No cardioversion due to risk of embolism?

[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.

[CountyRat]

I apologize Thelma; it was not my intent to be argumentative. I thought that the comment required a response because (I thought) the poster was criticizing you for proposing your ideas about the patient's care, which was entirely appropriate for you to do. I meant no offense and I am sorry if I gave any, or if I misconstrued the poster's meaning. Yes, let's get back to the subject:

I appreciate your summary of the patient's condition and minimal response to pharmacological intervention, but there is one more thing that I would like to know; how did the patient look? Did the administration of medication cause her to suffer less distress? If it did, that could be an indication that there was time for the scan before cardioverting. If she was looking worse, I would be more concerned, though I do not have the expertise to evaluate that risk/benefit question. (Risk/benefit evaluation: an academic sounding process for deciding which of two devils you are least unwilling to dance with.)

[SweetMelissaRN]

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....

I had a similar situation. If a patient is in A Fib/SVT for 48 hrs a TEE MUST be performed bc with SVT/a fib the risk of blood stasis in the heart is extremely high and when blood sits still, we all know it coagulates... Coagulated blood + small/vital vessels = a recipe for disaster! If their is a significant decrease in CO is present, sometimes providers will choose not to wait for the TEE, but I've only seen that once... Otherwise they often choose rate control over rhythm control!

[akulahawkRN, ADN, RN, EMT-P]

I'm not a nurse yet... but don't let that fool ya. My background includes some education in exercise science and quite a bit of prehospital time. Why do they choose rate control first? Simple. Often it's CO. Above about 160 bpm, CO actually drops off. Slow the rate down below 160 and CO returns to a more normal level. Why does it drop off at about that level? There's not enough time to fill the ventricles and with a PRI <.20 sec in normal people the atrial kick isn as effective. athletes often are a degree block because it physiological adaptation to exercise. their hearts bit enlarged well so that they can maximize co. at rest this shows up very slow heart rate maintaining an adequate remember when you see someone completely asymptomatic with hr>

So, control the rate first. Get that under control then worry about the rhythm. Precisely because of the clot problem, I'd be very careful about cardioverting a patient (chemically or electrically) if they've been having symptoms >48 hours. At least in the case of A-Fib, if the patient is stable, they're supposed to be anticoagulated for a while before attempting to cardiovert them. Given that the patient was apparently symptomatic for that long, I'm actually surprised the doc elected to even try to slow the rate without checking for possible clot formation first, unless the patient was unstable to where the benefit outweighed risk, at first.

Just my two cents... for what it's worth! (and I reserve the right to be completely wrong and learn...)

[thelema13]

Honestly, she looked like crap. I had a feeling she would poop out soon, and when we did cardiovert her, she was slumped over the siderail, crying and exhausted. Giving her some electricity definitely woke her up and made her cry more.

She was pretty unstable in my opinion: HR >240, RR >40, hypertensive. Just my opinion.

Could never find her labs, lost in downtime paper charting somewhere in some filing cabinet. I do know the cardiologist advised to cardiovert.

And we flushed the adenosine with 10cc and squeezed the NS bag and held her arm upright after pushing the adenosine.

[CountyRat]

Honestly, she looked like crap. I had a feeling she would poop out soon, and when we did cardiovert her, she was slumped over the siderail, crying and exhausted. Giving her some electricity definitely woke her up and made her cry more.

I can understand your concern, which I am sure was appropriate. We have received some good input in this thread, maybe we will get more over time.