Unsedated Cardioversion

COmedic17 · Mar 26, 2015

Although I can't say I have ever met someone who is allergic to corn, so I assume it's not a common occurrence.

Carlos Danger · Mar 26, 2015

That's a new one. Interesting.

COmedic17 · Mar 26, 2015

From my understanding it's due to the dextrose in it being corn based.

Corn syrup is in about everything so I doubt it's a common allergen.

Brandon O · Mar 26, 2015

The "don't hate me later" effect of benzos is nothing to sneeze at...

Burritomedic1127 · Mar 26, 2015

NYBLS said:
Where did I say I would not provide analgesics?

Right here: "But I hate the distinct fear that we are nervous to do something that can save a life because it will hurt. No kidding it will hurt, but so does an IV, IO and EJ. Am I going to abandon those items and good care because of the pain? No."

Remi said:
I would say that if someone is sick enough that you doubt their ability to safely tolerate more than 0.5 mg of midazolam, then they probably don't need anything at all. Would that much Versed "tank her pressure"? I would expect not, but it could have some negative effects, and the BP is already low, and you might not have a clear picture of all the comorbidities. Plus, I would question how effective such a small dose would be at meeting your goals, especially if you aren't going to wait 5 minutes or so for the effects to peak.

DEmedic said:
0.5mg of versed won't be worth a fart in a windstorm when you cardiovert someone. Even after 5mg, they still howl like a banshee. They usually don't remember it though.

I agree 0.5mg might be pissing in the wind but it's something. Pain meds/sedation effect people differently based on pt's weight, size, meds, you name it. 50mcg of fentanyl for nana, might not do anything for a normal healthy young pt.

COmedic17 said:
Do what you do, but I am not going to waste time sedating an unstable patient with crappy skin vitals and a falling BP.

Now I've cardioverted people before without sedation and I agree 100% there is a time and a place for that. My point with everything is based on that one pt that is "technically unstable" but NOT clinging on fighting for life, any sedation (even if just an attempt) is respectful.

COmedic17 · Mar 26, 2015

Your very stub.......persistent.

Burritomedic1127 · Mar 26, 2015

COmedic17 said:
Your very stub.....persistent.

That's the Irish blood sorry ha. To be honest, i cant stand lazy people (not you guys) in regards to pain management. The line of why give pain meds when the hospital is right down the roads drives me crazy (more than baseline). People withholding pain meds cause its close to shift change and don't want to deal with the narc replacement process is just BS

Carlos Danger · Mar 26, 2015

I'm just saying you have to be very careful when sedating a hemodynamically compromised patient. Especially if they are elderly or have certain other comorbidites, even very small doses can have exaggerated effects.

We all like to make our patients comfortable, but sometimes, when a patient is clinically unstable, avoiding brief discomfort is just not worth the risk that comes with it.

If you are concerned enough that you feel it's best to use tiny doses, then it's probably safest to just forgo it altogether. You can always give something afterwards when their CO has improved.

COmedic17 · Mar 27, 2015

Brandon O said:
The "don't hate me later" effect of benzos is nothing to sneeze at...

That's not a lie.

I have sleep insomnia (have since I was a child) and have been on every thing from ambien, lunesta, melatonin, you name it I tried it and I either sleep walked (understatement. I Would get up and cook meals..) or was extremely groggy in the morning ( probably from cooking and doing God knows what else all night) so I got perscribed a low dose benzo to basically "sedate" me long enough to fall asleep, but wear off before I started walking around, etc.

But even at my low dose if I take it and don't immediately go to bed I won't remember anything I did prior to bed. Including random purchases on Amazon and eBay.

Christopher · Mar 27, 2015

Remi said:
In what way? Do you have a reference for that?

Electrical cardioversion has far fewer side effects than antiarrhythmics. If I have to choose, for myself, between adenosine/lidocaine/amiodarone/procainamide or cardioversion, I'm taking cardioversion. Stable or unstable. The whole idea that antiarrhythmics are somehow safer than electrical cardioversion has baffled me for years.

Carlos Danger · Mar 27, 2015

Christopher said:
Electrical cardioversion has far fewer side effects than antiarrhythmics. If I have to choose, for myself, between adenosine/lidocaine/amiodarone/procainamide or cardioversion, I'm taking cardioversion. Stable or unstable. The whole idea that antiarrhythmics are somehow safer than electrical cardioversion has baffled me for years.

