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The Curbsiders Internal Medicine Podcast
#473 Rapid Response Series: Narrow Complex Tachyarrhythmias with Dr. Noble Maleque
01:02:36
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- [00:00]
Podcast Announcer
Hey, before we get to the show, I wanted to remind you to check out our patreon@patreon.com curbsiders. If you haven't signed up yet, sign up now to get ad free episodes, twice monthly, bonus episodes, and a whole bunch of other cool stuff@patreon.com curbsiders.
- [00:18]
Dr. Noble Malik
How did George Washington's parents know that he wasn't going to be a cardiologist when he grew up? I don't know, because after he cut down that cherry tree, he couldn't tell if fiber.
- [00:35]
Dr. Moni Amin
Noble Moloch for the win.
- [00:41]
Podcast Disclaimer Voice
The Curbsiders podcast is for entertainment, education and information purposes only, and the topics discussed should not be used solely to diagnose, treat, cure or prevent any diseases or conditions. Furthermore, the views and statements expressed on this podcast are solely those of those and should not be interpreted to reflect official policy or position of any entity aside from possibly cash. Like more hospital and affiliate outreach programs, if indeed there are any. In fact, there are none. Pretty much. We aren't responsible if you screw up. You should always do your own homework.
- [00:58]
Dr. Noble Malik
And let us know when we're wrong.
- [01:06]
Dr. Moni Amin
And welcome back to curbsiders. I'm Dr. Moni Amin, joined by my eternally effervescent co host, Dr. Meredith Trubitt. How are you this evening?
- [01:13]
Dr. Meredith Trubitt
Doing well, Moni, Thanks.
- [01:15]
Dr. Moni Amin
On tonight's show, we're gonna discuss the management of acute tachyarrhythmia's narrow complex with our hospitalist guests, dear friend of the Curb legend, Dr. Noble Malik. I'll remind you a little bit about him here in a second as well as the topic. But first, Meredith, will you please remind the good people in the audience what it is we do on this show?
- [01:35]
Dr. Meredith Trubitt
Sure, Moni. We are the Internal Medicine Podcast. We use expert interviews to bring you clinical pearls and practice changing knowledge. Before we jump to our bio for our guests, we just wanted to plug an episode on atrial fibrillation that Matt and Paul did, episode 363. So check that out. It goes into a little bit more depth on how to outpatient management for atrial fibrillation, and we're focused a little bit more on the inpatient rapid response situation. So hoping to hit on some of those pearls for the hospitalists.
- [02:03]
Dr. Moni Amin
Yeah, we had a great conversation with our guest, Dr. Noble Malik, who is an Associate professor in the Division of Hospital Medicine based at Emory University and his site is Hospital EUH Midtown. He also serves as an Associate Program Director for the J. Willis Hurst Internal Medicine Residency Program and is a small group advisor for the medical students at the Emory School of Medicine. And after graduating from Vanderbilt and before they were up to date, he completed his residency and chief residency at the University of Washington, Seattle. He spends most of his off time with embarrassing his two daughters and he really does welcome any thoughts and prayers about raising a teenager.
- [02:39]
Dr. Meredith Trubitt
And before we get started tonight, just a quick disclaimer on this episode. Obviously we're talking a lot about rhythm strips and EKGs, which are not always the most audio friendly. So please go and check out like the show notes and episode guide for this specific episode as we'll have some of those outlined in there for you guys to review as you're listening to the episode. So we'll get started.
- [03:00]
Dr. Moni Amin
A reminder that this and most episodes will be available for CME credit for all health professionals through VCU health@curbsiders.vcuhealth.org.
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Podcast Announcer
All.
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Dr. Moni Amin
Right, Noble, welcome back. We're going to start with the lightning round, the fast question thing. Can you remind us a hobby or an interest outside of medicine?
- [03:24]
Dr. Noble Malik
I really like watches and I reason like watches is because there's like a narrative and a story behind them all. That's something that I picked up maybe a few years ago. It's an expensive hobby. I mean, calling it a hobby makes me feel better about myself, but it's not really a hobby, more of an interest. I like to do deep dives on kind of YouTube videos and stuff to learn more about watches.
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Dr. Moni Amin
Oh man, I love watches so much. I have tried the Apple Watch thing a couple times only to remember that I love watches. So that that's actually not a great plan. So I hear you.
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Dr. Noble Malik
I have Apple Watch for just convenience sometimes, but I don't enjoy it.
- [04:06]
Dr. Meredith Trubitt
When you say watch as a hobby though, like, you mean like Apple Watch?
- [04:11]
Dr. Noble Malik
No. Yes. I mean watches that have dials and complications. And I think the best ones are the ones where they don't have batteries and they just kind of work. And I have windable ones which I like actually because I feel like a connection to the watch. And honestly with automatic ones you have to keep them on you or otherwise they run out.
- [04:34]
Dr. Meredith Trubitt
Yeah, I'll just say like I have both of my Grams watches from like after they died. Those are like, like what I kept from their house to like remember them by. So it's a very special. But I'm not a hobbyist. Like I don't know anything about like how the watch works or anything.
- [04:50]
Dr. Noble Malik
Yeah, but you have a connection to them. That's what's neat, I think. Yeah, and, you know, there's. There's this book which. Called Amanda's Watch, which is about stories related to people and their watches, which is a good read regardless of whether you like watches or not. It just kind of goes along with the connection that people can have.
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Dr. Meredith Trubitt
All right, should we do some picks of the week?
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Dr. Moni Amin
Yeah.
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Dr. Meredith Trubitt
Why don't you go first?
- [05:11]
Dr. Moni Amin
Yeah. Meredith can attest to the fact that I've been very excited about my pick of the week for a few weeks now. I got a Ninja slushie. Curbsiders is not sponsored by Ninja, but maybe they should be. It is a slushie maker, and I know everyone's like, I don't need another blender. You don't need one. There's no ice involved. You just put in your sugary drink, and it does its magic, and it's amazing. And I have made a mango Lassie slushie, which went swimmingly well at a Diwali party. Cherry Wild Cherry Pepsi slushie, which we won't talk anymore about, given when I consumed it. And then what else have I made? Milkshake, chocolate, vanilla, you know, so Ninja Slushie, Just one of those luxurious appliances that I don't need, but I'm really glad I have Meredith. What's your pick of the week?
