# Unsedated Cardioversion



## samiam (Mar 19, 2015)

So excuse my ignorance but I am currently watching night watch on a and e and they had a elderly gentleman conscious with tachycardia 160 to 200. They tried adenosine twice then looked at the guy and said well gonna have to hit you with some energy. Shocked him with 50 then 100 joules perfectly alert no sedation no pain meds no nothing. Is this normal? The guy kinda freaks out and screams from the pain.


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## jcroteau (Mar 19, 2015)

Was he unstable? If so, cardio version would be more important than the pain


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## captaindepth (Mar 19, 2015)

Its kind of hard to answer without a more complete clinical picture but there are certainly times when synchronized cardioversion is indicated without sedation/pain management. If the pt is in a rhythm where electrical cardioversion is indicated and is hypotensive (deteriorating mentation) than immediate cardioversion is indicated without sedation. If the pt is not hypotensive then a benzodiazepine can be given prior to the shock. I've been told that giving Versed post cardioversion does have some amnestic effects and the pt wont remember what it feels like to be hit in the chest with 100J. 

If the guy is perfectly alert and screaming from the pain, I'm guessing his pressure was ok enough to give Versed prior to the shock. Did they try any vagal maneuvers first before the Adenosine?


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## gotbeerz001 (Mar 19, 2015)

We had a guy at 220, alert and anxious but hypotensive so we cardioverted him without any sedation. He certainly felt pain but instantly converted to a rate of 80. He was very thankful. He wanted to AMA... We said no.


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## chaz90 (Mar 19, 2015)

I've had to cardiovert without sedation before...Hypotensive, declining mental status, and no IV access. Yup, time for some Edison Medicine. 

For procedural sedation like this when IV access is already available we administer 0.1 mg/kg of Etomidate. I'd be more than happy to use some ketamine for it too if we carried it.


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## Chewy20 (Mar 20, 2015)

Watched that too, and yes people are cardioverted without pain meds. Turns out in the show the guy was septic, so that was an uh oh trying to cardiovert him. Fluid bolus would have been more appropriate.


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## Chewy20 (Mar 20, 2015)

captaindepth said:


> Its kind of hard to answer without a more complete clinical picture but there are certainly times when synchronized cardioversion is indicated without sedation/pain management. If the pt is in a rhythm where electrical cardioversion is indicated and is hypotensive (deteriorating mentation) than immediate cardioversion is indicated without sedation. If the pt is not hypotensive then a benzodiazepine can be given prior to the shock. I've been told that giving Versed post cardioversion does have some amnestic effects and the pt wont remember what it feels like to be hit in the chest with 100J.
> 
> If the guy is perfectly alert and screaming from the pain, I'm guessing his pressure was ok enough to give Versed prior to the shock. Did they try any vagal maneuvers first before the Adenosine?


 
Forget what the BP was or if they even said, did not see anything besides them giving adenosine then the attempted cardioversion. It's a tv show, so who knows what was cut out.


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## Nova1300 (Mar 20, 2015)

chaz90 said:


> I've had to cardiovert without sedation before...Hypotensive, declining mental status, and no IV access. Yup, time for some *Edison Medicine. *
> 
> For procedural sedation like this when IV access is already available we administer 0.1 mg/kg of Etomidate. I'd be more than happy to use some ketamine for it too if we carried it.




I'm stealing this gem!!


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## chaz90 (Mar 20, 2015)

Nova1300 said:


> I'm stealing this gem!!


Please do  I certainly can't take creative credit for it anyway.


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## Carlos Danger (Mar 20, 2015)

I did a handful of cardioversions when I was doing ground EMS and I never used any type of sedation, because it wasn't even an option in our protocols. Frankly, in an emergent setting I don't think it's a big deal at all; the shock is certainly uncomfortable but it is extremely brief. You can always give analgesia afterwards if they are in pain, though I don't think I've ever had to. I don't think amnesia is a big priority at all either.

