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- Education with Integrity
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- The Trouble with Sinus Tachycardia
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Sometimes recognizing sinus tachycardia can give us fits. One of the most basic rhythms? The discussion that follows will highlight some of the difficulties sinus tach can present at high rates. The pitfalls of using the generalized term "SVT" will also be discussed.
This discussion is not meant to imply that this issue is easy to navigate. It can get very difficult, and very dicey. The consequences of misinterpreting the rhythm and missing sinus tach can have very deleterious effects for our patients. We are all good at recognizing sinus tachycardia at rates between , but when rates exceed it seems to become problematic.
Is it difficult to recognize this? When sinus tachycardia occurs at high rates, our ability to correctly differentiate it from other types of SVT apparently decreases. P waves start to blend into the T waves. Instead of talking about discreet stand alone P waves, we talk about "notches" and "bumps". We know what sinus tach is: Block down the AV node, and the dysrhythmia terminates. Quite a bit different from sinus tach. Different mechanisms, different treatments.
Several case studies involving the above strips and ones like it have appeared on our FB page, and the FB pages of other EMS educational sites. What we have seen is that an alarming number of folks incorrectly identify sinus tachycardia as one of the other SVTs and want to treat with Adenosine or cardioversion.
Consider this rhythm strip that appeared on our page and another educational paramedic page: The patient was a sick adult male, hypotensive. P waves are subtle, but they are there. Here is the followup ECG taken a couple of hours later. The patient was severely dehydrated and had received a few liters of fluid: Now that the rate has slowed, sinus tach is clearly visible. While we are discussing this, we should be clear about our terminology. Sinus tach is one of the Supraventricular Tachycardias.
They will generally be narrow tachycardias, unless aberrant conduction is present. What are we even taught about SVT? Generally speaking these days, when students are taught SVT they are taught that a narrow tachycardia faster than or is "SVT". How do we differentiate sinus tach from SVT?
If you were taught that, raise your hand. While we are on the subject, where did the rate limit of or come from? There does not seem to be any research I can find that even suggests that these numbers can be used to differentiate ST from other SVTs.
In fact, I could not find any research that demonstrates that absolute rate plays any part in differentiating ST from other SVTs. All I could find is references to the guideline used to determine the theoretical maximum sinus tachycardia in healthy people: It intends to illustrate that very young people can have ST at very high rates, and that as we age, it should be more difficult to achieve higher rates of sinus tach.
However, we deal with really sick patients, and theoretical guidelines are not good enough to help us with this issue. What I know is what you all know. Whether or not P waves are visible does not seem to factor into the equation. Sinus tach commonly exceeds rates of , and P waves are often discernable.
More on this in a bit. And these comments were made by the medics who are motivated enough to visit educational sites and participate. The result of this is that too many medics are not correctly trained to deal with this issue. Sinus tach is unrecognized. For staters, they may receive an inappropriate treatment.
A sick patient in sinus tach does not need to go through trials of adenosine, or even worse, cardioversion.
Education with Integrity
One of the most overlooked consequences of mistreating this rhythm is the fact that these patients are not getting the treatment they really need. These patients need lots of fluids. If medics are giving drugs and electricity, they certainly are not administering large boluses of NS.
It is easy to imagine how difficult the choice may seem. The sick patient in sinus tach will look shocky. He may have palpitations or chest pain, and may be altered. In other words, it will be very tempting to attribute the patient presentation to rate problem, even though the rate is compensating for their underlying medical issue.
Without a sound understanding of what sinus tachycardia really is, and what rate ranges are reasonable, it becomes much more difficult to make the right choice. Probably right about now, some of you will want to blame ACLS for all of this.
What does that mean? What it seems to mean to a great many people is that a rate greater than is "SVT". If the patient appears unstable, we are performing synchronized cardioversion by box 4. There is no mention of sinus tach anywhere on this algorithm. Here, if the tachycardia is narrow, you are directed to one of two boxes which require you to assess for the presence of sinus tachycardia.
I believe that a box like this in the adult algorithm would help clear up a lot of confusion. These are systemic conditions, not cardiac conditions. Sinus tachycardia is a regular rhythm, although the rate may be slowed by vagal maneuvers.
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It is a shame that fact is not reflected on the algorithm itself, because evidently a very large number of ACLS students do not read the manual and may incorrectly assume that rate is the determining factor. We brought in two well known electrophysiologists, Dr.
Readers of our blog will recognize them as past contributors and experts in their field. Normally a 30 year-old would have a max of But with the variation, ST could be as high as I see tons of patients for 'tachycardia', that's supposedly abnormal.
The Trouble with Sinus Tachycardia
Often its just ST. The short answer is that human heart rates vary quite a bit—at the high and low end. Adrenaline can easily push the sinus rate above Stress, anxiety, fever, dehydration, drugs, heat, and many other things can do this. If a patient has upright p-waves and the diagnosis is ST and is unstable, it's not because of a primary electrical disturbance. ST is a sign not a primary arrhythmia. Patients with ST should be resuscitated, but not with shocks, with fluids, oxygen and rest perhaps and comfort perhaps.
Perrin for his thoughts about using a rate of as a cut-off between sinus tach and other types of SVT and he had this to say: The septic, those in congestive cardiac failure, people with pulmonary emboli, hemorrhaging patients, etc, etc… all of these could hit heart rates of or higher.
It is an easy diagnosis to make as well — because the P will always be present. I asked if he had any first hand experiences with it: I have misgivings about this, especially for narrow-complex rhythms. We live in a city. ERs are close by. Why shock so quickly? There's some data that shocks harm the heart. As always, peer sourcing is great way to gain additional insight and expertise.
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Hopefully this discussion has been educational for those who thought that was any kind of limit for sinus tachycardia. The fact of the matter is that sinus tach at rates between not only exists, but is not uncommon.
We need to be better at assessing for sinus tachycardia, because it is the most common SVT. We need to make sure we are doing right by our patients, giving them what they need and keeping them our of harm's way.
We also need to be better educators and providers. They will say, "in the real world, they will know what to do". From what I have seen, it doesn't work like that. Providers fall back on what they were taught, which often happens to be incorrect. It begs the question, why are we teaching something we know is not correct?
That can't be good for anyone. For those who didn't know this information before, you know it now. Let's see if we can change the way we educate and provide care in this area. It seems to be a deeply rooted problem, ingrained in decades of education.