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Dr. Meredith Trubitt
So I think that I'm going to go with. I was recently in Seattle to see family, and we ventured to the Seattle Zoo, which I don't think it, like, it's necessarily like how, like, the San Diego Zoo is, like, reputable and everything. But what was interesting to me is they have completely different animals because, like, the climate is different and all these things. And so we got to see snow leopards that had just had these cubs and everything, and they were very fun. But the entire zoo seemed like a completely different place than the Atlanta Zoo, which has all of the savanna and the African animals, mostly, plus pandas usually, although the pandas are on hiatus right now. Another convo for a different day. But in Seattle, it's a lot of Asian, like, northern kind of animal.
- [06:57]
Dr. Moni Amin
So it just.
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Dr. Meredith Trubitt
It was cool. I enjoyed it. And they do all these, like, art lantern exhibits, like, this time of year, so they had all that set up, too. So shout out to the Seattle Zoo. And then we went and got some poke afterwards, which also very good poke because it was actually traditional Hawaiian poke.
- [07:14]
Dr. Moni Amin
I'm probably fresher.
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Dr. Meredith Trubitt
Yeah.
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Dr. Moni Amin
Yep. Well, that sounds lovely. And. And just like to be one with nature and. Or animals. Zoos aren't really natural, I guess, but here we are Anywho, I think that means we're ready for our first case, so I will take us there. So, Noble, you're on call. You get a page. There's a rapid on one of your patients in room 6C126, and your patient, Mr. Jason. And all you get on your pager, because apparently we're still using pagers, is that the patient's heart rate is 180 and a callback number. And so you get your phone and you're like, walking towards the patient's room to call the nurse. I think in these situations, I think it's always good to have a kind of a checklist of questions you want to ask the nurse as you're sort of making your way to the patient. And so I was kind of curious, like what. Like, what are those questions that you like to have addressed as you're sort of trying to figure out what to do next?
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Dr. Noble Malik
Sure. I would say the first two questions would be one, how are they doing? How is Jason, Mr. Jason doing? And then two, their vital signs. That would be the first two things I would ask right off the bat, as we're trying to get a sense of where we are and potentially what we need to do next. So I would ask about. If they don't give you all the vitals. I think all vitals really are important. Temperature, they're having a fever, their respiratory status, and obviously their blood pressure to go along with their heart rate would be the first two things I would ask after that, assuming that I'm not like, the answers from the nurse that'll make me start running, then I would ask how things were earlier. And then kind of in preparation for my arrival, I'd like to know more about, you know, can we. If the patient was already on telemetry, could they be on telemetry? Could we get a rhythm strip? Have we call for an ekg? It would be some of the kind of logistical things that can get started before I get there, including IV access and seeing what kind of access they have.
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Dr. Moni Amin
Yeah. For access, how important is it for it to be central versus peripheral in this situation?
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Dr. Noble Malik
Well, I think the first thought would be what types of medicines. And I know go through that, but you want the medicines to get there quickly. So at the minimum, it should be as large of a bore as possible. I don't think it has to be central line. Peripheral, I think is completely adequate. In fact, sometimes peripherals can be better in order to get the medicine to where they need to be quicker. So an 1820 gauge antecubital is actually better than a PICC line. So that would be really sufficient and adequate if you have a good peripheral.
- [10:04]
Dr. Meredith Trubitt
I think, too, before we go too deep into this, I think it's important to probably just name, like, what we're talking about a little bit here is that you're getting called, and kind of the question at hand is, like, rapid response, how sick is this patient? And that's kind of like the initial assessment that you're, like, going through right now. And I think, at least in my case experience, I feel like sometimes until I see that patient and lay my own eyes on them, it's hard for me to know how sick is sick and to, like, kind of activate those next steps. So I agree, like, getting the information over the phone, like a good set of vitals and everything is kind of your initial steps, but walking into the room is kind of probably your second step to kind of start going down your next pathways. So for Mr. Jason, the say we go in and find out that his, like, initial vitals are blood pressure of 80 over 55, respirations of 22, saturating 90% on room air, and his temp is 98 degrees. So I thought to probably start you now, like, laying eyes on him. You have these vitals, and you're probably a little bit more worried about him. Can we start by maybe just defining what stable versus unstable actually means?
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Dr. Noble Malik
Means, yeah, absolutely. I mean, that's really the crux of the point. Just as you talked about Meredith, as you're thinking from the phone, is this person stable or not? And I think when I think about the unstable patient, that's probably the first branch point we think about hemodynamics. Hypotension would probably be the one that I would think about, along with tachypnea and hypoxemia and then symptomatology, which could be anything from active chest pain to shortness of breath, which might signify heart failure to mental status. And are they speaking to us? How are they interacting? Which was where yourself or the staff could give you some sense of what was going on prior to everything. If they are not experiencing those hemodynamic parameters or those symptoms, chances are you're in the more stable range, which gives you some time to. To pause. And I just want to say, outside of stability, which I think is so important, I think there's also about comfort level. So I think it's a combination of what's stable or unstable for the patient, but also your comfort level and the people around you when you're in that scenario, which I think is really important. And I want to say that whenever I have a situation with tachycardia, I am nervous about it. And I think it's okay. I think it's actually a good type of nervous. But I think one of our roles potentially, as we are trying to counsel our patient or the people around the patient, potentially families, also the staff who are around you to talk out loud and talk about why or why not do you think this patient is stable or unstable and why you're acting in deciding the decisions you're doing next. So, yeah. So before you take a beat, I'll skip a beat and try to move forward with the. With your care plan.
- [13:10]
Dr. Moni Amin
Great pun. I guess I'm, like, wired to point them out now. I actually really liked you kind of talking about the comfort level of the people around you, specifically, like the nurses, because that does kind of play into the triage piece a lot of the time, because, yes, you're nervous in your brain, but you kind of have a plan. But making sure that everyone else that's helping care for the patient's comfortable, I think is just as important, probably more so because of, like, what happens next.