In the hospital, elective cardioversions are done with any drug or combination of drugs. Propofol and versed seem most common, but etomidate, ketamine, and opioid are used by some anesthesia providers, as well.


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## DrankTheKoolaid (Mar 20, 2015)

Same, have performed a dozen or so cardioversions and have only sedated 1.  If they were stable enough for sedation then I would use Verepamil which worked in all but 1 patient.  By that point he did become unstable and was to hypotensive to use sedation.


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## Burritomedic1127 (Mar 20, 2015)

Usually when cardioverting the pt is circling the drain, and the pressure is too low/unstable to sedate. I have sedated pts before but it doesnt happen everytime and its very pt/pressure dependent. For whatever reasons from the EMS gods, i constantly see hypotensive rapid afib pts that need to be cardioverted. Which brings me to this, would you ever not cardiovert a patient in rapid afib knowing that they have never been med complaint with their Coumadin/blood thinner? Only had one MD, who gave waves because I cardioverted the homeless non med complaint patient


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## jcroteau (Mar 20, 2015)

Any chronic afib patient we need orders to cardio vert up here.


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## NomadicMedic (Mar 20, 2015)

Cardioverted several people without sedation. Funny thing, it didn't bother me one bit. I didn't even feel it.


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## NomadicMedic (Mar 21, 2015)

Good video to watch, if you've never actually seen a cardioversion.


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## NomadicMedic (Mar 21, 2015)

And here's an unsedated cardioversion, looks like they just got a little bit of midaz on board…


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## Burritomedic1127 (Mar 21, 2015)

First rule of EMS, don't talk about EMS. Jinxed myself talking about cardioversions. Grandma had a SVT in the 200s


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## NomadicMedic (Mar 21, 2015)

...And I just watched that episode of nightwatch where they juiced the dude in SVT. 

"Turns out he was septic..."

Opps. Sorry about those shocks.


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## Shishkabob (Mar 23, 2015)

samiam said:


> So excuse my ignorance but I am currently watching night watch on a and e and they had a elderly gentleman conscious with tachycardia 160 to 200. They tried adenosine twice then looked at the guy and said well gonna have to hit you with some energy. Shocked him with 50 then 100 joules perfectly alert no sedation no pain meds no nothing. Is this normal? The guy kinda freaks out and screams from the pain.




First, who said he was unsedated?  A crap-ton gets edited out to fit within the time slot, thus he very well may have gotten Ativan or Versed prior to the cardioversion.

Second, I don't have NOEMS protocols available, thus I don't know if they even have sedation, let alone what the blood pressure cut-off may or may not be for them.  Maybe they have sedation but protocols prohibited its use in that period.  Maybe when he spoke to the physician on the radio he wanted to hold back the sedation. Etc etc etc.




DEmedic said:


> ...And I just watched that episode of nightwatch where they juiced the dude in SVT.
> 
> "Turns out he was septic..."
> 
> Opps. Sorry about those shocks.



I've given Adenosine to, and the hospital cardioverted several times, a lady who was tachy solely from dehydration from NV and diarrhea for a few days.   She was altered, hypotensive, 190s-200s, no fever, and minimal hx from family.   Our bad.  Live and learn.  As my medical director said during the QA process, "It's called practicing medicine for a reason."


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## NYBLS (Mar 26, 2015)

I was able to get a somewhat decent view of the BP on the show and it was in the upper 80s systolic. We could have missed some sedation in the editing as other have pointed out. He also tried pushing the adenosine through a 20 in the dudes hand and was mystified when it wasn't effective.


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## chaz90 (Mar 26, 2015)

NYBLS said:


> I was able to get a somewhat decent view of the BP on the show and it was in the upper 80s systolic. We could have missed some sedation in the editing as other have pointed out. He also tried pushing the adenosine through a 20 in the dudes hand and was mystified when it wasn't effective.



Agreed with the pressure. 88 over something if I remember correctly. 

