CASE

PRESENTATION
By SC Hazel Aspera
PATIENT HISTORY
 K.C.

27yo
GENERAL Female
DATA Nurse
Working in a clinic and diagnostic
center
 CHIEF
COMPLAINT
Dizziness and Syncope
HISTORY OF PRESENT
ILLNESS
KC was working a busy early morning shift.
She had 1 cup of coffee prior to her work.
30 mins PTA, she had sudden onset of pounding
heart and tolerable chest pains. She ignored this
and continued to work.
20 mins PTA, the clinic physician saw her leaning
to the wall with her fist on her anterior chest. She
complained of dizziness but no ringing of ears.
She eventually had syncope and was laid down
flat on bed.
 PHYSICAL
EXAMINATION
 BP100/60

VITAL HR 180 bpm

SIGNS
RR 24 cpm
Temp 36.7°C
 Slightly cool
SKIN
Good turgor
 Anicteric sclerae
HEENT Slightly pale palpebral conjunctivae
(-) Thyroid Mass
CHEST Equal expansion
AND Clear breath sounds
LUNGS
 Distinct heart sounds
Tachycardic
HEART Regular rhythm
No murmurs
 Flat
ABDOME Normoactive bowel sounds
N No palpable masses
No tenderness
EXTREMI Acyanotic nailbeds
TIES Strong pulses
SALIENT FEATURES
SALIENT FEATURES
An otherwise healthy young female
Presenting with palpitations, chest pain, and syncope
Doctor observed (+) Levine’s sign during episode
History of caffeine intake before the episode
On PE is tachycardic, distinct heart sounds, no murmurs
Slightly cool skin
Slightly pale palpebral conjunctiva
No thyroid mass
Rest of Hx/PE unremarkable
DIFFERENTIAL (Based on the Hx and PE)
DIAGNOSES
DIFFERENTIAL DIAGNOSES
HYPOGLYCEMIA
Cold, clammy skin
Dizziness
Syncope
Palpitations

Tachycardia
DIFFERENTIAL DIAGNOSES
MYOCARDIAL INFARCTION
Occurs more commonly in men, elderly
? Oral contraceptive pills can increase risk for thrombus formation
Chest pain radiating to back, arms, or neck
Levine’s sign
Palpitations

Loss of consciousness

DIFFERENTIAL DIAGNOSES
PULMONARY EMBOLISM
? Oral contraceptive pills can increase risk for thrombus
formation

 Chest pain

 Palpitations

 Dizziness

 Loss of consciousness
 Pleural Friction Rub

 Respiratory Signs on PE
DIFFERENTIAL DIAGNOSES
CARDIAC ARRHYTHMIA
 Some arrhythmias are common in young women
without history of heart disease

 May be triggered by stress or caffeine intake

 Chest pain

 Palpitations

 Loss of consciousness
DIFFERENTIAL DIAGNOSES
HYPERTHYROIDISM


Common in young females.
Palpitations



Tachycardia
Hypertension

 Tachypnea



Dizziness
Enlarged thyroid

 Heat sensitivity

 Chronic presentation
DIFFERENTIAL DIAGNOSES
ELECTROLYTE IMBALANCES
? May be caused by dehydration or inadequate intake.
Palpitations
Chest pain
Dizziness
May also trigger arrhythmias.
?
DIFFERENTIAL DIAGNOSES
CARBON MONOXIDE POISONING


Usually due to exposure in an enclosed space
Other persons may also experience the same symptoms


Headache
Palpitations


Tachycardia


Hypotension


?
Dizziness
Syncope
May trigger cardiac arrhythmias
DIAGNOSTIC TESTS
RANDOM BLOOD SUGAR
98 mg/dL (Normal: 70-150mg/dL)
ELECTROCARDIOGRAM (STEP-
BY-STEP)
1. DETERMINE THE RHYTHM

7.5 sm sq. 7.5 sm sq.

7.5 sm sq. 7.5 sm sq. 7.5 sm sq. 7.5 sm sq. 7.5 sm sq.

THE RHYTHM IS
REGULAR
 2. DETERMINE THE RATE
 
Since the rhythm is regular, we
can use this formula:
7.5 sm sq.

THE RATE IS 200 BPM

(TACHYCARDIC)
3. DETERMINE ORIGIN OF
IMPULSE
P-WAVE IS VISIBLE (BUT
APPEARS ABNORMAL, SOMETIMES
INVERTED) IN SOME LEADS
AND PRECEDES EACH
QRS COMPLEX; IS
INDISTINCT IN OTHER
LEADS
 3. DETERMINE ORIGIN OF
IMPULSE
IN V5 WE CAN SEE THAT
THE P-WAVES HAVE
DIFFERENT FORMS
(POSSIBLY BEING
BURIED UNDER THE QRS
COMPLEXES)

QRS COMPLEXES ARE

NARROW (NORMAL)

HE ORIGIN OF IMPULSE IS SUPRAVENTRICULAR

(SA NODE, AV NODE, ATRIAL)
4. MEASURE THE INTERVALS
RPI: 6 sm sq. or .24s
(normal: not > than PRI)
 QTc=
QTI: 6 sm sq. or .24s
=
= 0.43
PRI: 2 sm sq. or .08s QRS: 2 sm sq. or .08s
(normal: 0.12-0.22) (normal: <0.12)
(normal: ≤0.47 in women)
RR: 7.5 sm sq. or 0.3s

