Heart in overdrive

Does your heart race at the thought of managing tachycardia? Take 10 minutes to work through this module and leverage your AMBOSS resources!

It's March. You're a seasoned intern now. Prepared, persistent, and ambitious as Alexander Hamilton, you're absolutely crushing morning rounds today with your internal medicine team. As you wheel your “cow” (computer on wheels) toward the last patient on the team census, your pager goes off.

Click the pager icon to reveal the message.

You inform your senior resident about the page and suggest that you break off from the team to assess the patient. “Why don't we all go together?” the senior resident replies. “You can take the lead on the assessment and workup, and we'll all be there in case you need an extra hand.”

The medical students seem eager for some action. The attending agrees with the plan. “Don't worry, I won't jump in unless you need me to,” she says.

You're a bit nervous about having an audience, but you feel confident that you can manage this situation...and having backup never hurt anyone. As you head to the patient's room with the team, you take a moment to think through your general approach.

Question: What is one thing you must obtain during your initial assessment of this patient?

Make your choice, then click on the explanation bubble to reveal the answer.

• A 12-lead ECG
• The patient's astrological sign
• A chest x-ray

You decide as a team to take the stairs. On the way, you call the extension and ask the nurse to set up a 12-lead ECG so it's ready when you arrive. You also review what you know about the patient.

Question: Which information about this patient is most useful to know right now?

Make your choice, then click on the explanation bubble to reveal the answer.

• She is 48 years of age.
• She has seasonal allergies.
• She has a family history of breast cancer.
• She has a history of structural heart disease.

Read on to see what other information you should review about the patient before reaching her room, and where you might find this information.

More information, please...

• You've already looked at the patient's age, allergies, and past medical history. But to prepare yourself for seeing the patient, there are few more key pieces of information you'll need. You can usually find this information on your signout sheet from the morning shift change.
  • Code status
  • Reason for hospitalization
  • Hospital course
  • Medications
  • Recent laboratory results
• You'll also want to obtain some additional information from the patient's nurse once you arrive, including:
  • Onset and progression of tachycardia
  • Most recent vital signs
  • Associated symptoms

There's a calmness to the atmosphere at the nurses' station. It's the midday lull—all the morning tasks are done, and the nurses are quietly charting. As your entire team approaches, the nurses look up curiously...except for the patient's nurse, who jumps up to greet the team, hands you an ECG, and points to the telemetry monitor that continues to show tachycardia on the patient's tracing.

Question: What should you do after getting a quick report from the patient's nurse?

Make your choice, then click on the explanation bubble to reveal the answer.

• Have a teaching moment! Take 5–10 minutes to review the patient's ECG with the medical students.
• Try to determine the current rhythm using the telemetry monitor at the nurse's station.
• Assess the ECG while at the patient's bedside.

The first step in managing tachycardia is to determine if the patient is stable or unstable. The patient should be assessed at the bedside.

The nurse quickly leads your team to the patient's room. As you walk, you silently review the signs of unstable tachycardia that you don't want to miss. If the patient has any of these signs, you'll need to treat the tachycardia immediately.

Question: Which of the following findings are signs of unstable tachycardia?

Make your choices, then click on the explanation bubbles for more information.

• Acutely altered mental state or loss of consciousness
• Hypotension
• Shock
• Acute heart failure
• Ischemic chest pain

That's right—all of the above! And you can assess most of these signs quickly, even before entering the patient's room.

It's crucial to determine whether tachycardia is the cause or the result of an observed sign or symptom. If it is the result (e.g., sinus tachycardia in hypovolemic shock), treating the tachycardia will not improve (and may even worsen) the patient's condition.

“If you stand for nothing, Burr, what'll you fall for?”

Question: Which path would you like to explore?

Click on the corresponding link:

• Option 1: Unstable tachycardia
• Option 2: Stable tachycardia

Your patient's heart rate is back to normal, and so is yours! You've impressed your team with your cool, confident management of the patient's tachycardia. Now it's time to take a break . You decide to grab some lunch with the medical students and go over the patient's ECG in detail.

• You did a fantastic job:
  • Differentiating between stable and unstable tachycardia
  • Managing unstable tachycardia with pulse (Option 1)
  • Interpreting the ECG to help narrow the differential diagnosis in a nonemergency situation (Option 2)
  • Treating stable tachycardia based on the underlying rhythm (Option 2)
• For more practice determining the diagnosis in a patient with tachycardia, here's a flowchart to help narrow your differential.

Congratulations on completing this module. Hopefully you now feel more comfortable assessing a patient with tachycardia!

Personal story from an AMBOSS clinician

I was working an afternoon shift in a community emergency department when I was asked to evaluate a patient in the triage area who had lost consciousness. When I arrived at the desk, the patient had already woken up, did not appear sick, and was communicating normally.

We put the patient in a wheelchair and began transporting him to the resuscitation bay. On the way, he informed me that he drove himself to the emergency department; he had been feeling occasional bouts of lightheadedness at home and decided to come in after he woke up on the floor. He denied any chest pain or other concerning symptoms. Then, just as we approached the bed, the patient's eyes lost focus and he slumped forward, again unconscious.

We quickly transferred the patient to the bed, and the nurse cut off his clothing while I checked a pulse—it was weak, thready, and tachycardic. As we placed defibrillator pads on the patient and connected him to the monitor, we discovered the telltale silhouette of an implanted device under the skin of his upper chest. When we looked at the monitor, we saw the classic monomorphic wide-complex waveform of ventricular tachycardia.

Almost immediately, the AICD fired, and sinus rhythm returned. After emphasizing to the nurses the importance of not placing a magnet over the patient's pacemaker, I contacted cardiology (who were fortunately still in the building), we administered amiodarone, and cardiology quickly whisked the patient away for continued treatment.

The lesson I learned: Anything can happen, even with patients who appear well initially—stay attuned, and be prepared!