Dr. Ahmed Abanamy Hospital Nursing Department A Case Study of a Patient

1. Dr. Ahmed Abanamy Hospital Nursing Department A Case Study of a Patient with Supraventricular Tachycardia Prepared by: Armando G. Dawana Jr. (ER Department)

2. Demographic Data Name :Patient A Age : 55 years old Sex :Male Nationality :Saudi Marital Status: Married Date of Admission:December 13, 2012

3. Physical Assessment Skin • pale, cool, diaphoretic, good skin turgor Head • baldness on frontal area , gray in color, no infestation of lesion , skull symmetric Eyes • white sclera, pupils equally round, reactive to light, blinking symmetrical

4. Ears • equally on size and appearance, no discharge Nose and Sinuses • symmetrical appearance, no redness in nasal mucosa, Mouth • lips brownish, dental carries,moist with no lesion, oral mocusa pinkish Neck • no palpable lymph nodes, full of range in motion Breast • nipples are symmetrically equal and slight inverted.

5. Thorax and lungs • clear upon auscultation, thorax is symmetric Upper extremities • bilaterally equal, no lesions, no swelling, can perform complete range of motion Nails • nail beds are pale in appearance, poor capillary refill, and smooth texture

6. Abdomen • slightly distented, soft, positive bowel sound Lower extremities • both extremities are equal in size, same contour with prominences of joints, no edema, color is even, can perform complete range of motion Genitalia • skin of the penis is smooth, no ulceration, no discharge and no palpable masses

7. Patient History • Past Medical History • Patient A has a history of hypertension with daily medication given by his attending doctor. He was diagnosed since 10 years ago in a respected health institution. He was known smoker since he was 20years old.

8. Present Medical History • Patient A was presented in Emergency Department with chief complaint of palpitation, chest pain, dizziness, nausea and profuse sweating. He was conscious, oriented, alert and anxious. Vital signs were checked and humidified oxygen was administered via nasal cannula He was seen by our ER Physician. ECG was taken and seen by physician.ECG rhythm shows SupraVentricular Tachycardia with cardiac output of 158 beats per minute and attached to a cardiac monitor. Intravenous cannulation done and Adenosine 6mg was administered rapid bolus. No changes in rhythm. Repeated dose of Adenosine 6mg was administered rapid bolus. Intravenous fluid was started with Ringer lactate with KVO. No changes of rhythm show in the monitor. Repeated Adenosine 12 mg was administered rapid bolus and the rhythm was converted into sinus rhythm. ECG was repeated and shows Sinus rhythm. The attending physician informed the cardiologist regarding to the patient status. The cardiologist advised the patient to be admitted in CCU.All Laboratory investigation was sent to the Laboratory and Xray chest was done portable in ER. Pt A was shifted to CCU for the further management and was discharged few days later.

9. TOPIC PRESENTATION • Supraventricular tachycardia is a rapid heart rate (tachycardia, or a heart rate above 150 beats per minute) that is caused by electrical impulses that originate above the heart's ventricles. Many physicians include all of the many tachycardia that involve the atrioventricular node (AV node) under this classification, but others do not. Supraventricular tachycardia does not include those tachycardia rhythms that originate from the ventricles (ventricular tachycardias) such as ventricular tachycardia or ventricular fibrillation. Supraventricular tachycardia is also called paroxysmal supraventricular tachycardia and abbreviated either SVT or PSVT.

10. The incidence of paroxysmal SVT is approximately 1-3 cases per 1000 persons. • In a population-based study, the prevalence of paroxysmal SVT was 2.25 cases per 1000 persons, with an incidence of 35 cases per 100,000 person-years. AVNRT is more common in patients who are middle aged or older, while adolescents are more likely to have SVT mediated by an accessory pathway.

11. Paroxysmal SVT is observed not only in healthy individuals; it is also common in patients with previous myocardial infarction, mitral valve prolapse, rheumatic heart disease, pericarditis, pneumonia, chronic lung disease, and current alcohol intoxication. Digoxin toxicity also may be associated with paroxysmal supraventricular tachycardia

12. Sex-related demographics In a population-based study, the risk of developing paroxysmal SVT was twice as high in women as it was in men. • Age-related demographics The prevalence of paroxysmal SVT increases with age. AVNRT is seen more commonly in persons who are middle aged or older, while adolescents usually have SVT from an accessory pathway. The relative frequency of tachycardia mediated by an accessory pathway decreases with age.