SHORTENED PR
INTERVAL
LONG RP INTERVAL
5. DETERMINE AXIS
The axis is between 0 and 90°
Normal axis is -30° to +110°
net (+) deflection in Lead I

NORMAL AXIS /
NO AXIS DEVIATIO
net (+) deflection in avF
6. CHECK FOR CHAMBER
ENLARGEMENT
ATRIAL ENLARGEMENT:
none (P-waves are neither peaked nor broad)

VENTRICULAR ENLARGEMENT:
LVH: not enlarged by Sokolow-Lyon Criteria, Cornell Criteria
RVH: R-wave in V1 is not tall
7. CHECK FOR
ISCHEMIA/INFARCTION
None.
8. CHECK FOR ARRHYTHMIAS

SUPRAVENTRICULAR
TACHYCARDIA
8. CHECK FOR ARRHYTHMIAS

ELECTRICAL ALTERANS
THIS CAN BE CAUSED BY TACHYCARDIA, PULMONARY
9. CHECK OTHER FINDINGS
Since we have now established SUPRAVENTRICULAR
TACHYCARDIA, let’s check for the most common types.
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ELECTROCARDIOGRAM
FINDINGS

1. PAROXYSMAL SUPRAVENTRICULAR
TACHYCARDIA (PROBABLY AVNRT)
2. ELECTRICAL ALTERANS
MANAGEMENT PRIOR
TO ADMISSION
MANAGEMENT PRIOR TO
ADMISSION
Carotid sinus massage was done by their clinic physician.
Ordered D5W 500cc to be hooked on her at 10cc/hr.
HR still at 170 bpm
Ordered Verapamil 5mg IVTT but still continued the massage.
Before giving the Verapamil, heart rate was rechecked and
turned out to be at 95 bpm and gained consciousness.
She was still rushed to the hospital and eventually had another
episode of dizziness and syncope and was admitted in the ICU.
WORKING DIAGNOSIS
WORKING DIAGNOSIS
1. Paroxysmal Supraventricular Tachycardia, probably AV
Nodal Reentry Tachycardia, with Electrical Alterans
2. Syncope secondary to #1
3. R/O Hyperthyroidism
4. R/O Electrolyte imbalances (K+, Ca++, and Mg
disturbances may predispose to AVNRT)
5. R/O Old Myocardial infarction
CASE DISCUSSION
 OTHER
FACTORS?
 Hyperthyroidis
m
 Electrolyte
Imbalances
 Old/New MI

ATRIA

VENTRICLE
S
 TACHYCARDIA (esp >160bpm) PALPITATIONS

INCREASED MYOCARDIAL OXYGEN DECREASED VENTRICULAR FILLING

DEMAND TIME

CHEST PAIN DECREASED PRELOAD

+ LEVINE’S SIGN
 CHEST PAIN DECREASED PRELOAD
+ LEVINE’S SIGN

DECREASED CARDIAC OUTPUT

DECREASED BLOOD SUPPLY TO THE VASOCONSTRICTION TO DIVERT

BRAIN BLOOD TO VITAL ORGANS

DECREASED BLOOD SUPPLY TO

DIZZINESS SYNCOPE PERIPHERY
 DECREASED CARDIAC OUTPUT

DECREASED BLOOD SUPPLY TO THE VASOCONSTRICTION TO DIVERT

BRAIN BLOOD TO VITAL ORGANS

DECREASED BLOOD SUPPLY TO

DIZZINESS SYNCOPE PERIPHERY

SLIGHTLY PALE
SLIGHTLY
PALPEBRAL
COOL SKIN
CONJUNCTIVA
MANAGEMENT
SHORT-TERM MANAGEMENT
IMMEDIATE MANAGEMENT
Start IV Access (for medications)
PNSSiL at 10gtts/min (KVO rate).
Start O2 at 2LPM via nasal cannula
(may increase if hypoxemic).
Place on continuous ECG monitoring.
Do carotid sinus massage.
Give Adenosine 6mg rapid IV push;
repeat with 12 mg if needed.
Keep emergency cardioversion and
defibrillation available.
SHORT-TERM MANAGEMENT
REFER TO CARDIOLOGIST
ADDITIONAL DIAGNOSTIC TESTS
oTroponin-T and/or CKMB
oT3, T4, TSH
oCBC
oCoagulation tests
oEchocardiogram and/or Chest X-ray
oD-Dimer
o(Once stable) Stress Test
LONG-TERM MANAGEMENT
Educate patient on her condition, and that she might have repeat
episodes in the future.
Educate patient on doing Valsalva maneuvers for future episodes of
chest pain/palpitations.
Educate on avoiding coffee, alcohol, and other possible triggers.
Educate on mental health hygiene to avoid undue stress.
LONG-TERM MANAGEMENT
May take Verapamil 240mg PO PRN for episodes of chest
pain/palpitations.
 Advise patient to consult doctor if chest pain, palpitations not relieved after 1-2
hours.
 Advise patient to consult doctor if she thinks she may be or plans to get pregnant
while on this med.
If feasible, patient may undergo radioablation therapy for permanent
treatment of her condition.
THANK
YOU!
REFERENCES:
Harrison’s Principles of Internal Medicine, 20th ed.
American Academy of Family Physicians: Common Types and Treatment of SVT
ECG and Echo Learning:
https://ecgwaves.com/topic/av-atrioventricular-nodal-reentrant-tachyarrrhythmia-ree
ntry/
Dr. Ebarle’s slides on reading ECG
ACLS Notes
ECG Assessment and Interpretation (Lipman and Cascio)