I've had success with Adenosine through 20G in less than central locations. It's not ideal, but you have to work with what you have. I think the bigger reason it didn't work at all was that the patient was in fact tachycardic secondary to sepsis rather than any sort of AVNRT or PSVT.


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## Christopher (Mar 26, 2015)

Cardioversion of septic patients is a no-no. Far too often we forget compensatory tachycardia itself isn't what you treat.

That being said:
1. Sedate. If they can answer your questions they have time for and deserve sedation (unless they refuse).
2. Adenosine can/does work through distal peripheral IV's. Given this patient had a variable heart rate it is highly unlikely his rhythm was reentrant, thus adenosine did not work because it does not fix non-reentrant rhythms.


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## TheLocalMedic (Mar 26, 2015)

Christopher said:


> Cardioversion of septic patients is a no-no. Far too often we forget compensatory tachycardia itself isn't what you treat.



Agreed.  It can be easy to get hooked into the "Holy cow, look at that heart rate! We gotta do something about that!" mentality and then forget to look for other non-cardiac causes.


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## COmedic17 (Mar 26, 2015)

Sedation is for.....kittens.

In all honesty, if someone is unstable enough that cardio version is immediately necessary- I'm not going to waste valuable time sedating. If they are somewhat stable, I'm going to go the medication route first. If it's still an issue ( hospital is close to my "area" of response, so I'm doubtful) then I could sedate and cardiovert.
If I cardiovert a stable person without first trying a medication based treatment, The hospital will be less then pleased. If I waste time sedating a critical patient to cardiovert, the hospital will be less then pleased.

However make sure you SHOULD be cardioverting if your going to do it.
Also make sure you SHOULD be using medication (adenosine , etc) if your going to.

Cardioverting isn't beneficial to sepsis or hypovolemia.
Adenosine isn't beneficial... At all... To afib RVR. Also don't give it to people with heart transplants. Also, it might behoove you to ask a patient if they have a history of WPW.

Also, I like to toss on fast patches prior to adenosine. Especially for those patients who "never go to the doctor, so there for a have no medical history". Keep in mind if a patient has WPW there's a chance adenosine will put them into VTACH. Recent studies have shown its not as common as once believed, but it's a risk. In addition, if they have WPW with afib- adenosine is lethal. Don't be that person. 

Think about the patho-physc before any treatment. You can't be "robotic" as a medic. It's not " if A, then do B". You have to really think about the whole picture. 

I have met people who want to slam adenosine in peoples as soon as they see SVT on the monitor. Then you point out its An irregular rhythm. That changes everything. Or they see an SVT and ignore the fact the patients skin is on fire and skin is tenting. That also changes everything.


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## Burritomedic1127 (Mar 26, 2015)

COmedic17 said:


> Sedation is for.....kittens.
> 
> In all honesty, if someone is unstable enough that cardio version is immediately necessary- I'm not going to waste valuable time sedating. If they are somewhat stable, I'm going to go the medication route first. If it's still an issue ( hospital is close to my "area" of response, so I'm doubtful) then I could sedate and cardiovert.
> If I cardiovert a stable person without first trying a medication based treatment, The hospital will be less then pleased. If I waste time sedating a critical patient to cardiovert, the hospital will be less then pleased.
> ...



For the most part, you should have time to give some sort of sedation before cardioverting. Yes, if the pt is circling the drain, minimally responsive, with a pressure in the 50-60s refractory to fluid, then hell yeah light em up. But I'd be pretty pissed if I have some symptomatic arrhythmia going on with a pressure in the 80s and you didn't give me any sedation. I've heard many medics (not directed at you), say how " sedation or pain management is earned, it's not a right blah blah blah", which is garbage. We all want to "do no harm" and "less invasive/best for patient options". Sedation is truly caring for the pt. Just something to think about before you give grandma/grandpa their breakfast of a nice non sedated 100J


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## COmedic17 (Mar 26, 2015)

Burritomedic1127 said:


