Versed + hypotension

[crazycajun]

I don't think this is that likely, especially if you're doing 12-leads. Certainly the cables can become damaged --- he early LP12s were notorious for this -- but this isn't going to make VT appear where there was no VT before.

I have seen a Phillips monitor show VT when there was no VT present. I have also seen a Zoll show wide complex rhythm's because it was plugged into an AC outlet



This is just terrible, but speaks more to a basic lack of competence and an inability to perform a physical assessment. If someone doesn't understand what PEA is, and doesn't check vital signs on a patient, there are much bigger issues going on. Hopefully the crew in question has got chewed out and remediated.

Defends my point of treating the PT and not the monitor

Not sure I understand --- are you talking about cardioverting a perfusing tachyarrhythmia into a pulseless rhythm? Because this is simply a risk of cardioversion, that's got to be considered when you're balancing the relative merits of drug therapy versus cardioversion versus doing nothing.

See the issues above with the Phillips and the Zoll

 

[Veneficus]

Interesting that you base your argument against etomidate on a study done on compromised, septic patients, when all of the other material which studied etomidate vs Versed as a rapid one dose sedative for painful, one time events (such as cardioversion) showed no significant issues with that one time dose. Most studies showed etomidate as 'a safe, effective drug." The study you quoted showed that half of the PTs had adrenal insufficiency PRIOR to etomidate! And the conclusions of the study state, "Relative adrenal insufficiency is present in most patients with septic shock after the administration of etomidate. Caution is recommended when using etomidate in these patients."

I don't think that the small study you cited is enough to class etomidate as "a terrible drug".

Try these on.

http://www.sciencedirect.com/science/article/pii/S0196064403005109

http://www.theannals.com/content/38/7/1272.short

http://onlinelibrary.wiley.com/doi/10.1111/j.1553-2712.2001.tb00539.x/abstract

If I had to cardiovert a PT, who had a line up, was hemodynamicly unstable ... yet I felt required sedation prior to cardioversion, I would most likely chose etomidate over midazolam.

There are very few terrible drugs

Just drugs that don't work well on all patients.

The quest to find the perfect treatment for everyone is a fools undertaking.

There is a reason genetically based therapies are the future of medicine.

Because unless you are an indentical twin, no two people are the same.

Also if you hang around long enough, medicine is cyclic. (because our knowledge advances over time) It wasn't 20 years ago when we thought thalidomide was the worst drug ever developed, now it is a first line treatment in a different population.

 

[NomadicMedic]

There are very few terrible drugs

Just drugs that don't work well on all patients.

The quest to find the perfect treatment for everyone is a fools undertaking.

There is a reason genetically based therapies are the future of medicine.

Because unless you are an identical twin, no two people are the same.

Also if you hang around long enough, medicine is cyclic. (because our knowledge advances over time) It wasn't 20 years ago when we thought thalidomide was the worst drug ever developed, now it is a first line treatment in a different population.

Sure. But I'd be loath to see a medic student read this thread, go back to his/her class and say "Etomidate is an awful drug and we shouldn't use it. Ever!"

The goal of a thinking practitioner should be to research available treatment options and make sound decisions based on knowledge. There have been a couple of instances where I've cardioverted AFib with RVR and sedated the PT with Versed. Would I do that again? Depends. It's situational. Is etomidate a viable choice for me? Sure is. (Actually, it's the only sedation in the Delaware protocol for cardioversion.) If I felt I wanted to use versed instead, I wouldn't hesitate to call for the variance orders. But I'd also be able to defend my actions and explain why to the medical director.

 

[triemal04]

Interesting that you base your argument against etomidate on a study done on compromised, septic patients, when all of the other material which studied etomidate vs Versed as a rapid one dose sedative for painful, one time events (such as cardioversion) showed no significant issues with that one time dose. Most studies showed etomidate as 'a safe, effective drug." The study you quoted showed that half of the PTs had adrenal insufficiency PRIOR to etomidate! And the conclusions of the study state, "Relative adrenal insufficiency is present in most patients with septic shock after the administration of etomidate. Caution is recommended when using etomidate in these patients."

I don't think that the small study you cited is enough to class etomidate as "a terrible drug".

If I had to cardiovert a PT, who had a line up, was hemodynamicly unstable ... yet I felt required sedation prior to cardioversion, I would most likely chose etomidate over midazolam.

I don't think that anyone is going to argue that etomidate is not one of the better prehospital choices for procedural sedation, be it cardioversion, RSI, or something else; there's a huge amount of evidence that it is. Whether or not it does create problems for septic patients when given as a single bolus dose is debatable, and really there isn't a lot of definative info one way or the other.

Prospective study, found no signifigant change in mortality with etomidate. http://onlinelibrary.wiley.com/doi/10.1111/j.1553-2712.2008.00299.x/full

Based on kids and has some bearing. http://jcem.endojournals.org/content/90/9/5110.short

Reversable effects. http://www.springerlink.com/content/v587770g102w2736/

Mostly the common consencus that I've heard is that, while it may make treatement more difficult (need for more steroid administration) and may increase the amount of time spent in the ICU (something that also should be considered) the mortality isn't to changed.

 

[NomadicMedic]

I don't think that anyone is going to argue that etomidate is not one of the better prehospital choices for procedural sedation, be it cardioversion, RSI, or something else...