- [13:36]
Dr. Meredith Trubitt
And I think identifying what can actually be done. Sometimes there's barriers for nursing that doesn't exist for the care providers.
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Dr. Moni Amin
Yep.
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Dr. Noble Malik
Yeah. And I think in everyone's local cash lac, you have a sense of what, depending on the location of the patient and maybe the specialty or skill set of the staff involved, whether or not you have to start thinking about triage location. So that's another thing to think about. And also, I'm sure it impacts comfort level of the nurses and other people in the room.
- [14:13]
Dr. Meredith Trubitt
I think before we go on, just want to kind of maybe make a note here. So patient, let's say for him, who is unstable, like we're talking about him, kind of then going down a very specific algorithm on the, like, aha guidelines. The murky part of the situation is really when they're stable. And so we're going to kind of spend more time talking about that. I don't know if you have anything else noble you wanted to add, though, for the unstable patient, outside of what's kind of provided through the algorithm.
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Dr. Noble Malik
No, I think this, once again, the limitations when you're thinking about the possibility of things such as putting pads on patients, cardioversion of patients, that's definitely requires a comfort level. And honestly, I would say myself would require some counsel and consultation to kind of go down that pathway or you use your rapid response mechanisms if they really are in that kind of dire need to do things urgently emergently. But yeah, the pathway is pretty clear. If they're unstable, you're headed towards, towards towards a shock.
- [15:25]
Dr. Moni Amin
I mean it's one of those like do not pass go, do not collect $200 kind of just proceed straight down the algorithm situations. It's also really nice to hear you say noble as someone that more experienced than me that like your knee jerk is like we must call cardiology about what we're about to embark upon.
- [15:41]
Dr. Noble Malik
Oh yeah, of course with new taking, taking photos, having them at of the of the strips or the EKG and having them on standby is a lot easier these days. But we've been lucky to have colleagues that can help in the moment.
- [16:04]
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- [18:28]
Dr. Moni Amin
Okay, so that's an unstable situation. Um, but let's say that we're a little bit luckier and you didn't have to sprint to the room. And the same patient's blood pressure was 120 over 82 and respirations were 18, saturating 94% on room air and had a normal temp. He's not having any chest pain or shortness of breath or palpitations. He seems like he's mentating about his baseline per his nurse who's had him for a few days. So you get an ekg, and because you're much better at this than I am, you identify a narrow, complex tachycardia. So before we get too far into the what next part, can you kind of define what a narrow complex tachycardia or narrow complex tachyarhythmia is?
- [19:10]
Dr. Noble Malik
Sure. I mean, the tachyarrhythmia part is the heart rate, and usually we think about it anywhere over 100, but I think when we start to get nervous and when you start getting calls, they tend to be over 140. Probably would be the kind of number I have in mind. And then the QRS complex is what becomes narrow or wide. And traditionally the QRS complex less than 120 milliseconds or three small boxes on a typical EKG is what we think about as a narrow complex. And so when you see the fast heart rate, you see a narrow QRS less than three boxes, that becomes a narrow, complex tachyarrhythmia.
- [19:49]
Dr. Moni Amin
Gotcha. And how important is it for. For me asking for a friend to acknowledge or like, know the exact tachyrrhythmic I'm looking at, because as soon as I start hearing AVNRT or junctional or something at my brain just kind of just does not. It does not compute. So I'm. I'm curious how important that is. And do I just need to, like, buck up and figure this out or, like, what's your approach to that?
- [20:14]
Dr. Noble Malik
Well, I'm coming to this conversation. And you know, as a non cardiologist, a non EP trained physician, but as someone at a hospital where I think we are frontliners and the ones who responded to these, I feel that when you're at bedside, you're not going to be going through pathways with the patient and the nurses when I say calm them down. It's not like giving them an education on accessory pathways. So I think knowing and recognizing AVNRT and AVRT is mostly helpful when you are teaching someone. I don't necessarily think it's as valuable for me at the bedside. That being said, I think the things that I'm looking for are P waves. Are we seeing is it sinus tachycardia or is it not? And I think that is definitely what I feel is one of the key things to figure out, which I also think can be really challenging depending on the heart rate. That's the one. Again, one of the reasons that I get uncomfortable is that that a number of times I have seen rhythm strips that seem to be going so fast where I have no idea if there's a P there or not. And so is it sinus tachycardia or is this a supraventricular tachycardia as you're saying AVRT or avnrt? And the reason I think that's ideally something to differentiate is because we think about sinus tachycardia different, right? We think about the etiology, what's making them that way. We don't usually have to to act quickly or slow them down. We usually can try to figure out what's happening and try to mitigate those things or at least think about those circumstances and see if we can make any adjustments, whether it be pain or fluid status or anxiety or anything else that might be affecting their heart rate. But when something went so fast, you don't know, and something I often will go down the pathway of an SVT just because I really am not sure if I see P waves. The other thing I will say is we've been talking about narrow complex. But yes, figuring out whether this is narrow or wide is also an important differentiation which potentially will change the way you think about the patient and honestly how quickly your comfort level starts to really become more uncomfortable and need some guidance.
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Dr. Meredith Trubitt
So I guess just off of that comment then, we obviously are like trying to keep this to narrow so that we're not here for three hours talking about tachycardias. But I'm assuming that the reason you're making that comment is wide. You might be more concerned about things that need interventions faster.
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Dr. Noble Malik
After you pass the stable or unstable kind of piece when you have wide complex tachyarrhythmias. You're of course being worried about ventricular Tachycardia and whether or not that will quickly become an unstable tachycardia and oftentimes requires different antiarrhythmics that you may not be as familiar with or comfortable using. And I usually will ask for guidance.
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Dr. Moni Amin
On those situations just to make sure that I, like, understand this correctly. So your, your kind of thought process once we get past the stable unstable is like, is this sinus tack, first of all, is it narrow complex? And if it's narrow complex, is it sinus tack or not? Because in sinus tack, you're kind of trying to make sure that you're addressing other potential etiologies. But is it just less likely that there's some other etiology? If it's one of the non sinus tack ones, is that, is that a fair assessment?
