

This is why I was thinking that the initial dose of adenosine was more of a diagnostic tool than an attempt at cardioversion. I have seen 6 of adenosine given with the intention of slowing down the rate and the flutter waves just kept on marching through, very cool strip. Then once we had determined that it was a. flutter we proceeded accordingly. Is this maybe the case here OP?

thelema13 · May 12, 2013

This was the first time working with this doc. He would not listen to any of the nurse's suggestions. I do not know why we didn't continue with the adenosine, it didn't work so he switched instantly to diltiazem. We suggested an additional dose of adenosine but he declined. He seems like that type of doc that shuts down when people start making suggestions. We got her to bear down to invoke a vagal response, it did not work.

Honestly, we got the pt in the middle of downtime. Labs took forever. We had to wait for her GFR for the CT. I am guessing that she was in a storm, but the doc wasn't inclined to think so. Her drug screen was negative. I'm not 100% on her other labs, I will have to check them next time I am at work, if I can even find her records. But from what I remember, her CBC and CMP were pretty normal.

She was not fibbing or fluttering, perfectly in-rhythm SVT. Her respiration's made a nice baseline wave on the EKG:)

I was just extremely upset that we let her sit that long in that condition. We gave her 4mg of morphine to stop her coughing/hiccups, it seemed like that only thing that worked.

allnurses Guide · May 12, 2013

Was she producing anything with the cough?

Biffbradford · May 12, 2013

... snip ...
My question is: have you ever not performed a cardioversion due to risk of a clot? I mean, we tried 3 different meds with limited success. No place else to go than cardioversion. I was upset we didn't cardiovert right off the bat.
BTW, this is the first time I have seen absolutely no effect from adenosine, and yes we gave it properly.

Why are you upset?

It's not your call, that's not your job. If you can do better, consider med school.

XmasShopperRN, ASN, RN · May 13, 2013

Why are you upset?
It's not your call, that's not your job. If you can do better, consider med school.

I don't think the OP was expressing anything other than frustration about a situation with which he or she disagreed. 9 times out of 10, when a nurse smells a rat, there's usually a rat. The last I checked, nurses are still their pts' advocates, so they're allowed to use their experience and critical thinking even if that means, God forbid, disagreeing with a doctor.... I'm not really clear on how a nurse whose opinion doesn't match up with a doctor's is somehow overstepping a boundary. IMO, it's just the opposite. I've worked with some ER nurses who I'd want running my code any day over many physicians.... Really good, experienced ER nurses are worth their weight in gold and are just as vital to pt outcomes as the ER docs. And anyone who fails to recognize that because of a God complex and who isn't open to criticism is as dangerous as a loaded gun. IMO.

Ok, stepping off of soap box now :)

allnurses Guide · May 13, 2013

9 times out of 10, when a nurse smells a rat, there's usually a rat.

Is there some data on this? Seems like an awfully high percentage of nurses being right over docs.

XmasShopperRN, ASN, RN · May 13, 2013

Is there some data on this? Seems like an awfully high percentage of nurses being right over docs.

Probably not, but it seems as if my point has been mistaken. If a doctor's right, good nurses recognize that and don't seek out battles just for the sake of battling. My point is that nurses are supposed to speak up when they believe any aspect of pt care is lacking; not to challenge or disrespect authority, but rather as whatever's best for the pt. Case in point, when succ is ordered during a code as an RSI drug, and a nurse questions the order because the pt's ESRD; or a nurse who insists that an attending stay in a pt's room because of the nurse's certainty that the pt can't protect their airway and needs to be intubated despite the attending's proceeding 10 minute rant about why the nurse is an idiot and doesn't need a physician present to treat vomiting, and in less than 5 minutes the pt aspirates and codes. My point isn't that physicians make mistakes 24/7. The majority of doctors I've worked with are really, really good at what they do and bring a lot to the table. But I've also worked with a couple real lemons who, more times than not, exuded incompetence.

One might hope that after all of the years of school and residency that a physician would be batting a thousand in terms of correctness. But given that doctors are human and make mistakes, expecting perfection from a physician at all times based upon the letters after their name isn't good business.

So let me rephrase my previous post; in those extremely rare instances when a physician's judgment is made in error and a 'good' nurse challenges that physician's judgment and claims to smell the proverbial rat, I hypothesize that in 90% of those rare instances there's actually a rat hiding in the woodwork. Maybe I'll propose that as a topic for my capstone in hopes of producing verifiable data....

ezgreazin · May 14, 2013

how many ml did you flush the initial 6 of adenosine with? 10, 20ml?

cardiacrocks, BSN, RN · May 14, 2013

I work on a cardiac floor, I'm curious as well why a bedside TEE wasn't performed. Nonetheless, I have seen meds convert someone with a clot, the clot dislodged and the person had a stroke, very scary. It was a great ideal not to cardiovert this patient. Also, the fact that the pt had thyroid storm is a huge problem, HUGE. This needed to get under control, I'm also wondering what the mag level was. I hope the pt is okay now. Many times if someone is in rapid afib/aflutter it can look like SVT's.

CountyRat · May 15, 2013

Why are you upset?
It's not your call, that's not your job. If you can do better, consider med school.

Ouch! Isn’t that a little provocative, Biff? It certainly is the nurse’s job to participate in care planning. In an emergency, this is done quickly and quietly by discussing possible options with the doctor. Of course the doctor will make the final decision on the basis of his or her superior education. However, to suggest that nurses should not participate in the decision-making process unless they have “concider[ed] medical school” is offensive. More importantly, it is untrue. Did someone teach you this when you were in nursing school? If so, I suggest that you reject that instruction (and ask for a refund of your tuition).

thelema13 · May 15, 2013

Wow, how quickly people turn to arguing...

I was stating frustration because she was in distress, and we have the tools to improve he condition, so why wait around? I haven't heard of not cardioverting due to a clot, and since our options were running out, I was confused. It didn't make it any better that the doc wasn't very concerned about the patient and since I didn't understand his treatment, I asked questions but he never answered them. I was asking if anyone else had had a similar experience, possibly share the experience and outcome.

I am at a small facility, and the docs just CT everything. We would have had to call an ultrasound tech in. She came in at 0430.

Let's return the discussion to learning....