I seem to be having a run of stable patients in SVT lately in the urgent care I work at. We've always gotten an EKG, established IV access, tried vagal maneuvers and generally called 911 and had these folks transported to the ER. But a large proportion of the time, they are converted en route by EMS with adenosine - the ER then checks some basic labs and discharges them home. It occurred to me the other day that we could really do all this in UC. We have adenosine, labs, xray, etc. Am I being naïve to think these patients can be managed in UC (assuming successful conversion with adenosine and no significant comorbidities)? Would you ER folks rather have them in your building? Granted, this is probably a moot point anyway in that 90% of the physicians I work with are FP and their eyes would pop out of their heads if I even suggested pushing adenosine. I'm prior EMS and every time one of these folks walk through the door I'm itching to push it.
Treating SVT in urgent care
Posted 20 April 2017 - 02:08 AM
I too have an EMS background and I work in a cardiology office where we have all the drugs and equipment to do things like you mentioned. But we generally don't except in a true emergency.
Our office stops when we have to focus on one patient. We'll do it in an emergency, but prefer to get help so we can take care of our other patients too. Medic 8 is a half-mile up the street; one call and 2 to 6 nice folks show up to help and transport while we call the hospital and let them know what's on the way.
It's something like how floors differ in a hospital. On some, the staff can titrate IVs and manage vents while on other floors they can't. This is not so much because the nurses don't know how, but because the provider-to-patient ratio doesn't permit the attention to detail that would be required.
Hope this helps!
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Posted 20 April 2017 - 02:20 AM
I worked at a 24 hr urgent care for a while that functioned like a freestanding ED. we gave adenosine (and Cardizem for afib w rvr), but didn't proceed to cardioversion unless unstable. all the folks we converted still went to the hospital after for enzymes, etc.
my vote would be to give it if it does not delay transport. really no downside to adenosine.
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Emergency Medicine PA, EMT-P
Doctor of Health Science & Global Health
30 years in Emergency Medicine
Posted 20 April 2017 - 01:52 PM
Emed - I'm with you. I don't know why the drug scares my docs so much. Half life is 10 seconds, that sucker is gone before you can blink. Instead we stand around and wait for 5-10 minutes and hand the patient off to two guys who are going to push it in the back of a big truck. Makes no sense to me. We actually have POCT for enzymes (plus other basic labs) where I work. So theoretically we can run all the basic labs I see the ER run for these patients.
Posted 20 April 2017 - 11:42 PM
Knowing you mission and practice is key, you are not an ED practice. Soooooo, doing "Emergency Department" procedures is OK if there's no complication? BUT if one happens, you are up the creek w/o a paddle! Especially if all of the practice physicians aren't 100% behind your actions!!! I think that staying in your lane is best for you and your patients , don't let ego sink you.
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Posted 21 April 2017 - 12:05 AM
points to make
1-just because you can do something doesn't mean you should
2- is malpractice aware of you doing conversions in urgent care (more ED level)
3-the people in the waiting room came to an UC not ER and don't expect to be told to wait an extra 1-2 hours while you run this
4-let EMS handle it... yup back of a rig is not as good as ER, but UC is likely even worse when something goes wrong...
it is okay to realize where you fit in the system.....
all the above is fine if EMS is close and ER close
if you are hours away, remote.... well thats different...
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I vote for a Full Practice Authority and staged independent practice.
MBA, MS, PA
Posted 21 April 2017 - 09:54 AM
I'll carry on doing what we're doing. Appreciate the reality check.
Posted 21 April 2017 - 10:00 AM
Posted 21 April 2017 - 11:50 AM
Another comment from the stone age. Late 80's while in cardiology, we used to do conversions at a patient's bedside on the telemetry floor in our hospital (professional building was blended in with the hospital so we could walk 30 steps and be in the elevator to go to any floor in the hospital). Brevital was the anesthetic of choice.
Posted 21 April 2017 - 12:31 PM
I vote for ED. Adenosine is a well tolerated drug that works wonderfully in SVT. That said, even the best of us has been fooled by an afib w/ RVR that appeared regular-ish enough to pass for SVT. Giving Adenosine to a WPW, fib, aflutter or any polymorphic rhythm etc can quickly lead to hemodynamic collapse. I would ask if your UC is equipped to run a resuscitation? If not, they should go to the ED.
I would definitely advocate for vagal maneuvers in the meantime however; the latest and greatest:
Posted 22 April 2017 - 01:47 AM
I had read about the modified vagal maneuvers in SVT a while ago. Hadn't had chance to try it... until today.
30's male with crushing chest pain, pale, diaphoretic and a heart rate well north of 240. Modified vagal maneuvers as described above dropped him down to the 80s in less than 30 seconds... before his line was even secured. We didn't give adenosine at all. He stayed in a regular sinus rhythm after conversion, too. Not sure what happened to him as he was signed out pending lab results and a cards consult. But I was floored that it actually worked.
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