Tachycardia in a Patient With Alcohol Withdrawal

Vital Signs

• Temperature: 98.4 °F, axillary

• Blood Pressure: 150/90 mmHg

• Pulse: 179 beats per min (bpm) ( Fig. 6.1 )

  

• Respiratory Rate: 18 breaths per min

• Pulse Oximetry: 99% oxygen saturation on room air

Focused Physical Examination

The patient was a young male who appeared diaphoretic and visibly uncomfortable. He was alert, oriented, and responding to questions appropriately. Coarse tremors were present on the extension of the upper extremities. He denied difficulty breathing, palpitations, and pain. His cardiac exam showed tachycardia with normal heart sounds and no murmurs. His lung and abdominal exams were benign.

Interventions

A cardiac monitor was attached with telemetry showing narrow complex tachycardia. The patient was given lorazepam 2 mg IV because of concern for worsening alcohol withdrawal, given the elevated CIWA score. A stat 12-lead EKG was obtained, and it showed regular, narrow complex tachycardia; P waves could not be appreciated given a heart rate >150 bpm. The patient appeared to be in supraventricular tachycardia with an unknown underlying rhythm. He was asked to blow in a 10 cc syringe for 15 seconds, while simultaneously lowering his head and raising his legs. This maneuver was repeated without success. Then, 6 mg of IV adenosine followed by a 20 cc normal saline flush was given, which successfully converted the patient’s cardiac rhythm to normal sinus rhythm. Post-conversion EKG was obtained, which showed sinus rhythm at 110 bpm. Stat troponin and electrolyte levels were obtained, and potassium and magnesium were repleted intravenously. The patient was reloaded with phenobarbital, started on scheduled lorazepam doses, and remained on the medical ward with continuous telemetry monitoring.

Final Diagnosis

Supraventricular tachycardia