Slide 1: 30yo F with palpitations x3 hours. In the ED, HR=206, BP=110/70. [EKG] Management of this patient?
Slide 2: Psst…it’s a narrow complex tachycardia! Rhythm? Irregular (afib, a-tach/a-flutter, variable block MAT) or regular? It’s regular! -> P waves? Present (long RP interval – sinus tach, A-tach, atypical AVNRT/AVRT, junctional; short RP interval – AVNRT, AVRT) or absent? It’s absent! -> AVNRT, aflutter, AVRT, or junctional
Slide 3: Let’s check our work. [EKG shows tachycardia (HR>100), narrow complex (QRS<120ms), absent p waves] DDx: AVNRT, AVRT, junctional rhythm, A-flutter
Slide 4: BP stable but patient tachycardic. What now? In SVT, vagal maneuvers are first-line therapy. Valsalva maneuver x10-30sec, carotid massage (after rule-out bruit!), ice-cold water to face (immersion or towel).
Slide 5: Bonus: try the modified valsalva! [Gif of modified valsalva] Evidence? REVERT trial (2015). Methods? RCT – 433 ED patients with SVT. Outcomes? Std valsalva: 17% converted to sinus; Modified: 43% converted to sinus.
References
- Page RL, Joglar JA, Caldwell MA, et al. 2015 ACC/AHA/HRS Guideline for the Management of Adult Patients With Supraventricular Tachycardia: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society. Circulation. 2016 Apr 5;133(14):e471-505. Epub 2015 Sep 23. PMID 26399662
- Appelboam A, Reuben A, Mann C, et al. Postural modification to the standard Valsalva manoeuvre for emergency treatment of supraventricular tachycardias (REVERT): a randomised controlled trial. Lancet. 2015 Oct 31;386(10005):1747-53. PMID 26314489
Tags: absent p waves, cardiology, carotid massage, ice-cold water to face, modified valsalva, narrow complex tachycardia, narrow QRS, palpitations, regular rhythm, REVERT trial, supraventricular tachycardia, SVT, tachycardia, vagal maneuvers, valsalva