Chemical or Electrical Cardioversion?

[Aprz]

I know that ACLS teaches things like shortness of breath and chest pain as being hemodynamically unstable, but I still try Adenosine first if I consider them to be stable. Although the treatment is different, I approach it with the same urgency as a majority of my code 2 chest pain calls. So far, I have been very successful with converting all of my SVT calls (specifically AVRT and AVNRT if you are going to shout "but sinus tachycardia is technically an SVT also!) using Adenosine or the patient stimulated their vagus nerve. I haven't had a single one convert with Valsalva (blowing against a closed airway), keep forgetting to try modified Valsalva (I swear I'll do it next time!), but one did convert when the IV was started. The majority converted on the first dose with some converting on the second or third dose (we still have a third dose in the county I work in).

Um, some people really advocate for electricity instead of medicine, but not exactly sure why and what their threshold is. I got this vibe from ems12lead.com. @TomB or @Christopher, do you guys have any opinion on this?

 

[RocketMedic]

For afib rvr and SVT refractory to adenosine, I really like diltiazem. It seems to be a quick, effective and safe way to convert malignant tachydysrhythmias. I personally like to answer how we got to the point of needing to cardiovert and act accordingly.

 

[NomadicMedic]

An emergent cardioversion is one of those things that when you see someone who needs it, you know.

I've cardioverted a fair number of people, which i guess is kind of odd. There are medics on my service that have never cardioverted. Ever.

Anyway, if they're in a position where you're worried about the discomfort you may cause them, you should probably try drugs first.

When I've needed to cardiovert someone emergently, they've been pretty gorked, and fixin' to die.

I'm no IV ninja, but I've got skills (so what are you gonna do about it?) and I've got a drill. I'm gonna get access, they'll either get the correct meds or they'll get some sedation.

 

[CALEMT]

unless they look like they're fixing to die, are ALOC/Unconscious, etc.

While I'm still the student and I'm learning everyday. I typically use mental status if I go straight to Edison medicine over Adenosine or TCP over Atropine (for Brady of course). From what I read he seems like he's in the "gray" area ACLS wise wether you should go to synch cardioversion or Adensoine. Arguments can be made for both and granted I'm still the student, in my ACLS skills station I would've gone with Adensoine based on the patients vital signs and mentation. Altered I would go with Edison medicine.

 

[TXmed]

as far as the IM ketamine i mentioned. i meant it more as in if you wanna take few seconds to to do it. It is a decent idea for people who have more than one medic on scene or medic/nurse. Im not intending for it to significantly delay the cardioversion, the opposite actually, the idea was intended for people not to worry about vascular access (us people that are not IV ninjas lol) so as to not create a delay. Im not really carrying about full on sedation whatever i get from 1-2mg/kg is fine and if i have to cardiovert multiple times atleast it might help on the second shock lol.

 

[E tank]

An emergent cardioversion is one of those things that when you see it, you know.

Yep...I don't think there is too much disagreement with the idea that avoiding the big zap is the best thing to do if at all possible. Training and experience will determine if you think you have a little time to draw meds up and get them going and if there is enough blood moving to carry it to where it needs to go fast enough. You do reach that point in your career where you just "know".

And if you're not at that point, you should "know" that too. Futzing around with getting a bolus of a drug together when there ought to be pads on the chest is tacky. Until someone's Spidey Senses are dialed in, it has to be by the book.

 

[Tigger]

You "done good"! Treat the patient, not the monitor or the numbers.

Might have been hard to figure out he was in SVT without that monitor...

That phrase needs to die. Correlate the numbers with the patient. If it doesn't make sense, figure out what.

 

[GMCmedic]

While I'm still the student and I'm learning everyday. I typically use mental status if I go straight to Edison medicine over Adenosine or TCP over Atropine (for Brady of course). From what I read he seems like he's in the "gray" area ACLS wise wether you should go to synch cardioversion or Adensoine. Arguments can be made for both and granted I'm still the student, in my ACLS skills station I would've gone with Adensoine based on the patients vital signs and mentation. Altered I would go with Edison medicine.

Remember, real world =/= to ACLS.