I never said that antiarrhythmics are safer. I don't know. I've just never seen it substantiated that the reverse is true, despite hearing people say it my entire career.

And especially when you start talking about using drugs to facilitate electrical cardioversion in hemodynamically tenuous patients, the question of safety quickly becomes much less clear cut than simply "electricity is safer than chemistry".

Christopher · Mar 27, 2015

Remi said:
I never said that antiarrhythmics are safer. I don't know. I've just never seen it substantiated that the reverse is true, despite hearing people say it my entire career.

And especially when you start talking about using drugs to facilitate electrical cardioversion in hemodynamically tenuous patients, the question of safety quickly becomes much less clear cut than simply "electricity is safer than chemistry".

How about sedation/analgesics have a much more predictable effect/side effect profile than our antiarrhythmics (excepting adenosine)?

When I push fentanyl/etomidate/etc I generally know what to expect. When I push amiodarone I wonder if it'll work.

PotatoMedic · Mar 27, 2015

Part of me is just waiting for the ALPS study to show placebo worked best.

Carlos Danger · Mar 27, 2015

Christopher said:
How about sedation/analgesics have a much more predictable effect/side effect profile than our antiarrhythmics (excepting adenosine)?

When I push fentanyl/etomidate/etc I generally know what to expect. When I push amiodarone I wonder if it'll work.

I'd say it really depends on the patient. A youngish, otherwise healthy person with a good heart who just happens to have a PSVT? Sure, you can snow them all you want with whatever you want and 9/10 times they'll be just fine. It's hard to kill a young healthy person with fentanyl; probably even harder with etomidate.

But not everyone who needs to be cardioverted is young and healthy. There are plenty of comorbidities which, when combined with a low EF from the tachycardia, will make someone much less tolerant of any sedation than you might expect. Even small doses of sedation can significantly effect already-compromised hemodynamics.

Christopher · Mar 27, 2015

Remi said:
I'd say it really depends on the patient. A youngish, otherwise healthy person with a good heart who just happens to have a PSVT? Sure, you can snow them all you want with whatever you want and 9/10 times they'll be just fine. It's hard to kill a young healthy person with fentanyl; probably even harder with etomidate.

But not everyone who needs to be cardioverted is young and healthy. There are plenty of comorbidities which, when combined with a low EF from the tachycardia, will make someone much less tolerant of any sedation than you might expect. Even small doses of sedation can significantly effect already-compromised hemodynamics.

Vastly more predictable than pushing antiarrhythmics in the same patient.

Carlos Danger · Mar 27, 2015

Christopher said:
Vastly more predictable than pushing antiarrhythmics in the same patient.

Maybe. That hasn't been my experience at all though, doing anesthesia in the EP lab.

NYBLS · Mar 28, 2015

Burritomedic1127 said:
Right here: "But I hate the distinct fear that we are nervous to do something that can save a life because it will hurt. No kidding it will hurt, but so does an IV, IO and EJ. Am I going to abandon those items and good care because of the pain? No."

Despite what analgesics you provide the above procedures will still typically provide some discomfort. I never said I would not provide them, I just said it will probably still hurt.

Burritomedic1127 · Mar 30, 2015

NYBLS said:
Despite what analgesics you provide the above procedures will still typically provide some discomfort. I never said I would not provide them, I just said it will probably still hurt.

There was also nothing mentioned of fear of performing these procedures. If it's life threatening and you can fix it, fix it without pain meds (example needle decompression). Again, I'm not saying give pain meds to start IVs, but for other pt's, providing analgesia is not a "abandonment of good care." The question was never answered, why do you give lidocaine for a conscious IO?

triemal04 · Mar 30, 2015

Burritomedic1127 said:
There was also nothing mentioned of fear of performing these procedures. If it's life threatening and you can fix it, fix it without pain meds (example needle decompression). Again, I'm not saying give pain meds to start IVs, but for other pt's, providing analgesia is not a "abandonment of good care." The question was never answered, why do you give lidocaine for a conscious IO?

I must have missed something...was that a rhetorical question?

I think part of the problem that comes up whenever this debate comes back is that people have very, VERY different definitions and understanding of what a "critical" or "unstable" patient really is.

gotbeerz001 · Mar 30, 2015

Burritomedic1127 said:
The question was never answered, why do you give lidocaine for a conscious IO?

Cuz pushing fluid though the bone ****ing hurts...

Unsedated Cardioversion

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