88 y/o female with palpitations

[teedubbyaw]

I asked you questions and you answered with questions. So, I'm not going to play that game with you. You don't want to back up what you're saying, then don't, but don't turn it into an attack on me. I already gave my stance.

 

[triemal04]

I've explained why I'd go with treating this, and with a basis beyond "The hospitals close and I've seen patients stop on their own." I'm perfectly happy to do so again, or in more detail if that wasn't clear earlier.

Of course I asked you questions; I just don't understand your thought process. At all. Or you could say that I don't agree with what I can see of your thought process. At all. So I asked more questions so that it would be clearer.

If you don't want people questioning what you do...well...can't help you there.

 

[teedubbyaw]

you're the one describing her as asymptomatic. (OP)

So, she's in a period of afib/aflutter again. Are you seeing any clinical signs of her diminished atrial kick? Will you in an hour from now? And again, is 150 'really' high for an 88yo?

5 minute transport time, I'll get the best history I can for the doc and not push cardizem. When I'm an hour from the hospital, she'll get drugs pushed.

Yawn.

 

[triemal04]

Ok. I think I do get it now. As I said previously, you think that the lady is asymptomatic, not having any type of red-flags, and you won't treat her because you're close to the hospital. And have no better reasoning than that apparently.

For anyone else reading this who might learn something: apparently what is happening here is that it is recognized that there is a treatable problem, and it is recognized that the patient does in fact need treatment for that problem. It is further recognized that this treatment can be delivered (safely) in the prehospital setting. But the provider is not going to do it soley because they are close to the hospital, but would if they were further away. There are times when it is certainly appropriate to take this line of thinking and do this; but there should be a good reason behind it. If the decision to withhold treatment is only based on distance to the hospital, and not on the impact on the patient...you're doing it wrong.

 

[teedubbyaw]

You're good at concluding complete and utter ********, aren't you?

If your treatment is based on whether or not the patient will have a 'wait time' at the hospital, then you're doing it wrong.

 

[zzyzx]

Teedubbyaw, if you had a 22 y/o who went into SVT five minutes before arriving at the ER, and who was totally stable, would you bring her into the ER in SVT?

 

[teedubbyaw]

That's a blanket question.

If I didn't have a 12 lead, IV access, and a good Hx, then chances are by the time I get that, we'll be at the hospital. A 'totally stable' 22yo can sustain tachycardia very well.

 

[teedubbyaw]

P.S I have no idea what a blanket question is. lol

 

[triemal04]

I was going to say something else...but I don't see any reason to waste my time. I'll just reiterate for anyone else reading this; everyone get's to make the decision on what kind of paramedic they want to be. You can treat your patients in an appropriate manner, or you can dump your patients off on someone else and let them deal with it. The choice is yours.

And with that, I'm out.

 

[teedubbyaw]

Avoid questions with personal attacks. You're a real hero. Delay definitive care because you want to disperse your priorities poorly.

 

[RocketMedic]

I'd treat it. Tachydysrhythmias become lethal quite quickly if left alone.

 

[k9Dog]

Looks like stable v-tach, our treatment is amiodarone 150mg drip over 10 minutes. Put on defib patches in case it deteriorates

 

[Doczilla]

I have no idea. I would like to learn more about diltiazem (cardizem).

I believe it can also be given to treat atrial fibrillation with rapid ventricular response and fascicular ventricular tachycardia. It seems reasonable to me to administer it to treat a symptom caused one of those cardiac arrhythmias. I guess we should be thankful it is not in my scope, haha. Hopefully I knew more about it if it was in my scope of practice.

What's your threshold for diltiazem administration. Seems like that's something you'd administer to somebody symptomatic (eg palpation), but stable versus somebody who is hemodynamically unstable or at risk of rapidly deteriorating (eg rate of 300 with 1:1 atrial flutter).

I believe it comes packaged as 125 mg in 125 mL. I think you give it as 5 mg/hr and decrease/increase it in 2.5-5 mg/hr increments. I have no idea how to bolus it.

@teedubbyaw I don't think it was him who gave the cardizem. I thought it was the physician at the ER?

@zzyzx On the EKG Club on Facebook, we remove the name and date of the EKG. If it is not removed, they delete it. Although this isn't the EKG Club, I think it would be good to get into the habit of that. They do it in case there is anybody who is super old that would narrow down who it is with the help of the date I think.

As with any drug, try to look at the underlying physiology you're working on. Drugs do either one or two things:

A) Block some type of physio, or

B) Stimulate some type of physio

This is relevant because, (and this is really interesting to me) the atrium is the ONLY membrane in the entire body that uses calcium to depolarize. That immediately draws a line between the usage of sodium channel blockers and calcium channel blockers, because inversely, the ventricles use sodium to depolarize. Atrial arrythmia? Block calcium.

On a quick sidebar, students ask me all the time why paralytics don't kill patients due to arrythmia. Well, there's your answer there: the heart doesn't use AcH to depolarize like skeletal muscle does.

You could almost draw a line right through the atrium and ventricles, and pick which antiarrythmic to use. The only work you've gotta do after that is interperet where the problem Is from the ECG!

One last thing, we prefer cardizem to other CCB's, (nicardipine, amlodipine, etc), because of their selectivity. The amount of nicardipine needed to control an atrial arrythmia would tank their pressure into oblivion.

Hope that helps!