- [23:55]
Dr. Noble Malik
Well, I would say the things that might drive a sinus attack can also drive someone to go into a supraerticular tachyarrhythmia. But there are, as we'll talk about, different ways to manage them that might get them out of their tachycardic state. And then we didn't talk about this, but I think the regularity of the complexes are something else that we need to think about is, say, regular tactics tachyarhythmia, or is it an irregular, irregularly regular tachyarhythmia, which also would change your differential for what the rhythm is.
- [24:27]
Dr. Meredith Trubitt
So we were kind of talking about this a minute ago. Where you can see sinus tack, you can't find a P. You don't know if the P is under the T or where anything is. And one time someone told me a joke about electrophysiologists, that you can give them multiple electrophysiologists, the same ekg, and you'll get multiple different answers as to whether there are P waves or not. So which I think is why we're kind of having this episode in the first place, because if they can't figure it out, then I don't know how hospitalists are supposed to know what's going on.
- [24:56]
Dr. Noble Malik
True story. This happened my cash lack last month. Tachyarhythmia. I did take it to three cardiologists. The cardiology fellow, the CCU cardiologist, and then the electrophysiologist. And I got three different interpretations. Yeah, I made me feel good about myself, I'll be honest, because I sheepishly went to them and like, you know, forgive me for showing you the ckg. I'm sure it's so easy. No, I mean, that's the other point. I would like to state to all the hospitals, I think that it is not easy. I think it can be really challenging sometimes.
- [25:33]
Dr. Meredith Trubitt
Yeah. So you just got to kind of, I think the point. So usually when you first walk into the room, you have like the rhythm strip. We talked about asking for the EKG at the, like, upfront. What are their tools? History, physical, any other findings that kind of help you determine what may actually be going on?
- [25:52]
Dr. Noble Malik
This is where having your nurses and staff give you some sense of what happened prior to them calling you. Was this like all of a sudden, sudden dich Arrhythmia was something that was kind of slowly, gradual. Not slowly, but gradually became more tachycardic. The history, you know, thinking about once again, what could be the triggers from symptomatology to medications to other things that they may have done. And depending on when you're seeing them, if you're seeing them kind of early in their course, things that they may have experienced prior to coming to the hospital will impact that as well. And then ultimately we'll use some of our maneuvers to maybe help us, guide us in our thought process as well in terms of what if you reduce sympathetic tone, what that does to their heart rate. But I think some of the story history is really important and getting a sense of that can really help you.
- [26:52]
Dr. Meredith Trubitt
Okay. And then I think Moni's going to talk a little bit about this too. But we'll go into like, vagal maneuvers and medications. But I'm assuming some of that also will help you determine what's going on. So it's a little bit which I just like, highlight here for like our often said hospitalists like mantra, which I feel like is diagnosis and treatment are happening at the same time.
- [27:16]
Dr. Noble Malik
Oh, absolutely. We do a lot of diagnostic maneuvers that are also therapeutic.
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Dr. Moni Amin
Speaking of. So you were going to move this case along. So you talk to the nurse and the tele folks and they tell you that the patient was in normal sinus in the 70s and then immediately just spiked. So it seems maybe this isn't sinus tack based on the rapid onset and not really seemed like the patient was unchanged when it happened. Here's a fun one. You tell the patient to do the vagal maneuver, which. Or to bear down, which I've gotten some funny looks when I've asked for that. I don't know if you have. And then of course, you start doing the carotid massage. All things that they're probably just confused by, especially if they're feeling well. So kind of go through some of those. And then if we were children, you would be throwing ice buckets on them, which was highlighted in an adult in an episode of the Resident many years ago. Sorry, let's talk about the Valsalva and that kind of thing.
- [28:20]
Dr. Noble Malik
Well, as you said, I think that it is probably one of the more funny things when you are demonstrating the Valsalva and wanting them to do it yourself. As I get older, it gets harder and harder to. For myself to keep control. And so the interesting thing about the Valsofa is that it's actually you have to do it for a pretty long time, anywhere between 15 to 30 seconds, which is a long time to be bearing down. And there have been relatively recent changes in how maybe what is more efficacious from before, where you would have them bear down, usually kind of sitting up. This was, I think in 2015, they did a randomized controlled trial where this idea of this modified Valsalva, they still bear down. So that's part still the same. And then so one of the things, if you have a syringe, like a 10cc syringe, you can have them blow to try to move the plunger. And so that's a little bit less graphic than having a bowel movement is to kind of give them the syringe and have them kind of blow through it. And that does the same purpose. The study was 15 seconds. Guidelines will say 15 to 30 seconds, but after they do that, they lie flat and then you basically do a straight leg raise. In a sense, you raise their legs and that's supposed to help reduce their vagal tone as well. And in this particular study, that modified Valsalva was 2 and a half times more likely to lead to resolution of their tachyarhythmia, which I think is significant and definitely worth doing. I will say that I have not seen people do that modified Valsalva frequently. So I feel like the study kind of went under the radar. And part of the reason is that the AHA guidelines are pretty old, like 2014, 2015, and the study was happened after that. So it may not have really been incorporated. But so I think that for the future I would recommend using the modified Valsalva. So that does require them to go after they do the bearing down piece, they go flat, the legs are raised and then. And hopefully. And you can see what happens after that.
- [30:41]
Dr. Meredith Trubitt
So point of clarification. So they sit up like you give them the syringe or they bear down, whichever one they understand. Then you, you like just flat. And then it's both legs.
- [30:54]
Dr. Noble Malik
So that's a great point because that might limit the ability of people to perform the modified Valsalva. If they have something related to their lower extremities or they can't lay flat for whatever reason, then you can't really perform that. And I'll say other things that you want to think about when you're considering the Valsalva, whether you do the regular or the modified are, I guess there are contraindications potentially. You can say people who've had to referred recent mis, those who have really bad aortic stenosis. So you have to either know that or do an exam. People have bag glaucoma because you're asking them to cause the Valsalva piece. And so it's once again, not a knee jerk. I think you also have to have some thought process prior to going through that pathway to make sure that the patient is able to tolerate it.
- [31:41]
Dr. Meredith Trubitt
Okay, I didn't know the leg raise part.
