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DogLovingPA

Treating SVT in urgent care

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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. 

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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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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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UGoLong, your explanation does makes sense in that one patient may pull resources for a bit from the other 8 folks sitting in my waiting room. Generally EMS is close, we have one office where it can take awhile (took them 30 min to get to me once with a pediatric status asthmaticus - almost just threw her in my car and drove her myself).

 

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.

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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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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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You guys make some good points. That's exactly what I wanted to know - am I just getting ahead of myself because I miss riding the ambulance from time to time and being naive in how things can go wrong. And I agree with you Ventana - I'd rather be in the back of an ambulance if things go wrong. Those guys run codes, my docs do not (not a knock on my docs, the are great but are FP and haven't seen a code since residency).

 

I'll carry on doing what we're doing. Appreciate the reality check.

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Ps. CAdams, I would never actually push adenosine with out the doc I'm on with knowing and okay with it (which would never likely happen so my original question was more hypothetical really in wondering if it was ridiculous to think I could do such a thing). Our team is always 1 PA, 1 doc and while we see pts independently we usually have a pretty good idea of what the other one is doing most of the time. Plus, they have to sign off real time on any EKG I get.

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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.

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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: 

 

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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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