#SimBlog: Facing Your Demons

Simulation can often bring out peoples worst fears. However, it can bring about unexpected educational opportunities to practice those skills that you don’t feel so confident on. I often think of simulation as a fun way to face your demons 😈

One of my biggest demons in medicine for many years was the fitting patient. It took me quite a while to come across anyone that was genuinely fitting; but even when I suspected it I would begin to sweat and panic – anxious at the thought of dealing with a fitting patient.

Then on one life-support simulation courses they gave me a fitting patient, and my demons slowly turned into angels that I could face 😇

Our Scenario

A normally fit and well 35-year-old man presents to the Emergency Department with a feeling of palpitations in his chest. He is on no medication and tells you that this is the first time it has happened. The triage nurse helpfully does an ECG (see below). After seeing his ECG the triage nurse sends him to the ER.

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A: Ventilating in Air

B: Bilateral and equal air entry. RR 20, O2 Sats 99% in Air

C: Pulse Regular, 180bpm BP 107/82

D: GCS 15/15

E: Nil of note

Why We Simulated?

Supraventricular tachycardia (SVT) is a fairly common presentation to the ED, of the types of tachycardia’s that present to us. Being able to manage it and understand the Resuscitation Council guidance is important. Tachycardic adult patients can be a scary presentation. Being comfortable with the algorithm and how to implement it is crucial.

Learning Outcomes

1. It is okay to ask for the guideline if you don’t remember what it is.

2. Remember: if the patient has any of the adverse features, they may need pacing.

Things to remember about SVT (from Whinnett et al. 2012)

• Supraventricular tachycardia comprises a group of conditions in which atrial or atrioventricular nodal tissues are essential for sustaining the arrhythmia.

• Common symptoms include palpitations, chest pain, anxiety, light headedness, pounding in the neck, shortness of breath, and uncommonly syncope.

• They are produced either by disorders of impulse formation and/or disorders of impulse conduction.

• For patients presenting with a regular narrow complex tachycardia, initial management is usually to slow atrioventricular node conduction, using either vagal manoeuvres or adenosine.

• Drug treatment may reduce the frequency of symptoms, but complete suppression is uncommon Catheter ablation, a procedure done under local anaesthesia in the cardiac catheter laboratory, is usually curative.

Further Reading:

• BMJ: Whinnett IM, Sohaib SM, Davies DW. Diagnosis and Management of Supraventricular Tachycardia. 2012. BMJ 2012;345:e7769.
• #EM3: SVT & Modified Valsalva Manoeuvre (#SimBlog)
• The Lancet: REVERT Trial
• RCEM Learning: Supraventricular Tachycardias