> For the most part, you should have time to give some sort of sedation before cardioverting. Yes, if the pt is circling the drain, minimally responsive, with a pressure in the 50-60s refractory to fluid, then hell yeah light em up. But I'd be pretty pissed if I have some symptomatic arrhythmia going on with a pressure in the 80s and you didn't give me any sedation. I've heard many medics (not directed at you), say how " sedation or pain management is earned, it's not a right blah blah blah", which is garbage. We all want to "do no harm" and "less invasive/best for patient options". Sedation is truly caring for the pt. Just something to think about before you give grandma/grandpa their breakfast of a nice non sedated 100J


 I think you may of overlooked this part of what I said 

*If someone is unstable enough that cardio version is immediately necessary- I'm not going to waste valuable time sedating. If they are somewhat stable, I'm going to go the medication route first. If it's still an issue ( hospital is close to my "area" of response, so I'm doubtful) then I could sedate and cardiovert.

*
I'm not an unreasonable person. If the patient is reasonably "stable" and other treatments are not providing a favorable outcome, of course I'll sedate. But I'm not going to to cardiovert a completly stable person-ever. There's no reason. They are stable. If they are crashing, I'm not wasting time on sedation. If they are symptomatic but not circling the drain ( so if they are "reasonably stable"), medication has been unresponsive, then I will sedate. However transport is typically never over 10ish minutes (max, typically less) so I have never had to sedate/cardiovert a "reasonably stable" patient. 
*
*


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## NYBLS (Mar 26, 2015)

I think we need to keep in mind that cardioverting a patient is sometimes significantly less dangerous then going the medication route. Am I saying we should just shock people? No. 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.


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## Carlos Danger (Mar 26, 2015)

NYBLS said:


> I think we need to keep in mind that *cardioverting a patient is sometimes significantly less dangerous then going the medication route*. Am I saying we should just shock people? No. 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.



In what way? Do you have a reference for that?


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## Burritomedic1127 (Mar 26, 2015)

COmedic17 said:


> I think you may of overlooked this part of what I said
> 
> *If someone is unstable enough that cardio version is immediately necessary- I'm not going to waste valuable time sedating. If they are somewhat stable, I'm going to go the medication route first. If it's still an issue ( hospital is close to my "area" of response, so I'm doubtful) then I could sedate and cardiovert.
> 
> ...


Like I said it wasn't directed at you. And I'm not going to go full ACLS refresher, but I would hope you would never cardiovert a stable Pt ever. My point is not the algorithms we choose, medicine before Edison and all that. My point is, if it came to the point where your findings deemed an electrical therapy appropriate than it's not you could sedate, it's you should sedate. So would not want to sedate the grandma in rapid Afib with crushing chest pain, low BP, looks like crap, but PERFECT mental status? Doesn't matter if I'm on a call one block from the hospital, short transport times shouldn't be a deciding factor if some gets sedated. Personally, I wouldn't leave the house till everything was taken care of. With the stable, unstable, reasonably unstable Pt terms thrown out the window, if a pt can hear you and understand what your saying, regardless if transport time, and need to be cardioverted, give some sedations. It's like the old be kind rewind sayings of VHS tapes, you don't have to but you should.


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## Burritomedic1127 (Mar 26, 2015)

NYBLS said:


> I think we need to keep in mind that cardioverting a patient is sometimes significantly less dangerous then going the medication route. Am I saying we should just shock people? No. 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.