- [31:44]
Dr. Moni Amin
Yeah, this was all news to me. So very, very helpful. And also kind of seeing the comedy of trying to convince the rapid response team to do something like that. But that's just my new game.
- [31:55]
Dr. Meredith Trubitt
And then what about carotid massage?
- [32:00]
Dr. Noble Malik
Carotid massage is a thing. It's in the guidelines. And if you recall back in late when you were in medical school about not causing the people have to stroke out. So you want to make sure you listen for brewies or maybe be aware if they've had history of carotid artery disease, in which case you would not be massaging their carotid, but their legs should be extended, kind of turned away from you, and then you are massaging for five seconds. It's not a long time. Assuming that they don't have bruis or any concerns for bruis, that can work. Probably less efficacious than the valsalva, which is less than the modified.
- [32:38]
Dr. Meredith Trubitt
Okay, so like, and I guess my only question is, like, there's no benefit to doing like. Like being like, hey, I'm gonna do this carotid massage. Then, like, going to, like, a modified Valsalva. Like, you're just going to pick one of them and then go to meds, or would you ever do one and then the other?
- [32:56]
Dr. Noble Malik
I think my real answer is that depending on how quickly you are able to get to the meds, if you have time, then I don't necessarily see why you couldn't do it as a maneuver while you're waiting for things to be set up. And if you have a rapid response team or emergency team that has access to the crash card. And that's where it's held. Fine. Previous episodes where I've had to wait for the dentist need to come from pharmacy. Then you have to try other things. But I would quickly go to the dentist scene if one of the maneuvers didn't work.
- [33:30]
Dr. Moni Amin
Work.
- [33:31]
Dr. Meredith Trubitt
Okay. So I guess moving the case along. We did the modified Valsalva patient feels a little bit dizzy, but heart rate's still elevated at 170. We were just talking about we're going to kind of move to the medication portion of this adventure. So you already mentioned the adenosine. So why don't we start with that kind of as our next step?
- [33:56]
Dr. Noble Malik
Yeah. The dentistine in the tachyrhythmia algorithms tends to be really first line for a lot of these SVT or even tachyarrhythmias. And I think it's one of those things which you see on tv. I mean, honestly, it is a really neat thing to do. It's scary as well to do the adenosine. I think we all have that vision of mind of the asystole that happens with adenosine. So first of all, they should have pads on. That's already kind of happened prior to all this. But definitely if you're doing adenosine, you need pads, you need the IV access. It's a push, a rapid push and then followed by a flush. So once again, the bigger the gauge and the better the process will be. I think you want to just as we talked about with the Valsalva, prior to doing the adenosine, you want to know is it safe to do the adenosine, which it is most. Most of the time, the things that you want to be aware of are bronchospasm, people who have asthma, maybe bad copd or having really active reactive Aurora disease and bronchospasms. You would be really cautious about people who have heart block already, people who are hypotensive that might actually might have strayed into the unstable piece of it. But if they're hypertensive or if they have volume overload, you're worried about heart failure. Then I would be really cautious with adenosine. And that puts us patient similar to the path of unstable. You'd be heading towards potentially a cardioversion. We all think about counseling and doing some shared decision making with our patients about what we're doing and why we're thinking about this. Recognizing that they are going to feel. They can have all sorts of feelings, flush some sensation of Chest pain, the impending doom, which is what you kind of remember hearing about in textbooks about the feeling. I mean, for anyone who is given a density, yes, those are all real things and they will say that, but it's so fleeting and transient that by the time they think about it, they're already kind of already getting better. But it is something how we counsel patients. Maybe we, I would say I personally may not do as much of, is talk about why we put the pads. Because yes, you can run into trouble sometimes with adenosine, and especially if they have a pre excitation syndrome, which you might not have been able to catch beforehand. But for the most time, it works quickly. If they have svt, it usually breaks the rhythm, which is what we're hoping for. And whether it's the AVNRT or the avrt, it does tend to work. And if it doesn't work, you still get good information. And the way I've told my learners, and in fact the episode where I mentioned where I went to three cardiologists, include the EP and I, I think that if you are doing adenosine and sometimes you see in a rhythm that's not svt, that's okay. I mean, I think you need to be doing that because it will. As it turns out, that patient was sinus tac. And like I said, all three cardiologists didn't see it that way and neither did I. And so I think it's important, it's worthwhile to do almost no matter what. If it doesn't break, then you, you get to see the underlying rhythm and then you get to see how quickly it goes back to attack arrhythmia, especially if it is not something that will break with the adenosine.
- [37:15]
Dr. Meredith Trubitt
Can we just talk for a minute about dosing and all that kind of good stuff?
- [37:20]
Dr. Noble Malik
Sorry, I meant to mention that I think traditionally the dosing is 6mg followed by 12 and then followed by 12 again, which is kind of the classic pathway. I know that there are occasions where cardiologists say we'll go straight to the 12 milligrams. I don't really know how they decide one or the other. I say my personal practice is due to 6, 12 and 12 and then.
- [37:44]
Dr. Meredith Trubitt
Anything else? I mean, we already talked about kind of how you're counseling the patients, but anything else you need to know during the administration, part of it or anything else for the hospitalist?
- [37:55]
Dr. Noble Malik
No. As long as they have the gauge, they have the flush afterwards, which most of the time the nurses and your rap response team will probably be managing for you or the ICU nurse. And you want to make sure you have enough prior to starting because you have to, I think. I'm not sure if you can assume you're going to. Only the one dose would be enough. So I kind of want to prepare for the need. But you'll know quickly. And I will say that it does require some questions coordination, because whoever's running the EKG strip needs to be able to print it out as you are administering it. So there's definitely some coordination that gets involved where you're actively asking them to push it in a scene, looking at the rhythm strip, interpreting the rhythm strip potentially with colleagues or help if you have anyone with you and then monitoring the patient and how the patient's doing from their vital signs as well. So back to the idea that it is, it's a scary thing to do. I mean an anxiety provoking thing to do.