13. ANATOMY AND PHYSIOLOGY • The heart is located in the mediastinum, the cavity between the lungs. The heart is tilted so that its pointed end, the apex, points downward toward the left hip, while the broad end, the base, faces upward toward the right shoulder is surrounded by the pericardium, a sac characterized by the following two layers: The outer fibrous pericardium anchors the heart to the surrounding structures. The inner serous pericardium consists of an outer parietal layer and an inner visceral layer. A thick layer of serous fluid, the pericardial fluid, lies between these two layers to provide a slippery surface for the movements of the heart.

14. The wall of the heart consists of three layers: • The epicardium  is the visceral layer of the serous pericardium. • The myocardium   is the muscular part of the heart that consists of contracting cardiac muscle and noncontracting Purkinje fibers that conduct nerve impulses. Cardiac cells (cardiomyocytes) are in this layer. • The endocardium is the thin, smooth, endothelial, inner lining of the heart, which is continuous with the inner lining of the blood vessels.

15. As blood travels through the heart, it enters a total of four chambers and passes through four valves. The two upper chambers, the right and left atria, are separated longitudinally by the interatrial septum. The two lower chambers, the right and left ventricles, are the pumping machines of the heart and are separated longitudinally by the interventricular septum. A valve follows each chamber and prevents the blood from flowing backward into the chamber from which the blood originated.

16. Two prominent grooves are visible on the surface of the heart: • The coronary sulcus (atrioventricular groove) marks the junction of the atria and ventricles. • The anterior interventricularsulcus and posterior interventricularsulcus mark the junction of the ventricles on the anterior and posterior sides of the heart.

17. The pathway of blood through the chambers and valves of the heart is described as follows: • The right atrium, located in the upper right side of the heart, and a small appendage, the right auricle, act as a temporary storage chamber so that blood will be readily available for the right ventricle. Deoxygenated blood from the systemic circulation enters the right atrium through three veins: the superior vena cava, the inferior vena cava, and the coronary sinus. During the interval when the ventricles are not contracting, blood passes down through the right atrioventricular (AV) valve into the next chamber, the right ventricle. The AV valve is also called the tricuspid valve because it consists of three flexible cusps (flaps).

18. The right ventricle is the pumping chamber for the pulmonary circulation. The ventricle, with walls thicker and more muscular than those of the atrium, contracts and pumps deoxygenated blood through the three-cusped pulmonary semilunar valve and into a large artery, the pulmonary trunk. The pulmonary trunk immediately divides into two pulmonary arteries, which lead to the left and right lungs, respectively. The following events occur in the right ventricle

19. When the right ventricle contracts, the right AV valve closes and prevents blood from moving back into the right atrium. Small tendonlike cords, the chordaetendineae, are attached to papillary muscles at the opposite, bottom side of the ventricle. These cords limit the extent to which the AV valve can be forced closed, preventing it from being pushed through and into the atrium. • When the right ventricle relaxes, there is less pressure in the right ventricle and more pressure in the pulmonary trunk. This high pressure in the pulmonary trunk causes the valve to close, thereby preventing the backflow of blood and the return of blood to the right ventricle.

20. The left atrium and its auricle appendage receive oxygenated blood from the lungs through four pulmonary veins (two from each lung). The left atrium, like the right atrium, is a holding chamber for blood in readiness for its flow into the left ventricle. When the ventricles relax, blood leaves the left atrium and passes through the left AV valve into the left ventricle. The left AV valve is also called the mitral or bicuspid valve, the only heart valve with two cusps.

21. The left ventricle is the pumping chamber for the systemic circulation. Because a greater blood pressure is required to pump blood through the much more extensive systemic circulation than through the pulmonary circulation, the left ventricle is larger and its walls are thicker than those of the right ventricle. When the left ventricle contracts, it pumps oxygenated blood through the aortic semilunar valve, into a large artery, the aorta, and throughout the body.

22. The following events occur in the left ventricle, simultaneously and analogously with those of the right ventricle: • When the left ventricle contracts, the left AV valve closes and prevents blood from moving back into the right atrium. As in the right AV valve, the chordaetendineae prevent overextension of the left AV valve. • When the left ventricle relaxes, this results in less pressure in the left ventricle and higher pressure in the aorta. This high pressure causes the aortic semi lunar valve to close, thus preventing the return of blood to the left ventricle.

