SimFridays - supraventricular tachycardia

Today we were in resus for a run through of how we would assess, investigate and treat an adult patient presenting in SVT. We looked at the decision making that is required to safely and efficiently manage their care.

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The simulated case: 
A 66 year old male, who noticed a sudden onset of palpitations at home this morning, approximately 3 hours ago. He’s feeling subjectively unwell, though denies any pain. He’s never felt like this before. He has a background of hypertension - controlled with an ACE inhibitor - and smokes around 10 cigarettes per day. 

He arrived by ambulance, and as a result of his fast heart rate was directed straight to resus, where the sim team took over. 

What happened?
Steven was only complaining of a pounding sensation in his chest and feeling “unwell”, though couldn’t elaborate much further. His 12 lead ECG showed narrow complex regular tachycardia with absent P waves, suggestive of an SVT. 

​Following an ABCDE assessment, it was decided the best course of action was to attempt vagal maneuvers. A modified valsalva maneuver was demonstrated, and unsuccessful. The team then moved onto adenosine, which was also unsuccessful in restoring sinus rhythm.

Steven then started to feel light-headed and developed an aching sensation across his chest. 
In the process of preparing sedation for a synchronised DC cardioversion, Steven’s blood pressure dropped to 65/30 and he lost consciousness. 

An emergency synchronised DCCV was performed, restoring sinus rhythm. 

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What did we think? 
In debrief we discussed:

Treatment strategies:
“Adverse features” that are essential to assess for are:
Myocardial Ischaemia
Shock
Syncope
Heart Failure

These can indicate the need for DC cardioversion. 
An effective ABCDE assessment and primary survey of the acutely ill adult, coupled with effective history taking is therefore key to managing this case. As with all situations, the ground can shift and regular reassessment is essential. 

Non-technical skills:
We discussed decision heuristics and non-technical skills in the context of a stressful and rapidly changing scenario. The effective use of mini-summaries really helped the team share the mental model and understand the direction the case was progressing in. 

Situations where decision making needs to be challenged were reviewed, and we talked about speaking up using the PACE format:
Probe - “are you sure about…”
Alert - “don’t you think this will cause…”
Challenge - “I’m afraid this is going to harm the patient…”
Emergency action - “STOP what you are doing! I will get help…”

The guidelines:

ALS Tachydysrhythmia Guidance: (See original quality version here)

​REVERT team discussing the Modified Valsalva Manoeuvre: (original link here)

To do:
RCEM learning on SVT here  [ ]

If you took part in the sim, you can use this blog as a starter to reflect on your own experience of it   [  ]


Blog by: Joey Giles, Senior Advanced Clinical Practitioner

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For clinical decisions please refer directly to the guidance. This blog may not be updated. All images copyright- and attribution-free in the public domain or taken by the author.