SVT with chest pain is unstable for ACLS skills

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[MackTheKnife]

I've never had to sedate with IM ketamine before cardioverting someone, and I wouldn't necessarily say don't do that. But I wonder if someone could criticize it because the required IM dose for effect might possibly induce some cardiac excitation which is sort of what is being treated with a shock in the first place. Curiosity only, but has anyone ever wagged a finger over that?

Isn't a side effect of Special K bradycardia? Might be beneficial.

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[Carlos Danger]

Isn't a side effect of Special K bradycardia? Might be beneficial.

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Tachycardia is much more common.

 

[MackTheKnife]

Tachycardia is much more common.

Thanx. I wasn't sure.

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[TomB]

"The man called 911 complaining of chest pain, but he appeared in no significant distress. He was alert, oriented, and ambulatory on scene. His rate was 220, with a BP of about 85/50. I know this meets every indicator to move straight to electrical therapy, but given how non-symptomatic he appeared, I couldn't move past at least trying Adenosine first."

There's a fine line between symptomatic and hemodynamically unstable. "Alert, oriented, and ambulatory" indicates that immediate synchronized cardioversion is unnecessary (level of consciousness is a key indicator, IMHO). In this situation I would start out with vagal maneuvers, followed by adenosine, and synchronized cardioversion if the patient's condition deteriorated.

 

[TXmed]

I use etco2 as an additional means of justification

 

[dutemplar]

Plus versed has that whole amnestic quality. So they may not remember the kick in the chest by a mule.

But hey, if you have time to draw up versed, ketamine, whateva... may as well take the time to give adenosine a try.

I've only lit up one SVT so far. Cruuuuushing chest pain he thought was killing him, rate of like 260-280, dizzy, lightheaded and feeling like he would pass out, pressure was crap and had the FTD look. I pulled the paddles out while calmly explaining "this part is gonna suck, but you should feel much better in a few seconds..." as my partner slammed herself against a far wall just in case I aimed at her... ZZAP! OWWWW! (long string of Spanish expletives)... and rate back to 140, internal chest pain gone, some external chest discomfort and the lingering smell of burning hair, but hey. Details.

 

[Rialaigh]

If the patient can open their eyes and is oriented in answering any questions I have then that pretty much tells me they can wait for me to try some medications. Electricity is reserved for people that are dying, not almost dying.

as a side note, my mother has dealt with SVT on and off for the past thirty years. She will go into SVT at 200-220 and wait 12-16 hours before seeking medical treatment... because she is stubborn...f you asked she would say she is feeling weak and maybe dizzy, but in no way does she need electricity. The vast majority of patients we pick up could remain in SVT for a while (especially if the patient is under the age of 50 or 60)....this is an emergent condition, just usually not "Minute to minute" life and death sensitive.


Second side note - If I pick up a 40 year old male in SVT at a rate of 200 which started 15 minutes ago, if the guy has a pressure and is not in a terrible amount of discomfort then ill shoot to get it regulated with vagal or meds. But if it doesn't convert and we are 10-15 minutes from the hospital I'm probably just going to give him a ride, a physician in the ER can make a determination on some sedation, proper electricity dose, and involve cardiology prior to cardio version if they choose. This patient isn't going to suddenly go unresponsive on you In the next 15 minutes, sometimes less is more.

 

[Carlos Danger]

sometimes less is more.

Quoted for emphasis.

 

[RocketMedic]

I think a lot of this depends on what medications you carry and what the expectations of QI and your medical director are. We've got some options y'all in CA don't have

 

[Eden]

I definitely agree with the approach the majority stated here. If alert and oriented I'd probably withhold cardioversion and go to meds first.
And yes for hemodynamiclly stable nct ccbs work very well. Use verapamil quite often.
Nice discussion.

 

[E tank]

And yes for hemodynamiclly stable nct ccbs work very well. Use verapamil quite often.
Nice discussion.

This brings up an interesting point...anyone have any actual experience with an SVT with a diagnosed or undiagnosed WPW? Maybe one that you picked up on?

 

[MackTheKnife]

I suppose you ask about SVT and WPW as to whether or not adenosine would work? I guess it would depend on whether or not the aberrant pathways are susceptible.

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