Giving pain management is good Pt care. End of story. I'm not saying sedate someone for every IV but electrical therapies are big painful procedures where sedation will help the pt. Next time you see someone get cardioverted in the ER, not pre hospital, tell me if the MD/PA/RN doesn't have some sedation medication running. Explain to me then why you give lidocaine for a conscious IO


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## Burritomedic1127 (Mar 26, 2015)

Man I need to proof read my posts for spelling. "Give some sedations" is my new term haha


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## COmedic17 (Mar 26, 2015)

Burritomedic1127 said:


> Like I said it wasn't directed at you. And I'm not going to go full ACLS refresher, but I would hope you would never cardiovert a stable Pt ever. My point is not the algorithms we choose, medicine before Edison and all that. My point is, if it came to the point where your findings deemed an electrical therapy appropriate than it's not you could sedate, it's you should sedate. So would not want to sedate the grandma in rapid Afib with crushing chest pain, low BP, looks like crap, but PERFECT mental status? Doesn't matter if I'm on a call one block from the hospital, short transport times shouldn't be a deciding factor if some gets sedated. Personally, I wouldn't leave the house till everything was taken care of. With the stable, unstable, reasonably unstable Pt terms thrown out the window, if a pt can hear you and understand what your saying, regardless if transport time, and need to be cardioverted, give some sedations. It's like the old be kind rewind sayings of VHS tapes, you don't have to but you should.


 


Your essentially repeating everything I just said, so I'm going to assume your more concerned about arguing then reading what I actually said.

I stated I would never cardiovert a stable patient. Verbatim. In those exact words. 

I also stated I would sedate a "reasonably stable" patient if need be/I was able to, however transport times are so short by the time I tried the medication interventions, I would more then likely already be at the hospital. I'm not going to go park in a Walmart parking lot to elongate transport times to So I can have ample time to try all medicinal approaches, then sedate and Cardiovert. 

In response to your " So would not want to sedate the grandma in rapid Afib with crushing chest pain, low BP, looks like crap, but PERFECT mental status?" Statement , my answer is no. If her blood pressure is so low, and she looks like crap, she's not stable. You speak of algorithms. I ask you to please review the algorithm for unstable tachycardia. I believe it says "consider sedation" and cardiovert. I'm not going to let her go into VTACH becauseI was prepping for sedation why she was clearly very unstable.

In addition,  Please find me literature that states anybody with an intact mental status is automatically "stable". There's people who have been shot five times, have low BP, and are mentally alert. If they have a tension pneumo are you going to withhold that treatment due to them feeling pain? Are you going to waste time sedating them when they could crash any minute? I would sure hope you wouldn't. 

Sometimes what's in the best intrest of the patient isn't the most comfortable. 


But as I stated, a lot of the "points" you are trying to make are repetitive of things I have already said. So I don't believe you are reading what I am saying as much as you are looking for a reason to argue. 

I will have a DISCUSSION with you but I'm not going to continue on with a redundant argument.


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## Burritomedic1127 (Mar 26, 2015)

Where do i start

First off, ill repeat it was never originally directed at you.

Yes i was repeating your verbatim of saying i hope you never would, Because you were explaining, you never would cardiovert a stable person.  This is us agreeing

Just my style of medicine, i would never move a pt that needed to be cardioverted to the rig, so i wouldnt have to stop at at walmart parking lot. You have "ample time to try medicinal approaches, on scene. But hey i think they have really badass emt shirts for cheap. Dont know why we do anything prehospital anyways, we should drive fast.

For the example pt, i would be BS if you didnt sedate my grandma. Yeah her pressure is low (lets say 80), low pressure, chest pain = unstable (i just read my ACLS for the first time). Would 0.5 mg Versed tank her pressure? Prob not. Would it make her feel somewhat more comfortable when we cardiovert her absolutely. 

I consider sedation constantly, thats while all my pts that need to be sedated, get sedated.


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## Carlos Danger (Mar 26, 2015)

Burritomedic1127 said:


> For the example pt, i would be BS if you didnt sedate my grandma. Yeah her pressure is low (lets say 80), low pressure, chest pain = unstable (i just read my ACLS for the first time). Would 0.5 mg Versed tank her pressure? Prob not. Would it make her feel somewhat more comfortable when we cardiovert her absolutely.



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.


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## COmedic17 (Mar 26, 2015)

Burritomedic1127 said:


> Would 0.5 mg Versed tank her pressure? Prob not. Would it make her feel somewhat more comfortable when we cardiovert her absolutely.
> 
> I consider sedation constantly, thats while all my pts that need to be sedated, get sedated.




