Proper Workup in Young Hypertensive Tachycardia Patient


There were a couple of comments to the last post on Semantics that made me question whether or not it was proper to do a large workup on a young patient with tachycardia.

So I decided to create a poll to get everyone else’s opinion.

Assume that the patient’s use of K2 was disclosed. In a 17 year old (i.e. “young”) patient with persistent tachycardia unresponsive to treatment who uses synthetic marijuana, what testing should be performed?

[poll id=”11″]


    • Sounds reasonable to me (as a non-physician). Just because the patient tells you he’s taking K2 doesn’t mean he’s telling you the truth. Or that he actually knew what was in the stuff he took.

    • That’s the rub.
      If the patient admits to taking marijuana before you do the test, ordering a tox screen that shows marijuana makes you look stupid.
      But if the tox screen shows marijuana plus cocaine, you’re a genius.
      And if you miss the fact that the patient was using cocaine because you didn’t do the drug screen and then there is a bad outcome related to the cocaine, you’re getting served.

      • Dr. Pet Peeve on

        I have yet to encounter a scenario where a screen for drugs of abuse has changed my management in a positive way. Clinical toxidromes can and should be identified and treated appropriately, regardless of the results of these tests. They are fraught with false positives and false negatives, and typically only test for a few specific compounds. In addition, they are prohibitively expensive, and rarely (including this scenario) should they change management. For example, at my last institution an 8-item urine drug screen (cocaine, valium [not all benzos], opioids [not including synthetic opioids like dilaudid], methadone, amphetamines, marijuana, barbiturates, PCP) costed $1200, and would not test for many of the “bath salt” sympathomimetics my patients tended to use.

  1. 12 lead ECG, Troponin, ESR, CBC, CMP, TSH, and +/- d-dimer.

    Top five killers here:

    1. PE – consider with risk factors – if high (exogenous estrogen, smoker, recent surgery, etc.) CTAngio chest. If low, d-dimer.

    2. Arrhythmia – Brugada (leading to v-tach), PSVT and WPW come to mind. ECG provides simple assessment.

    3. Myocarditis/pericarditis – less likely, but simple bloodwork (CBC, ESR) provides decent assessment coupled with a good physical exam including auscultation.

    4. Intoxicant – agree the tox screen is worthless, too many substances not included. Huge implications for false positives and negatives. Good history, documentation of +/- toxidrome on physical exam (the eyes and skin tell all!).

    5. Endocrine – Hyperthyroid or Adrenal Crisis. Physical exam and simple bloodwork (CMP and TSH).

    Exclude these as above and you will likely also find other less sinister causes (electrolyte imbalances, severe valvular heart disease). Otherwise, follow-up with PMD for OP evaluation with a reasonable degree of certainty that no emergent condition exists.

  2. Worrying about looking stupid for ordering a drug screen is stupid. Order the damn screen: most kids think they know what they took, but they only know what they took…. they don’t know what someone else gave them.

    17 years old, no prior hx, and tachy refractory to reasonable therapy? Sure, I’ll look for a zebra or two, but it’s cardiac or drugs 9 out of 10 times.

    • But does knowing what drugs they were taking (if any) change the management? Perhaps avoiding certain beta blockers if cocaine is present, but can’t we do that anyway?

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