Unstable SVT Treatment

Handsome Robb said:

Is anyone allowed to do concurrent pain and sedation for cardioversion or pacing? I've always wondered why we use anxiolytics rather than analgesics since it's a painful procedure. Also, expanding on Nova's thought about getting a little more wiggle room for sedation, wouldn't it be just as if not more effective to use a smaller dose of midazolam concurrently with fentanyl rather than just straight midazolam? Not only is fentanyl very hemodynamically "stable", the smaller dose of midaz is going to to have less vasoactive actions than a big slug of it. The combo can render the same if not better results.

We can do concurrent pain and sedation for pain associated with a large muscle mass such as a femur fracture or back spasms on standing orders, only can use sedation for cardioversion and pacing without OLMD.

As far as the question about fluids, it's been answered well already. Not necessarily going to be a bad thing but if someone is symptomatic enough to warrant cardioversion as the first line treatment why go doinking around getting a line and spiking a bag? It always makes me wonder when people say "while I setup for cardioversion". It takes all of 30 seconds to place pads, select your energy setting and sync the monitor.

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Do you know what departments are using a benzo/fent combination for sedation, or for pain management with a Fx? I'd like to present this to EMS admin and the OMD if other departments can

46Young said:

Do you know what departments are using a benzo/fent combination for sedation, or for pain management with a Fx? I'd like to present this to EMS admin and the OMD if other departments can

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SSV (sierra sacramento valley) http://www.ssvems.com/?page_id=280
T6, isolate injury

46Young said:

Do you know what departments are using a benzo/fent combination for sedation, or for pain management with a Fx? I'd like to present this to EMS admin and the OMD if other departments can

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Teller County Colorado. Protocols attached, though they are a bit dated now with the new medical direction having eliminated a max dose from the pain control protocol, if benzos are not used.

Incidentally our new medical director has requested we cut down on this combination's use as it apparently could be considered starting down the conscious sedation road, which is out of scope. We now have Ketamine, which can be used with a benzo or opoid.

Actually I can't figure how to attach PDFs anymore (oops). Here is the quote, I can message you the pdf if needed.

2013 Teller County Pre-Hospital Protocols Page 235
 Patients aged 12-55 years, who are suffering from joint dislocations
and/or angulated fractures, and in significant pain from such, may
(as an option) be given 0.5 mcg/kg of fentanyl with 5.0 mg of
diazepam IV. Use two separate syringes, one for each medication.

 Patients older than 55 years of age, who are suffering from joint
dislocations and/or angulated fractures, and in significant pain from
such, may (as an option) be given 0.5 mcg/kg of fentanyl with 2.5
mg of diazepam IV. Use separate syringes for each medication.

 Patients 6-12 years of age, who are suffering from joint dislocations
and/or angulated fractures, and in significant pain from such, may
(as an option) be given 0.5 mcg/kg of fentanyl concomitantly with
0.2 mg/kg of diazepam (to a maximum of 5.0 mg) IV. Use separate
syringes.

 Be advised that the presence of debilitation, respiratory disease,
fluid and/or electrolyte abnormalities, and CNS depressants may all
have profound effects on patients receiving these medications.
Either do not use the above medications or provide them in
small increments and be very alert to hemodynamic and respiratory
parameters

46Young said:

This crossed my mind once when considering CPAP for the borderline hypotensive with APE, to elevate the legs and get a quick BP bump to offset the tamponade effect on the coronary vasculature and venous return regarding BP

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Dunno about this one. The increased afterload might make things worse. Anyway, what would you do after the effect wore off?

Brandon O said:

Dunno about this one. The increased afterload might make things worse. Anyway, what would you do after the effect wore off?

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I would hope that you would be at or near the hospital. Nearly all of the truly needed ALS interventions we do pre-hospitally are temporizing measures, they buy enough time to get the patient to definitive care. Unless he practices in a rural environment with extended transport times, the next steps probably will be the hospital's to figure out.

46Young said:

Do you know what departments are using a benzo/fent combination for sedation, or for pain management with a Fx? I'd like to present this to EMS admin and the OMD if other departments can

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That isn't analgesia, it's procedural sedation. Which is cool, if that's what you're shooting for.

The recent evidence, however, suggests that benzos have no role in augmenting analgesia, or in "sparing" higher doses of opiods - for a quick review see "For better pain control, add a benzo? (Part 1 - Trauma)"

@46Young REMSA does it.

Oakland county, MI