Unless is a cardiac arrest, it's typically load and go. Fire has them ready by the time We get there to go straight on my cot with baseline vitals taken


Secondly, for sedation it is "recommended" slow push of over 1-2 minutes. Versed also has an onset of 2-3 minutes of given IV. 15 minutes if given IM ( should you not be able to obtain a line). 3-5 minutes is a pretty significant portion of a ten minute transport. Even if your on scene, that's a significant amount of time to spend sedating a patient with a falling blood pressure and inadequate skin vitals.

A side effect is also hypotension..right along with a decreased respiratory drive, arrhythmias, and bronchospasm. Which is why a lower dose if recommended if BP is under 100. It is also recommended to "  use with caution" in patients over 70 years old for these reasons. Will .5mg aid in some of the pain assisted with cardio version? Maybe. But is it worth prolonging cardio version in an unstable patient? I don't believe so. I have dumped 10mg of versed (max dose) in intubated patients and they have still kept fighting.


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


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## NYBLS (Mar 26, 2015)

Burritomedic1127 said:


> Giving pain management is good Pt care. End of story. I'm not saying sedate someone for every IV but electrical therapies are big painful procedures where sedation will help the pt. Next time you see someone get cardioverted in the ER, not pre hospital, tell me if the MD/PA/RN doesn't have some sedation medication running. Explain to me then why you give lidocaine for a conscious IO



Where did I say I would not provide analgesics?


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## COmedic17 (Mar 26, 2015)

And to add to the lidocaine/conscious IO- there's even exceptions to that too.

It's not recommended, for use in 2nd&3rd degree heart blocks, WPW, people allergic to corn, or if they have recieved Amio. 

If lidocaine was contraindicated I would still drill without it. If they are in bad enough shape to need an IO I think the pain is the least of their problems. 

Is pain management preferable? Yes. But it's not always possible or the best option for the patient.


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## Carlos Danger (Mar 26, 2015)

COmedic17 said:


> And to add to the lidocaine/conscious IO- there's even exceptions to that too.
> 
> It's not recommended, for use in 2nd&3rd degree heart blocks, WPW, *people allergic to corn*, or if they have recieved Amio.



That's a new one to me. Do you have a reference for that?


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## NomadicMedic (Mar 26, 2015)

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.


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## COmedic17 (Mar 26, 2015)

Remi said:


> That's a new one to me. Do you have a reference for that?


Sure. Ill look some up real quick



Here's an easy to read reference

http://www.drugs.com/mtm/lidocaine-injection.html




Here's some references that are a little longer, but more reputable sources.

http://www.fda.gov/Safety/MedWatch/SafetyInformation/ucm342035.htm

http://dailymed.nlm.nih.gov/dailymed/archives/fdaDrugInfo.cfm?archiveid=11189




And here's some pdf files 

www.medsafe.govt.nz/profs/datasheet/l/lidocainesol.pdf

www.accessdata.fda.gov/drugsatfda_docs/label/2012/018461s056lbl.pdf


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## 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.


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## Carlos Danger (Mar 26, 2015)

That's a new one. Interesting.


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## 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.


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## Brandon O (Mar 26, 2015)

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


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## 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.


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## COmedic17 (Mar 26, 2015)

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


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## 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


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## 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.


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## 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.


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## 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.


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## 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".


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## 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.


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## PotatoMedic (Mar 27, 2015)

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


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## 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.


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## 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.


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## 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.


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## 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.


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## 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?


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## 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.


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## 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...


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## Burritomedic1127 (Mar 30, 2015)

triemal04 said:


> 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.



