No cardioversion due to risk of embolism?

  1. 1 35 yr old female comes in crying, anxious, coughing. States her chest hurts. Hx of Graves disease. EKG shows SVT 240's. RR 40's, and BP 140's/100's.We get her ready for a dose of adenosine, doc walks in and starts asking his questions. She says she has felt like doo-doo for the past 2 days.

    6mg adenosine without effect.
    20mg diltiazem brings HR to 200.
    5mg lopressor drops HR to 180.

    She's on the pads, about to cardiovert, doc tells us to stop until we get a CT angio due to "risk of a clot" because "she's been like this for the past 48 hours. She has chest pain, she could have a PE."

    What?

    I'm sure she has been in SVT for the past 2 days. And I'm sure her chest hurts cause she is throwing a clot, nothing to do with her HR or BP. And I bet she is in a thyroid storm.

    1.5 hours later, after we get labs back and get the CT angio is negative, cardioversion is successful, she sits at sinus tach at 110 until she is admitted.

    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.
  2. Visit  thelema13 profile page

    About thelema13

    thelema13 has '3' year(s) of experience and specializes in 'ED'. From 'Florida'; Joined Jun '11; Posts: 286; Likes: 362.

    28 Comments so far...

  3. Visit  KBICU profile page
    3
    Quote from thelema13
    35 yr old female comes in crying, anxious, coughing. States her chest hurts. Hx of Graves disease. EKG shows SVT 240's. RR 40's, and BP 140's/100's.We get her ready for a dose of adenosine, doc walks in and starts asking his questions. She says she has felt like doo-doo for the past 2 days.

    6mg adenosine without effect.
    20mg diltiazem brings HR to 200.
    5mg lopressor drops HR to 180.

    She's on the pads, about to cardiovert, doc tells us to stop until we get a CT angio due to "risk of a clot" because "she's been like this for the past 48 hours. She has chest pain, she could have a PE."

    What?

    I'm sure she has been in SVT for the past 2 days. And I'm sure her chest hurts cause she is throwing a clot, nothing to do with her HR or BP. And I bet she is in a thyroid storm.

    1.5 hours later, after we get labs back and get the CT angio is negative, cardioversion is successful, she sits at sinus tach at 110 until she is admitted.

    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.
    I have seen MDs not do CVSNs may times because of this reason. If the patient had a clot in the atria and you cardioverted them, you'd throw the clot into the lungs and possibly be a lot worse off. You could try adenosine up to three times (12mg the next two times) and continue med management if CVSN wasn't a possibility. If the patient is in the rhythm for an unknown amount of time, what the doc did is a very common course of action.
    Esme12, redrn007, and canoehead like this.
  4. Visit  psu_213 profile page
    1
    Would the CTA show a clot in the atria? I know the gold standard to check for an clot before cardioversion is a TEE. Does at CTA serve the same purpose? In addition, if the clot is already in her lungs (which would show up on the CTA), would there be more harm if they did the cardioversion?

    A couple other questions of curiosity: did the doc check renal labs before the CTA? Do they have to? She is only 35, but our CT policy is not to check Cr before any use of CT contrast. Based on lab work, was the pt in thyroid storm?
    redrn007 likes this.
  5. Visit  KBICU profile page
    2
    Quote from psu_213
    Would the CTA show a clot in the atria? I know the gold standard to check for an clot before cardioversion is a TEE. Does at CTA serve the same purpose? In addition, if the clot is already in her lungs (which would show up on the CTA), would there be more harm if they did the cardioversion?

    A couple other questions of curiosity: did the doc check renal labs before the CTA? Do they have to? She is only 35, but our CT policy is not to check Cr before any use of CT contrast. Based on lab work, was the pt in thyroid storm?
    I've never seen a CTa for checking an atrial embolus but your right that he was using that to check for PE. I cant really think of a reason why a CT wouldn't show the clot but it would depend where it was i suppose. I agree that TEE is usually used to check the back of the heart for embolus...does the OP know why they didn't go this route? I'd have to hear more about the patient
    Esme12 and redrn007 like this.
  6. Visit  Altra profile page
    6
    Yes, I think the doc's concern was appropriate. And I disagree that it is likely that she had maintained a HR in the 200s for 48 hours ... even a young person is unlikely to tolerate that rate for that long. And I have seen adenosine fail to convert a rhythm.
  7. Visit  KBICU profile page
    0
    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?
  8. Visit  psu_213 profile page
    1
    Quote from Kara RN BSN
    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?
    If I remember from my first ACLS course correctly...if adenosine converts the SVT, it is d/t a reenterant pathway (I guess this is what is meant by "true" SVT). If adenosine does not covert the rhythm, it is another type of SVT--such as a fib with RVR or a very fast sinus tach.
    Esme12 likes this.
  9. Visit  KBICU profile page
    1
    Esme12 likes this.
  10. Visit  rjflyn profile page
    0
    But doesnt ACLS also say a pt with chest pain and a heart rate in excess of 150 is by definition unstable and waiting around for a hour and a half for a test probably isn't the greatest course either. I for one want to know what the cardiologist he talked to said.
  11. Visit  BostonFNP profile page
    1
    I have seen CTs done prior to cardioversion for this reason.
    Last edit by BostonFNP on May 12, '13
    Esme12 likes this.
  12. Visit  CodeteamB profile page
    0
    I have several questions. Was the adenosine being used in an attempt to cardiovert or was it diagnostic (I'm figuring the latter since only one dose of 6 was given).

    If this was the case it makes more sense to me. In my understanding converting the heart to a normal rhythm with a clot in the atrium will have the same effect whether you do it with medication or electricity.

    I also have never seen a CTA to look for clots in the atrium, but you say there was concern that she already had a PE, so was the CT maybe for that? I guess the CTA would also show an atrial clot as BostonFNP has seen it done.

    Our policy is that if we can identify onset within the last 48 hours we will cardiovert, otherwise our physician will get an echo first, and yes this is common.
  13. Visit  BostonFNP profile page
    0
    Quote from CodeteamB
    I have several questions. Was the adenosine being used in an attempt to cardiovert or was it diagnostic (I'm figuring the latter since only one dose of 6 was given).

    If this was the case it makes more sense to me. In my understanding converting the heart to a normal rhythm with a clot in the atrium will have the same effect whether you do it with medication or electricity.

    I also have never seen a CTA to look for clots in the atrium, but you say there was concern that she already had a PE, so was the CT maybe for that? I guess the CTA would also show an atrial clot as BostonFNP has seen it done.

    Our policy is that if we can identify onset within the last 48 hours we will cardiovert, otherwise our physician will get an echo first, and yes this is common.
    It's not ideal but there have been a few studies on cardiac CTs for eval of LAATs
  14. Visit  XmasShopperRN profile page
    0
    Quote from Kara RN BSN
    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?
    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.


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