SVT

Becky asks:

My MC’s ex-boyfriend to come back with not-so-good-but-not-outright-

bad intentions to try to force her to take him back. He’s been leading a high-stress life-style (Dental School, top of his class, used to be an cyclist but stopped exercising, angry about no perfect job post school, turned-mean, etc.) and then she leaves him because he’s so awful and after almost 9 years of waiting to get married and live happily ever after, he tell her he doesn’t know if he really wants to be with her. Okay. That’s the back story on him.

Basically, he shows up in the throws of a nervous breakdown/panic attack that looks a lot like a heart attack. And that’s my question: Can a panic attack have similar/same symptoms of a heart attack? I want him to be hospitalized at least over night, so it needs to be bad enough to have to be monitored for 24+ hours, but not bad enough to kill him or leave him there long-term.

Jordyn Says:

As far as the scene, it can work medically. I think instead of a panic attack– you should go with an arrhythmia called SVT (supraventricular tachycardia.) I’ve included some links for you. At its simplest, SVT is a super fast heart beat. For an adult– it would be a sustained, unwavering heartbeat over 180 beats/min.

http://www.mayoclinic.com/health/tachycardia/DS00929/DSECTION=causes

http://www.cnn.com/HEALTH/library/heart-arrhythmias/DS00290.html

http://www.webmd.com/heart-disease/tc/supraventricular-tachycardia-overview

The reason to change it to this type of medical condition is if the medical team determines he had a panic attack– he will not be observed overnight. However, if he had an arrhythmia for which he was hemodynamically unstable (low blood pressure)– then observing overnight is warranted– particularly if they converted him out and he went back into it.

When you have SVT– it can feel like you’re having a heart attack. Many of the symptoms can be the same. Chest pain. Pain down the left arm. Jaw pain. Difficulty breathing. Low blood pressure. Sweating (diaphoresis). Pale, cool, clammy skin.

I don’t know if this is the direction you want to go but would be my suggestion.

There’s nothing like watching a TV show and seeing medical personnel come in with the paddles (even these are rarely used) to shock a patient. Many people say this is “jump-starting” the heart and this is really the wrong clinical picture to give as far as medical accuracy is concerned. The use of electricity on the heart actually stalls it.

What?!?

How could that possibly be helpful to a patient?

Heart cells are very unique, cool little contraptions. Each cell in your heart can generate a beat. Yes, that’s right, every little teeny one. Most often, the normal conduction system of the heart overrides this unique property of heart cells, and the electricity flows from the AV node to the SA node so the heart contracts in a normal, orderly fashion.

Heart Cells: Douglas Cowan, Children’s Hospital Boston

The heart’s normal beat is important because when the top (the atria) contract, it pushes the remaining blood that doesn’t flow via gravity when the valves open into the ventricles. When the ventricles contract, it pushes blood out to the rest of the body.

The purpose of blood flow is really oxygen delivery to the cells. Of course, there are other functions but this is primary. Without oxygen delivery to the cells, cells will die. Lack of oxygen delivery to the cells is called shock.

We’ll talk more about shock in later posts.

Defibrillation (or unsynchronized cardioversion) is only used in a few arrhythmias. Ventricular tachycardia and ventricular fibrillation. These arrhythmias appear when something has affected the heart’s normal conduction system– such as a heart attack, electrical injury, lack of oxygen. They are more common to the adult population than to the pediatric.

In these arrhythmias, the heart’s normal conduction system is no longer working properly and other cells in the heart become active in an attempt to keep the patient alive. The problem with these arrhythmias is that they do not produce a pulse.

No pulse is clinical death. So, we must get back the patient’s pulse back in order for them to have a chance at survival.

What defibrillation actually does is stop the heart by briefly terminating all electrical activity in hopes that the heart’s normal conduction system will begin to work and a palpable pulse will then ensue.

Important note— there must be some electrical activity for defibrillation to work. So, it is not indicated for the treatment of asystole or when the patient has “flatlined”. This is done often in television shows and is a clear medical inaccuracy.

Electricity is also used in another condition called supraventricular tachycardia (SVT). Supra means above. So this rhythm is a very fast rhythm generated somewhere in the atria. Sometimes, when the heart beats incredibly fast, it doesn’t have enough time to fill with blood. When it fills with less blood, it pumps less blood out. Less blood out means less oxygen delivery. The patient can have signs and symptoms of lightheadedness, dizziness, sweating, chest pain, and difficulty breathing to name a few. They still have a pulse though it may be weak and thready.

The goal of using electricity in this instance is again to disrupt this pathway by stalling it in hopes that the heart’s normal conduction system will take over at a much slower rate.

There is also a medication that can be given that will chemically stall the heart, too. It is called adenosine and is used in the stable patient presenting with SVT. It is used in instances of fast rhythms to slow the pulse down.

Does this change your impression of how defibrillation really works?