- [38:57]
Dr. Meredith Trubitt
And I think it maybe for the listeners out there because I actually think we all have a little bit different practice habits when we were talking about this before we even recorded. But like, I think I don't use adenosine a whole lot. Like I think that I probably go to second line therapies much faster. And maybe that's because of the rhythms that I'm seeing, to be honest. But just curious, like in your opinion, like, do you think that maybe at least I feel like I'm shying away from the adenosine because of what that asystole looks like. And so I'm just curious whether that's something like should be less afraid of.
- [39:31]
Dr. Noble Malik
I feel that obviously when you have experience and less experience, you're going to make sense. As I mentioned, it's definitely a scary thing to do. I think you could get information with the other medicines, especially if there's an underlying rhythm that you can tell when it slows down. So if you're using a beta blocker or a calcium channel blocker, if it responds, then you will see the heart rate slow and potentially you might see a P wave. And that will be really helpful to you. Whether or not that AV nodal action is enough to break the rhythm, that is unclear. It might. And so when there's a kind of indication of a dendency, and I really aim in discomfort, once again, this idea of discomfort or comfort level, which I think is a really important piece, we have those other AV nodal agents like the beta blockers and the Calcuttana blockers to use.
- [40:28]
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- [41:36]
Dr. Meredith Trubitt
And so then like, obviously you mentioned the contraindications to the adenosine. So those would all be reasons that then like beta blocker, calcium channel blocker, ends up being second line.
- [41:47]
Dr. Moni Amin
Right.
- [41:47]
Dr. Noble Malik
Or if in a control setting, you know, if those were not options for what other reasons? You could also then move to, you know, cardioversion as well. Yeah, so with the dosing though, I think the. So I'll talk about that a little bit. If you're used to using, let's say, but if you're not using an infusion like a Metoprolol IV, it's anywhere between two and a half to five milligrams, which I tend to use five milligrams. And you can repeat that every 15 minutes, every 20 minutes to see the effect. Watching the blood pressure with the calcium blockers, specifically like the diltiazem type of medications, and this is similar to kind of irregular rhythms. The guidelines say we should do 0.25 milligrams per kilogram, which I would say at my local cath lab can sometimes be a pretty hefty dose for some of our folks, which can be sometimes like 20 to 25 milligrams of IV diltiazem, which I think also stretches the comfort level of many of us, including myself, which is why the 10 milligram dose is so commonly. I don't know about your experience, but 10mg seems to be is a dose that I think you will see done a lot. I will say that is. I'll just say it's underdosing from the standpoint of the guidelines and in your.
- [43:12]
Dr. Meredith Trubitt
Practice, like, if you did this adenosine 6 and 12, are you typically going to the third 12?
- [43:20]
Dr. Noble Malik
No.
- [43:21]
Dr. Meredith Trubitt
Like if. Okay.
- [43:22]
Dr. Noble Malik
Well, by that time I will have help.
- [43:25]
Dr. Meredith Trubitt
Yes. I appreciate the honesty.
- [43:29]
Dr. Moni Amin
I mean, we can all remember the first time we saw Dennisine get pushed, and that's pretty much what comes rushing to the front of my mind every time I think about having to do it. So I think we're all addressing the very spoken anxiety right now. I can appreciate that.
- [43:47]
Dr. Meredith Trubitt
Yeah. Well, it's good news because for our patient, he got the 6 milligrams of the adenosine and did well. And so we didn't even have to go down this 12 milligram situation. And after everyone had their brief heart attack with the seeing the systole, he returned to his normal sinus rhythm, and we had both diagnostic and therapeutic answers for his svt. I think just to quickly recap kind of this first case, I think kind of the highlights in reality are that a fair amount of what we were trying to go through is that this is still going to be your algorithm. It's important to kind of note what those rhythms could be. But at the end of the day, probably worth trying some vagal maneuvers, trying the adenosine and having a friend nearby, maybe for your own comfort level and recognizing what that comfort level is. And then can always try your beta blockers and calcium channel blockers as well, to kind of get you through that rapid response situation in the hospital. Did you have any other pearls, Mooney?
- [44:51]
Dr. Moni Amin
No, I think that's a really good recap of that situation.
- [44:55]
Dr. Meredith Trubitt
Fantastic. So I'll take us to case two. So it's busy at cash Slack today, and you get another page for another rapid response for a heart rate of 150. And you go and triage the patient over the phone while you're walking to their room. And you have already determined that they are stable per the vital signs. And on arrival and quick exam, the patient, Mr. Digge, again, seems stable. You're waiting on the first EKG, but per the cardiac monitor, it looks narrow, but this time it looks irregular compared to the last time. So you quickly learn that this patient, Mr. Diggy, is a 61 year old with a past medical history of HFrEF secondary to ischemic cardiomyopathy. And he had a PCI two months ago, and he's here for acute decompensated heart failure. And so you're, I guess, still waiting for his ekg. But let's say they've printed it out during this conversation, and it looks like it's atrial fibrillation with rvr. So kind of, what are our initial, like, steps here for this specific rhythm?
- [46:02]
Dr. Noble Malik
Yeah, I think. I mean, the conversation we just had about the tachyrhythm still really much applies here. I think this is an extraordinarily common scenario with atrial fibrillation with a rapid rate. And I still also, I will say similarly can feel very uncomfortable even though the rhythm is not made. Not a mystery, because it's still going pretty fast. And usually these patients don't tolerate being that fast for so long. So this case is, I think, pretty complicated with Mr. Diggy. And first is, once again, are they stable or are they unstable? And the definitions are pretty similar to what we talked about before. You think about hemodynamics, and they think about symptoms. So from their blood pressure to their mentation, in this case, think about, are they having active ischemia, Are they having heart failure? Which, this is complicated because he's here for decompensated heart failure. And if they're having those things that puts you down a pathway, you're like, this person might not be able to tolerate his tachycardia for a long period of time. On the flip side, many times they're fine and they just aren't going fast. And one of the things I really enjoy about tachyarhythmias is that when you're not kind of called to action, like, immediately, it is a. You know, it's a puzzle. It's a diagnostic puzzle that we have to kind of sort through about what's happening and why are they doing this. Is it related to, in this case, the fact that he's having decompensated heart failure and that it's a volume issue, in which case maybe we address that. That might be helpful. Or is it something else? So I start with, who's the patient? How is the patient? And is this patient stable enough for me to do some of my diagnostic research reasoning, or do I need to kind of do urgent action?