23. The coronary circulation consists of blood vessels that supply oxygen and nutrients to the tissues of the heart. Blood entering the chambers of the heart cannot provide this service because the endocardium is too thick for effective diffusion (and only the left side of the heart contains oxygenated blood). Instead, the following two arteries that arise from the aorta and encircle the heart in the artioventricular groove provide this function. • The left coronary artery has the following two branches: the anterior interventricular artery (left anterior descending, or LAD, artery) and the circumflex artery. • The right coronary artery has the following two branches: the posterior interventricular artery and the marginal artery.

24. Blood from the coronary circulation returns to the right atrium by way of an enlarged blood vessel, the coronary sinus. Three veins, the great cardiac vein, the middle cardiac vein, and the small cardiac vein, feed the coronary sinus.

25. ETIOLOGY • SVT and paroxysmal SVT are triggered by a reentry mechanism. This may be induced by premature atrial or ventricular ectopic beats. Other triggers include hyperthyroidism and stimulants, including caffeine, drugs, and alcohol. • Paroxysmal SVT is observed not only in healthy individuals; it is also common in patients with previous myocardial infarction, mitral valve prolapse, rheumatic heart disease, pericarditis, pneumonia, chronic lung disease, and current alcohol intoxication. Digoxin toxicity also may be associated with paroxysmal SVT. • PSVT is a caused by short circuit or electrically irritable areas in the atrial tissue. Examples of PSVT include Atroventricular nodal re-entrant tachycardia (AVNRT), atrial Flutter, Focal Atrial Tachycardia and Wolff-Parkinson-White Syndrome.

26. AVNRT arise from malfunctioning of the AV node. In most people, the AV node conducts impulse along a single pathway. In AVNRT, a second pathway exists, giving rise to a potential short circuit driven rapid heartbeat. • Atrial Flutter (AF) is an abnormality of the heart rhythm , resulting in a rapid and sometimes irregular heart beat. It occurs when electrical impulses take an abnormal path through the atria, typically circulating around the tricuspid valve in the right atrium. More unusually atrial flutter can also arise in the left atrium after atrial fibrillation or following cardiac surgery on the mitral valve.

27. Focal atrial tachycardia arise from single site within the left or right atrium, in contrast to atrial flutter and atrial fibrillation, which involve mltpile sites or larger circuits. • Wolff-parkinson-white syndrome or wpw syndrome, is the presence of extra, abnormal pathway in the heart, between the atria and the ventricles, that leads to periods of a very fast heart beat.

28. Causes • Paroxysmal (also termed sporadic) supraventricular tachycardia usually occurs without other symptoms. However, it may be associated with a number of medical conditions, such as the following: • Hardening of the arteries (atherosclerosis) • Heart failure • Thyroid disease • Chronic lung disease • Pneumonia • Pulmonary emboli, or blood clots migrating into the lung arteries from elsewhere in the body • Pericarditis • Certain drugs and social habits • Cocaine abuse

29. Alcohol abuse • Smoking • Drinking too much caffeine in coffee, tea, or soft drinks • Emotional stress • Pregnancy • Structural abnormalities, such as Wolff-Parkinson-White (WPW) syndrome, in which extra electrical tissue sets up abnormal electrical circuits that predisposes the heart to arrhythmias which include PSVT, A fib, AF, and ventricular fibrillation • PSVT may also occur as a side effect of medications such as digitalis, asthma medications, or cold remedies. • In some cases, the cause of PSVT is unknown. PSVT is the most common arrhythmia in infants, children, and pregnant females.

30. SIGN AND SYMPTOMS • PSVT can cause a number of symptoms, depending on a person's overall health and how fast their heart is beating. People with heart damage or other coexisting medical problems experience a greater degree of discomfort and complications than those who are healthy. Some people have no symptoms at all. • Symptoms can come on suddenly and may go away by themselves; they can last a few minutes or as long as 1-2 days. The rapid beating of the heart during PSVT can make the heart a less effective pump so that the body organs do not receive enough blood to work normally. The following symptoms are typical with a rapid pulse of 140-250 beats per minute:

31. Palpitations (the sensation of the heart pounding in the chest) • Dizziness, light-headedness (near-faint), or fainting • Shortness of breath • Anxiety • Chest pain or tightness • In infants and very young children, symptoms are sometimes difficult to discern. However, those infants with irritability, poor feeding, sweating, poor coloration of skin, and who exhibit a pulse rate of 200-250 beats per minute may have PSVT.

