PSVT in mechanically ventilated patient

[LakeSuperiorFishing]

I had a patient the other day, mechanically ventilated, on weaning protocol who abruptly went into narrow, stable ST for 2 hours plus -- on metoprolol and dig daily, given additional metoprolol with seemingly minimal effect, who abruptly went in to NSR at 65 after a bowel movement.

If, after a delivered breath, her ET tube was fully occluded for 20-30 seconds, would increased intrathoracic pressure have possibly been an effective 'vagal maneuver'? (Was on PRVC, and breathing 2-4 breaths above vent setting, again, on weaning mode).

Other thoughts? (Tried bag of ice over eyes, not a candidate for carotid massage, known DVE, PE, anti coagulated). Thanks in advance.

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[Hamhock]

Hey LakeSuperiorFishin -- are you fishing from something now?

HH

 

[jdh71]

Sure. Why. Not.

I think I respond to at least two having a major deuce push brady codes per year.

 

[deleted171991]

Very possible. Urinary retention is another frequent cause for tachycardia.

Occluding the ET tube could qualify as a Valsalva maneuver, but I wouldn't play like that with an ICU patient. I have seen patients code just from recruitment maneuvers. I think adenosine is the right answer in most cases of suspected PSVT. The close second right answer is definitely not beta-blockers; diltiazem (unless contraindicated) is much better at decreasing conduction.

Btw, @LakeSuperiorFishing, what are you? APRN/PA student?

 

[deleted547339]

Very possible. Urinary retention is another frequent cause for tachycardia.

Occluding the ET tube could qualify as a Valsalva maneuver, but I wouldn't play like that with an ICU patient. I have seen patients code just from recruitment maneuvers. I think adenosine is the right answer in most cases of suspected PSVT. The close second right answer is definitely not beta-blockers; diltiazem (unless contraindicated) is much better at decreasing conduction.

Btw, @LakeSuperiorFishing, what are you? APRN/PA student?

Yea, but if the patient is already on a beta-blocker, that seems reasonable.

 

[BigRedBeta]

Tried bag of ice over eyes, not a candidate for carotid massage, known DVE, PE, anti coagulated). Thanks in advance.

Have used a lot of ice, as we do it pretty commonly in peds with newborns in SVT: you can't just lay it on there, it's literally never going to work. What you really want to do is actually trigger a combination of valsalva, the oculocardiac reflex, and trigger the dive reflex. I literally was told as a resident "you gotta smash them like a bug" with the ice bag. You want to cover their mouth so they gasp against the bag and struggle which would be difficult in an intubated patient.

 

[AdmiralChz]

Have used a lot of ice, as we do it pretty commonly in peds with newborns in SVT: you can't just lay it on there, it's literally never going to work. What you really want to do is actually trigger a combination of valsalva, the oculocardiac reflex, and trigger the dive reflex. I literally was told as a resident "you gotta smash them like a bug" with the ice bag. You want to cover their mouth so they gasp against the bag and struggle which would be difficult in an intubated patient.

Well now, that sounds pleasant....

 

[PTPoeny]

Oh, yeah, they hate it. In residency I took care of a kid with recurrent SVT who would start screaming every time anyone got ice from the machine... He had to get moved to the other end of the unit...

 

[WheezyBaby]

Well now, that sounds pleasant....

Parents love it

 

[WheezyBaby]

Sure. Why. Not.

I think I respond to at least two having a major deuce push brady codes per year.

Took care of a kid with multiple dookie arrests during the same hospitalization. Real fun