Tachycardia in a Patient with Severe Pain

Case Study

A rapid response code was activated for a patient who developed persistent tachycardia on continuous telemetry. Upon the arrival of the condition team, the patient was noted to be a 60-year-old male with a past medical history of peptic ulcer disease and alcohol use, admitted two days prior for severe abdominal pain. The patient had undergone an esophagogastroduodenoscopy (EGD) a few hours before when the condition was called. EGD had shown evidence of gastritis. The patient had been started on proton pump inhibitors.

Vital Signs

Temperature: 97.6 °F, axillary
Blood Pressure: 170/90 mmHg
Heart Rate: 160 beats per min (bpm) ( Fig. 7.1 )

Fig. 7.1

Telemetry strip showing regular, narrow complex tachycardia with identifiable P waves consistent with sinus tachycardia.
Respiratory Rate: 30 breaths/min
Oxygen Saturation: 99% oxygen saturation on room air

Focused Physical Examination

The patient was a middle-aged male who appeared diaphoretic and visibly uncomfortable. He was awake, oriented, and responding to questions. His abdominal examination showed epigastric tenderness but no distension or guarding. The remainder of his examination was unremarkable.

Interventions

A cardiac monitor and pads were attached immediately, with telemetry showing narrow complex, regular tachycardia. The patient was given 2 mg intravenous (IV) morphine immediately for pain relief. Electrocardiogram (EKG) was obtained, which showed sinus tachycardia. Complete blood count (CBC), electrolytes, lactate, amylase, and troponin level were ordered. The patient’s history of peptic ulcers and recent findings of EGD were noted. The patient was given a dose of antacid medication and sucralfate. An additional dose of 4 mg IV morphine was given for unresolved pain, and a chest/abdominal X-ray was obtained at the bedside, which was unremarkable. Stat computed tomography (CT) abdomen and pelvis were ordered, which showed findings consistent with acute pancreatitis. The patient was started on treatment for pancreatitis with adequate fluid hydration and a pain control regimen.

Final Diagnosis

Sinus tachycardia in the setting of severe pain caused by acute pancreatitis.

Sinus Tachycardia

Sinus tachycardia is a heart rate greater than 100 bpm generated from the sinus node. It can be classified clinically into normal or physiologic (appropriate sinus tachycardia) and primary sinus tachycardia ( Table 7.1 ). Sinus tachycardia is the most common rhythm disturbance.

Table 7.1

Features of normal and primary sinus tachycardia

	Features/subtypes
Normal sinus tachycardia	• Appropriate increase in heart rate in response to physiological, pathological, or pharmacological stimuli
Normal sinus tachycardia	• Physiological causes ■ emotion, anxiety, panic attack, physical exertion, pain • Pathological causes ■ Disease-related: heart failure, myocardial infarction, valvulopathies, pericarditis, pulmonary embolism, pneumothorax, asthma, pneumonia, pulmonary edema, thyrotoxicosis, hypoglycemia, pheochromocytoma, anemia, hypovolemia, fever, infection, shock ■ Medications: norepinephrine, dopamine, dobutamine, salbutamol, atropine, methylxanthines, chemotherapeutic agents such as doxorubicin and daunorubicin, albuterol, amphetamines, ecstasy, cannabis, cocaine, lysergic acid diethylamide ■ Withdrawal: beta-blockers, illicit substances, alcohol ■ Dietary exposures: caffeine, chocolate, and alcohol
Primary sinus tachycardia	• Increase in heart rate that is not appropriate for the degree of physiological, pharmacological, or pathological stress
Primary sinus tachycardia	• Inappropriate sinus tachycardia ■ Persistently high (>100 bpm) resting heart rate in the absence of a precipitating cause ■ Usually associated with palpitations • Postural orthostatic tachycardia syndrome ■ Inappropriate sinus tachycardia triggered by orthostatic stress, relieved by lying down in the absence of orthostatic hypotension and autonomic dysfunction • Sinus node reentry tachycardia ■ Sudden onset, paroxysmal, non-sustained sinus tachycardia