- [47:57]
Dr. Meredith Trubitt
So I personally feel like the patient who always comes in with AFIB with RVR is the person who came in with suspected heart failure. Like, you don't have a diagnosis of heart failure. So can we talk through maybe a little bit about the medication choices then that you're making? Because, like, some are going to be more contraindicated than others. And the heart failure setting.
- [48:19]
Dr. Noble Malik
Yeah, I think it's fascinating, I'll say that. Disclose that I am not a pocus expert. And so I just can't put a probe on someone and tell their EF or if I could, I wouldn't trust myself to make a decision based on that. And many times we are not in Mr. Diggy. We have a sense that he has a reduced ejection fraction, but oftentimes we don't know what their ejection fraction is. And even with some of the context clues and physical exam stuff, which might give you a sense of sense, if you don't feel as confident with that part of your physical exam, you might have to proceed as if they might have reduced ejection fraction or at least an EF that is worrisome, I want to say reduced under 40%, under 35%. The reason that plays a role is that we think about specifically our choices are beta blockers and calcium channel blockers. Those are still our go tos for rate control with atrial fibrillation. And then even though Mr. Digge might want us to use digoxin, that is not something that I think we have a lot. There's a lot of literature about, but I think many practitioners may not be used to using digoxin anymore. And so that campfire level has reduced and I don't think we tend to talk about it as much. So we have talked about the metoprolol again, the beta blockers and the calcium Shannon blockers. When people have a reduced CF and decompensated heart failures, the calcium shadow blockers are at least written about to be less ideal to use. And so that's probably the first kind of things we think about and that kind of gets passed along. When you look at the guidelines, though, when people have decompensated heart failure, really neither the beta blocker or the calcinato blocker are things you should be using. That's why this particular case with Mr. Digge may be complicated for us. If we gave him some furosemide and he didn't improve from a volume status and this is really just part of the syndrome, then we would have to think about other medications for patients who have reduced ejection fractions, specifically antiarrhythmics like an amiodarone, for example, for people who.
- [50:29]
Dr. Meredith Trubitt
Are ill and so on. The previous case, we talked about the dosing for the diltiazam and the metoprolol, which I assume is going to be the Same dosing you would use here.
- [50:41]
Dr. Noble Malik
Very much so it's the same with the 0.25 milligrams per kilogram. Actually, the second dose, if that doesn't work, is really 0.35 milligrams per kilogram. So you're really going to some hefty doses. And I will just say out loud, I think one of our concerns is that oftentimes their blood pressure isn't like they're not hypertensive. They are either normal or maybe on the lower end of their blood pressure, which once again gives us pause to use. I'll just relay that there have been a number of studies that looked at this where even if their blood pressure was in the 100, the 95, 110, they tend to tolerate the AV blockering agent. It's another reason why people tend to reduce the dose of the dilt from the recommended 0.25mg per kg to I would say an arbitrary but common dose of 10 milligrams to see what happens. And the telegrams will still work for many patients.
- [51:39]
Dr. Meredith Trubitt
And then if the person is someone that you deem needs the amiodarone because they're truly half rough, they have the EF of 15% and you're in the room and technically stable, but not confident that's going to last for a while. So you've decided on the amio. What dosing is that?
- [52:01]
Dr. Noble Malik
Well, there's a bulletin infusion with amiodarone, so it's 150 milligrams. It's given pretty slowly over like 10 minutes. And then usually you follow that up with an infusion of amiodarone. Ultimately they get switched over to an olamide. But from the acute management standpoint, it's really just getting started with the 150 milligram bolus and then have the pharmacy prepare the infusion once again. That usually does take some time, at least on our cash, like to get the amiodoidone infusion started. So it's one of the things where you're communicating again to if you have a pharmacist nearby to start thinking about that if that's going to be your possibility of using amiodarone.
- [52:42]
Dr. Meredith Trubitt
And then I just want to go back for a second to I sometimes think of these patients a little bit on a spectrum when they have ref, because sometimes I think that I and I do this like they're state, they're stable for the moment and I try like an oral metoprolol because I know that they're going to need some sort of beta blocker too in the future. And this is just our opportunity at this point that we're going to start it. And then it's not as aggressive, especially if their blood pressures usually hang out kind of in, you know, softer than you like phase. It feels better to me. But then that puts it kind of like, it's very like, practitioner, like, dependent to say, like. And I don't think any of that's guideline driven. Like, that's just saying, like, hey, this person seems a little bit more stable than this person. And so that one gets oral and this one gets Ivan. So I don't know if that's really a good practice or not.
- [53:35]
Dr. Noble Malik
Well, I'll start with saying that when you take a step back and you're thinking, like, what is our goal with treating this patient? Are we treating a number? Are we treating a patient? Are we trying to avoid a complication? Are we trying to avoid a problem? I would start with that. And many times that's what the tachyarrhythmias, once again, if they're not unstable and we have time to think about situation, situation, it becomes uncomfortable for other people, but the patient can tolerate it. While we are kind of deciding what to do. And you might have a number in mind about where you like them to be, but the guidelines will say that they are stable. You can do oral medications. There's no necessarily urgency to use IV medications. It seems a little bit counterintuitive because we know it takes a little bit longer for those medications to work. But generally speaking, their blood pressure tolerates it better than an IV push of a metope or a triple L diltiazem. If you're concerned about that, the idea of using the beta blocker for, let's say, GDMT reasons, usually not in part of my equation, honestly, because once again, usually when I think about the tachyarrhrhythmia at the time, usually it's about preventing complications of a tachyrrhythmia. Like, in the short term, like, they're stable now. How long can they tolerate the tachycardia before they start having symptoms? So I'm not usually in my mind thinking about gdmt. But that being said, I think that makes a lot of sense though, to use a beta block to see how they tolerate it in case you are now tend to probably, like you said, put them on a beta blocker afterwards.
- [55:19]
Dr. Meredith Trubitt
Thanks.