Agree completely with different definitions of stable VS unstable. The question about the IO was in regards to "abandoning good care because of the pain" post earlier. Cardiac arrest/unresponsive sure IO with no lidocaine but a pt who is conscious and for whatever reason needed an IO, IMO, should get a local anesthetic. I'm required to give a min of 20mg and up to 40mg of lidocaine with a conscious IO. Wouldnt slam a flush home and watch them go through more pain for the garbage line of "this is saving your life."


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## Burritomedic1127 (Mar 30, 2015)

gotshirtz001 said:


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



Truth


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## triemal04 (Mar 30, 2015)

Burritomedic1127 said:


> Agree completely with different definitions of stable VS unstable. The question about the IO was in regards to "abandoning good care because of the pain" post earlier. Cardiac arrest/unresponsive sure IO with no lidocaine but a pt who is conscious and for whatever reason needed an IO, IMO, should get a local anesthetic. I'm required to give a min of 20mg and up to 40mg of lidocaine with a conscious IO. Wouldnt slam a flush home and watch them go through more pain for the garbage line of "this is saving your life."


Ok, figured that was it, just making sure.


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## TheLocalMedic (Apr 3, 2015)

Alright, so I'll throw this one out there for the crowd to chew on...  

I had a guy the other day that we found laying on the ground, gasping with crushing chest pain, saying that he was having a heart attack.  He was in rapid a-fib at a rate around 200, no radial and a pressure at 80 systolic.  No history of a-fib, he was a little obtunded (not terrible, knew where he was and could follow commands, but thought the year was 1990-something, age was 60 something, no dementia).  I tried for IV access twice, but no luck, and his presentation started to look even more dramatic.  

So I lit him up.  200J sync cardioversion without sedation.  I told him it would hurt and he basically gave me the thumbs up to just get it over with, and got the expected "MOTHER F*&#$!!!" response when I hit him.  He converted, symptoms disappear, rate is a nice, stable 80 sinus rhythm and 12 lead looks pretty clean.  

Was it the most fun experience of his life? No.  Did it work?  Yes.  Afterwards he was feeling so relieved he tried to hug me.  

To me that seemed like a pretty clear-cut case of an unstable patient, and I wasn't about to screw around with more IV attempts to try and get some Versed on board before zapping him.  However, after reading this thread I'm willing to bet that there are some people out there who disagree, and I'm curious to hear what your thoughts are.


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## Carlos Danger (Apr 3, 2015)

TheLocalMedic said:


> To me that seemed like a pretty clear-cut case of an unstable patient, and I wasn't about to screw around with more IV attempts to try and get some Versed on board before zapping him.



I agree, seems pretty clear cut to me. I don't know for sure that I would have even taken the time to attempt an IV. Even if I had an IV I don't think I would have given him anything.


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## NomadicMedic (Apr 3, 2015)

I would have just lit him up. Maybe not with 200j, but certainly some electricity. 

Cardiovert first, apologize later.


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## Burritomedic1127 (Apr 4, 2015)

TheLocalMedic said:


> Alright, so I'll throw this one out there for the crowd to chew on...
> 
> I had a guy the other day that we found laying on the ground, gasping with crushing chest pain, saying that he was having a heart attack.  He was in rapid a-fib at a rate around 200, no radial and a pressure at 80 systolic.  No history of a-fib, he was a little obtunded (not terrible, knew where he was and could follow commands, but thought the year was 1990-something, age was 60 something, no dementia).  I tried for IV access twice, but no luck, and his presentation started to look even more dramatic.
> 
> ...



Would have done the same. Nothing wrong with that. From the picture you painted it sounded like he was decompensating pretty quick


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## samiam (Apr 4, 2015)

This is quite interesting where this has all gone. From a personal experience, I am not exactly sure what I would rather have. I have had a nice 2 hour run of A-Fib with actual QRS's getting thru at about 203bpm and god knows how many P waves there were. I got the pleasure of adenosine x3 and then a nice cardioversion. I feel like I would still go for the adenosine first than the cardioversion assuming it was unsedated. Mine was with propofol and versed so I was fine but I feel like it would have not been pleasant had it not been. Then again adenosine is really not the most pleasant experience feeling like you are about to slip away and die x3.