32. INTERVENTION • Physical Examination • Electrocardiogram (ECG):  The ECG is a painless, quick, noninvasive test that detects the electrical activity of the heart. Through 12 electrodes, or leads, attached to the chest, arms, and legs, tracings or waves are detected and represent the electrical activity of the heart from 12 different views

33. . This allows detection of a number of different kinds of problems in the heart. The ECG can help identify many different arrhythmias including PSVT and in some cases its underlying cause. However, further tests or even therapy may depend on the findings of the ECG.

34. A narrow complex tachycardia or atrial tachycardia which originates in the 'atria' but is not under direct control from the SA node. SVT can occur in all age groups Looking at the ECG you'll see that: Rhythm - Regular Rate - 140-220 beats per minute QRS Duration - Usually normal P Wave - Often buried in preceding T wave P-R Interval - Depends on site of supraventricular pacemaker Impulses stimulating the heart are not being generated by the sinus node, but instead are coming from a collection of tissue around and involving the atrioventricular (AV) node

35. Ambulatory ECG:  By the time a person reaches a medical facility, the symptoms will sometimes have stopped and the ECG will be normal. This is frustrating to the patient and the doctor because an accurate diagnosis depends on capturing the rapid heartbeat on an ECG. Ambulatory monitoring often solves this problem by monitoring the heart over a period of time, usually 1-2 days. The ambulatory ECG is more likely to document any abnormal heart rhythms that a person may experience. The patient wears the monitor device, called a HOLTER MONITOR, while they go about their daily activities. Patients also keep a diary while wearing the device to allow the health care professional to detect any abnormalities on the ECG recording during times when the patient has symptoms.

36. Echocardiogram (ECHO):  This is a noninvasive ultrasound examination of the heart. A small handheld device is passed over the chest. It transmits pictures (sonograms) of the heart walls and valves to a television screen. It also measures how well the left ventricle is pumping. The echo is used to screen for any problems in the heart structure, valves, or muscles. The echocardiogram is used frequently in patients with SVT's that are irregular, but infrequently in PSTVs.

37. Stress test:  The stress test is an ECG done both at rest and while the heart is under stress, usually with exercise on a treadmill or an exercise bicycle. If a patient cannot exercise, they can be given a drug that will temporarily "stress" the heart. This test helps in the diagnosis of coronary heart disease, that is, blockage of the coronary arteries by fatty plaques (atherosclerosis). Coronary heart disease prevents the heart from getting enough blood, and this can cause abnormal heart rhythms. This test is used in some patients who may have stress-induced PSVT and for other heart-related problems, such as poor blood supply to the heart (ischemia).

38. Cardiac catheterization and coronary angiography: If the stress test result is abnormal or if the patient has chest pain, shortness of breath, or loss of consciousness, he or she may undergo cardiac catheterization under local anesthesia to assess disease in the heart and heart valves. Angiography is a type of imaging study that uses a dye in the arteries to highlight blockages and damage. Usually, this test is not done in patients with PSVT unless they have significant risk factors for coronary artery disease and severe symptoms.

39. Electrophysiologic study:  Patients may need this test if they have rapid heartbeats, but their body does not tolerate treatment, or if the heart has created new electrical pathways that contribute to the abnormal rhythm. This test involves placement of several pacemaker electrodes into the heart chambers to record electrical activity. The electrodes are placed via a catheter that is threaded through the veins to the heart, under local anesthesia in the cardiac catheterization lab. This test is rarely used in patients with PSVT.

40. Lab Tests Blood tests may be performed to rule out thyroid disease and evidence of heart muscle damage due to coronary artery disease. Urine tests and additional blood tests may be performed to rule out abnormal levels of drugs or illegal drugs that can cause rapid heartbeat.

41. TREATMENT • Vagal maneuvers:  Coughing, holding the breath, immersing the face in cold water, and tensing abdominal muscles as if having a bowel movement are called vagal maneuvers because they increase the tone of the vagus nerve on the heart. Increased vagal tone stimulates release of substances that decrease the heart rate, which in some people, can break the abnormal electrical circuit and stop PSVT.