- [55:19]
Dr. Moni Amin
Yeah. Before we go to the next section, I just wanted to touch on a blast from the Past. Did you say digoxin? Yes. Okay. This is dating myself. We weren't completely anti did when I was training. So if I recall, and correct me if I'm wrong, it's actually not a completely ridiculous choice. If someone is somewhat unstable and you're worried about like some of the heart failure type stuff. Correct.
- [55:47]
Dr. Noble Malik
Digoxin is used for Hefref. It can be used in Hefref and often that's one of the indications for it when you have reduced ejection fraction. I mentioned that, as I said, people are out of practice using it. That means that I have used it in the last two years, but it's because of out of practice. You have to look up the dosing, you have to look up how do you do it and the loading dose. So it's definitely is not something that kind of rolls out of your brain as your script of knowing exactly what to do. But I know it can be extraordinarily effective and it's in your toolkit. I would just say that it's in your toolkit to use if you have other concerns for the other medications. Amiodorone can have some issues with certain populations and some side effects. And potentially that would be something that you might be nervous about. I think, once again, if you're at this stage, you're probably requiring some counsel from a cardiologist or specialist to help you kind of navigate that.
- [56:50]
Dr. Moni Amin
Yeah, for sure. So kind of to round out our discussion, a couple of the considerations I think every hospital has when a patient develops this fib flutter picture. The first is anticoagulation, both in the setting of it continuing persisting or somebody that it came and then it went. And so kind of talking through the anticoagulation for both those subsets of patients.
- [57:15]
Dr. Noble Malik
Yeah, I think I wish it was so easy, like put them on a direct anticoagulant and then kind of move on with their life. But I don't think it's that simple when you think about. I'll step back and go back to what I was saying in terms of what are your goals for this particular interaction. Anticoagulation is for reducing stroke risk. If this is someone who is headed towards cardioversion to revert back to a sinus rhythm, then I would be more prone to do anticoagulation. If you have the access of the service line and the people who can do a transesophageal echo at the same time, then it becomes potentially probably less urgent to do the anticoagulation in this for someone who is. You're going to reduce their heart rate, but they have atrial fibrillation. Now you're using your scoring systems to decide whether they're going to require full term anticoagulation. Most of them do. But I think the question is I'm a. I'm managing their acute tachyarrhythmia with afib. It's not the first thing that comes to my mind, honestly, is the anticoagulation. I am thinking about all the things we talked about to manage their heart rate, but then kind of after things maybe stabilize a little bit. And we're thinking about now rhythm control once again, for patient centered for symptoms. In discussion with the cardiologist, if that's something that they're thinking about doing, then anticoagulation becomes a consideration. Prior to that.
- [58:53]
Dr. Moni Amin
Gotcha. And so kind of with the conversation with the cardiologist, I imagine that's who you're talking to kind of for the longer term, like, do they need a cardioversion? Do they need an ablation? Because you and I aren't going to be going into an EP lab to do any of that. And you're right, it's never the first thing that comes to mind for me. It's usually like, I've done all the acute stuff and I'm like, oh, crap. I should probably think about their anticoagulation. Meredith, did you have anything else?
- [59:22]
Dr. Meredith Trubitt
No. I think we could go to take home points.
- [59:24]
Dr. Moni Amin
Yeah.
- [59:25]
Dr. Meredith Trubitt
Yeah.
- [59:25]
Dr. Moni Amin
So noble. Do you have any take home points for us?
- [59:28]
Dr. Noble Malik
I'll start with it is okay to be anxious about dachyarrhythmia, so kind of take your own pulse as you are like, you know, working towards the patient, having your mind, your confidence in are they stable or are they unstable and making that kind of decision point when. Which will help direct you to the algorithm and follow the algorithm, which is really helpful. And really, it's pretty straightforward when you're thinking about narrow complex tachycardias, at least, and recognizing your. Are they in sinus tachycardia? Do they have a supraventricular tachyarrhythmia? Thinking about the vagal maneuvers, adenosine. And then you have your AV node agents, calcium channel blockers or the beta blockers, and then amiodarone as an option as well. And if they're Y complex, that's ventricular tachycardia unless proven otherwise. And I would ask for help and talk to someone.
- [60:29]
Dr. Moni Amin
Awesome. Anything to plug for us.
- [60:32]
Dr. Noble Malik
Well, I will say that if this is my kind of strange story. But speaking of if you have a light bulb that's broken and this happened to me last week, they have these things where you can buy and you kind of fit it in and it takes it all apart. That's a 10 out of 10. It worked and I was shocked. I was fully accomplished. So my plug is for if you happen to have a broken light socket, don't live in the dark like I was.
- [61:00]
Dr. Moni Amin
You can take it out and who said More Episodes.
- [61:09]
Dr. Meredith Trubitt
This has been another episode of the Curbsiders bringing you a little knowledge food for your brain hole.
- [61:13]
Dr. Moni Amin
Yummy.
- [61:14]
Dr. Meredith Trubitt
Still hungry for more?
- [61:15]
Dr. Moni Amin
Yep.
- [61:16]
Dr. Meredith Trubitt
Join our Patreon and get all episodes ad free plus twice monthly bonus episodes at patreon.com curbsiders you can find show notes@the curbsiders.com and sign up for our mailing list to get our weekly show notes in your inbox including including our Curbsiders Digest, recapping the latest practice, changing articles, guidelines and news and internal medicine.
- [61:35]
Dr. Moni Amin
And here at Curbsiders, we're committed to high value care practice, changing knowledge and to do that we need your feedback. So please email us@askcurbsidersmail.com it also helps a lot when you subscribe, rate and review the show on YouTube, Spotify or Apple. Podcasts. A reminder that this and most episodes are available for CME Credit for all healthcare professionals through VCU Health at curbsiders. VCUHealth A special thanks to our writer producer, the wonderful Dr. Caroline Coleman who put this episode together and to our whole Curbsiders team. Our technical production is done by the team at podpace. Elizabeth Proto does our social media, Jen Watto runs our Patreon, Chris the Chew Manchu moderates our Discord and Stuart Brigham composed our theme music. And with that, until next time, I've.
- [62:17]
Dr. Meredith Trubitt
Been Dr. Moni Amin and I am still Meredith. True bit. Thank you and good night.