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Clinical Cases and Images – Cardiology – Atrial fibrillation (AFib) with rapid ventricular response (RVR) due to central line placement

Atrial fibrillation (AFib) with rapid ventricular response (RVR) due to central line placement

Author: V. Dimov, M.D.

Reviewer: A. Kumar, M.D., Medical Director of IMPACT (Internal Medicine Preoperative) Center and Medical Director, Blood Management, Department of Hospital Medicine at Cleveland ClinicA 39-year-old African American female (AAF) with past medical history (PMH) of diabetes mellitus type 1 (DM1) was admitted to the hospital with an infected right diabetic foot ulcer. She needed intravenous access (IV) access for Unasyn (ampicillin and sulbactam) and laboratory work, and failed several peripheral line attempts.Past medical history (PMH)

Diabetes mellitus type 1 (DM1), hypertension (HTN).

Medications

Insulin, lisinopril.

Physical examination

Vital signs stable (VSS).

Well-developed and well-nourished in non-apparent distress (WD/WN in NAD).

Chest: Clear to auscultation bilaterally (CTA (B).

Cardiovascular system (CVS): Clear S1S2.

Abdomen: Soft, non-tender and non-distended (NT, ND).

Extremities: right diabetic foot ulcer with signs of infection.

What happened?

A right internal jugular (IJ) central line was placed. Immediately after the catheter was placed, she complained of shortness of breath (SOB) and palpitations. Her oxygen saturation (SpO2) was 100% on room air, and breath sounds were equal and clear bilaterally.

What is the most likely diagnosis?

Is it a pneumothorax?

Heart rate (HR) was 140 bpm and irregular. Is it due to PVCs (premature ventricular complexes)?

What tests would you order?

The best option would be to withdraw the line. An alternative approach is described below.

The treatment team ordered a STAT EKG and chest X-ray (CXR).

The EKG showed atrial fibrillation (AFib) with rapid ventricular response (RVR).

The CXR showed that the triple lumen catheter (TLC) was at the level of the right atrio-ventricular (AV) junction.

Triple lumen catheter (TLC) at the right atrio-ventricular (AV) junction on CXR (click to enlarge the images).

Atrial fibrillation (AFib) with rapid ventricular response (RVR) due to a TLC at the right atrio-ventricular (AV) junction (click to enlarge the images).

What would you do?

Withdraw the central line. Repeat the CXR and EKG.

What happened?

The TLC was withdrawn 5 cm. The conversion to normal sinus rhythm followed immediately and there were no further complaints.

A central line in the superior vena cava (SVC). This is the correct position for an internal jugular (IJ) central line on CXR (click to enlarge the images).

Conversion to normal sinus rhythm (NSR) after the central line was repositioned (click to enlarge the images).

Final diagnosis

Atrial fibrillation (AFib) with rapid ventricular response (RVR) due to central line malpositioning.



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