42. Carotid massage: Carotid massage can release chemicals to slow the heart rate. Carotid massage is generally limited to young, healthy people because older people are at risk for stroke. In the emergency department, the patient will be connected to a heart monitor because the decrease in heart rate can be dramatic. Carotid massage involves gently pressing and rubbing the carotid artery located in the neck just under the angle of the jaw.

43. Medications: ADENOSINE Indication : • First drug for most forms of stable narrow complex SVT. Effective in terminating those due to reentry involving AV node or sinus node. • Diagnostic manuever : stable narrow-complex SVT

44. Precautions / Conraindications • Contraindicated in poison/drug induced tachycardia or second- or third- degree heart block • Transient side effects include flushing, chest pain or tightness, brief periods of asystole or bradycardia, ventricular ectopy. • Less effective( large doses may be required) in patients taking theophylline or caffiene. • Reduce initial dose to 3mg in patients receiving dipyridamole or carbamazepine, in heart transplant patients, or if given by central venous access.

45. If administered for irregular, polymorphic wide-complex tachycardia/VT, may cause deterioration(including hypotension) • Transient periods of sinus bradycardia and ventricular ectopy are commonafter termination of SVT. • Safe and effective in pregnancy.

46. Give Adenosine 6mg as rapid push in a large vein over 1 second . Follow with 20ml saline flush and elevate the arm immediately. • If doesn’t not convert within 1-2 minutes, give a 2nd dose of Adenosine 12mg rapid push following same procedure above. Adenosine may cause bronchospasm; therefore , Adenosine should not be given to patient with asthma.

47. If adenosine is unsuccessful other medication can be used: • Calcium channel blockers Diltiazem Indication • a calcium-channel blocking agent used to produce peripheral and coronary vasodilation in the management of heart disease. It can decrease the rate. Adverse effect • Dizziness • Heart failure exacerbation Contraindication/ precaution • Avoid in patients with Wolff-Parkinson-White syndrome or wide complex tachycardia. • Closed monitoring of blood pressure. Dosage: 0.25 mg/kg intravenous bolus.

48. Verapamil Indication • It works by relaxing the muscles of your heart and blood vessels. • used to treat hypertension (high blood pressure), angina (chest pain), and certain heart rhythm disorders. Adverse effect • fast or slow heartbeats; • feeling like you might pass out; • fever, sore throat, and headache with a severe blistering, peeling, and red skin rash; • restless muscle movements in your eyes, tongue, jaw, or neck; • feeling short of breath, even with mild exertion; • swelling, rapid weight gain; or • nausea, stomach pain, low fever, loss of appetite, dark urine, clay-colored stools, jaundice (yellowing of the skin or eyes). Less serious side effects of verapamil may include: • constipation, nausea • skin rash or itching • dizziness, headache, tired feeling • warmth, itching, redness, or tingly feeling under your skin.

49. Contraindication • Severe left ventricular dysfunction. • Hypotension (less than 90 mm Hg systolic pressure) or cardiogenic shock. • Sick sinus syndrome (except in patients with a functioning artificial ventricular pacemaker). • Second- or third-degree AV block (except in patients with a functioning artificial ventricular pacemaker). • Patients with atrial flutter or atrial fibrillation and an accessory bypass tract (e.g., Wolff-Parkinson-White, Lown-Ganong-Levine syndromes). • Patients with known hypersensitivity to verapamil hydrochloride. Dosage: Adults, initial: 5-10 mg (0.075-0.15 mg/kg) given over 2 min (over 3 min in older clients); then, 10 mg (0.15 mg/kg) 30 min later if response is not adequate. 1-15 years: 0.1-0.3 mg/kg (2-5 mg, not to exceed 5 mg total dose) over 2 min.  If response to initial dose is inadequate, it may be repeated after 30 min, but not more than a total of 10 mg should be given to clients from 1 to 15 years of age. Infants, up to 1 year: 0.1-0.2 mg/kg (0.75-2 mg) given as an IV bolus over 2 min.

50. Digoxin Indication • slowing the heart rate and strengthening the heart contractions. • helps slow the heart rate by reducing the number of electrical impulses that pass through (but do not originate in) the atrioventricular (AV) node into the lowerheart chambers (ventricles). Adverse effect • Confusion. • Nausea. • Loss of appetite. • Visual disturbances. • Slow (bradycardia) or rapid (tachycardia) heart rates.