Really? Farmer2DO is arguing that exact point.

...Etomidate is OK for emergent airway situations, but when considered in the context of critical care medicine, it's a terrible drug.

Why would be okay for "emergent airway situations", but not for cardioversion? I'm confused by this logic. :glare:

But I'm thrashing this deceased equine. :deadhorse:

 

[triemal04]

Really? Farmer2DO is arguing that exact point.



Why would be okay for "emergent airway situations", but not for cardioversion? I'm confused by this logic. :glare:

But I'm thrashing this deceased equine. :deadhorse:

I probably should have phrased that "...one of the better prehospital choices for procedural sedation in non-septic patients..." Given that both the study referenced by Farmer2DO and the rest of his comments dealt with adrenal infufficiency and/or sepsis, that seemed to be what he was getting at. Or I'm wrong. Either way...I could care less.

 

[Handsome Robb]

I have been in EMS since 1985. I was a licensed medic from 1986 to 1998. I left EMS for 2 years to go into Health and Safety and came back in 2000. I stepped down to an I level cert in 1998 because it was easier to get the required IST hours. Because of my experience I remained an I for 11 years as I made the same amount of money with less headaches. I only decided to go back and renew my medic certs for reasons that would allow me to continue in the field until I decide to retire. I have trained EMT's and Medics for over 15 years.

Fair enough. I'll keep my mouth shut.

 

[Veneficus]

Just my opinion, but I think the reason etomidate is falling out of favour is because it was overhyped as "one of the safer choices."

There was this idea going around it didn't have profound cardiovascular effects, and true to medical science, when something seems too good to be true, then it is not true.

Also common to medicine when opinion swings far in one direction, like a pendulum it swings back equally as far.

Moderation is key.

 

[mycrofft]

Anytime I hear the phrase "mother's milk" in relation to a procedure, device or drug, I stay away.

 

[mycrofft]

PS:
Re the EKG situations noted above (bad interps etc) try these:
1. Per a machines in a GP's office's ointerp, the pt has, by retrospective review by a cardiologist, A Fib times five years, whereas the machine's interp was "occasional PVC".
2. Did EKG on a pt I KNEW had an arrhythmia (it was palpable and auscable). EKG looked and interpreted WNL! Found out it was re-printing the last EKG in memory instead of taking new ones. We sent it in for repair and never got it back.

 

[Fish]

It always seem like people are quick to point out the " I once saw..... I have seen...." in these situations, but we all need to remember that those are irregular and exceptions and are not the norm. I understand different areas of the Country expect different things out of their EMS services, I just know in the area I work if a Vtach patient is brought in that you did nothing for without justification you will certainly be getting a "what for???" from the ER Doc and your EMS systems QA Team. Ask a Cardiologist and they will tell you that Sync Cardioversion is effective and has a great percentage of favorable outcome, the risk of converting someone to a non-favorable rhythm is low....... very low. Ammiodarone does have its draw backs I will agree, but so does remaining in Vtach for extended periods..... What do ER Docs do with Vtach that we were not able to convert in the field? They attempt to convert it as well. I am no 20yr Medic, this is my 7th year in EMS...... But in those 7 years I have never seen a Doctor "sit and monitor" any patient in Vtach for an extended period of time, they have always taken steps towards conversion whether it be Medication or Electricity. And I have never seen a Medic do this either. Anyway, my two cents. Sounds like everyone one here has different experiences in these situations. Thought I would share mine......

 

[Fish]

Really? Farmer2DO is arguing that exact point.



Why would be okay for "emergent airway situations", but not for cardioversion? I'm confused by this logic. :glare:

But I'm thrashing this deceased equine. :deadhorse:

Ketamine!

 

[Veneficus]

It always seem like people are quick to point out the " I once saw..... I have seen...." in these situations, but we all need to remember that those are irregular and exceptions and are not the norm. I understand different areas of the Country expect different things out of their EMS services, I just know in the area I work if a Vtach patient is brought in that you did nothing for without justification you will certainly be getting a "what for???" from the ER Doc and your EMS systems QA Team. Ask a Cardiologist and they will tell you that Sync Cardioversion is effective and has a great percentage of favorable outcome, the risk of converting someone to a non-favorable rhythm is low....... very low. Ammiodarone does have its draw backs I will agree, but so does remaining in Vtach for extended periods..... What do ER Docs do with Vtach that we were not able to convert in the field? They attempt to convert it as well. I am no 20yr Medic, this is my 7th year in EMS...... But in those 7 years I have never seen a Doctor "sit and monitor" any patient in Vtach for an extended period of time, they have always taken steps towards conversion whether it be Medication or Electricity. And I have never seen a Medic do this either. Anyway, my two cents. Sounds like everyone one here has different experiences in these situations. Thought I would share mine......

I have seen an ER doc sit on vtach patients while they waited for cardiology to come and have a look, who ultimately cardioverted a patient.

I would not say it is a common thing to do, but I would caution people about looking at the final action and its outcome without knowing what went into the decision.

 

[Mad Russian]

Etomidate is a useful agent for procedural sedation because it provides effective, brief, deep sedation with little hemodynamic compromise.

 

[jwk]

I have seen an ER doc sit on vtach patients while they waited for cardiology to come and have a look, who ultimately cardioverted a patient.

Then this wouldn't be an ER doc that I'd want treating a member of my family.