It definitely seems like the stability of the patient is key here. If they are walking and talking then please give them some propofol!


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## NomadicMedic (Apr 4, 2015)

...of course the stability of patient is what you take into consideration. That's what what this whole discussion has been about.

unstable patients get electricity.

stable patients get sedation... Than electricity


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## MonkeyArrow (Apr 4, 2015)

Had a case today in the ED of a man with previous cardiac Hx and an ICD with Vtach in the 120s. CC was chest pain and palpitations. He was talking and perfusing well on 2 L 02 home oxygen, but still in Vtach. EMS crews who brought him in couldn't find a IV after sticking him multiple times. In essence, he didn't get any treatment en route. At our facility, he received 2 PIVs upon arrival. Shortly thereafter, he decompensated and his SpO2 stats dropped. Even though he suddenly went from being "stable" to "unstable", we still took the time to give him 100 of Fent and 20 of etomidate before cardioversion. He also was given successive 100 and 75 mg boluses of lidocaine by the EDP and cardiology, because the patient stated that it had worked for him before. The lido didn't work, and we moved onto cardioversion, successfully converting with 120 J. He went into a ventricular rhythm in the 55-65 bpm range, with a pressure somewhere over 70/50. Somewhere in there, we also pressure infused a liter of saline into him. Pt. survived to CCU admission, talking and breathing on his own. His pressure remained in the 70/50 range, and his SpO2 at 100% on nasal cannula.

Point of the story: I don't really know. Maybe it's that what really seems unstable to us really isn't all that abnormal. This guy states he had baseline vitals of 80/60, so his presenting BP wasn't that abnormally low. Sure, we delayed cardioversion by 3-4 minutes in an "unstable" patient, so what? Most of us out there in the field would have immediately though this patient is sure to die, this is not a perfusing rhythm. By the looks of it, it wasn't. But this pt. probably had this rhythm for the better part of two hours.

On a side note, I would also like to point out that this is another example of what a hospital can do for a patient that EMS cannot do out in the field. Push lidocaine for Vtach as a first line drug? Interrogate the ICD? (His ICD did not fire because the threshold was set higher than 120)

*Note, while I have been calling it Vtach, it is more technically wide-complex tachycardia. However, there were no p-waves or discernible QRS complexes. However, it was determined between the EDP and the cardiology doctors that this was ventricular in origin.


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## NomadicMedic (Apr 4, 2015)

If a patient was able to articulate that Lidocaine had successfully converted his ventricular rhythm in the past, you could be damn sure I'd be on the phone with medical control requesting orders.

He would also have pads on his chest and the life pak would be in SYNC.

**That's one thing that paramedics can do pre hospital.  I'd bet that the doc in the ED wasn't looking at lido as his first line drug either. But that expert consult from cardiology was a smart thing. 

And would you still be grinning about how you waited those 3 or 4 minutes to give the PT etomidate and fent and then you couldn't convert him back to a sustainable rhythm?

Tl;dr? Cool story bro. Cardiovert unstable patients. Period. 

**ps: O2 sats, not stats.


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## Tigger (Apr 4, 2015)

MonkeyArrow said:


> Had a case today in the ED of a man with previous cardiac Hx and an ICD with Vtach in the 120s. CC was chest pain and palpitations. He was talking and perfusing well on 2 L 02 home oxygen, but still in Vtach. EMS crews who brought him in couldn't find a IV after sticking him multiple times. In essence, he didn't get any treatment en route. At our facility, he received 2 PIVs upon arrival. Shortly thereafter, he decompensated and his SpO2 stats dropped. Even though he suddenly went from being "stable" to "unstable", we still took the time to give him 100 of Fent and 20 of etomidate before cardioversion. He also was given successive 100 and 75 mg boluses of lidocaine by the EDP and cardiology, because the patient stated that it had worked for him before. The lido didn't work, and we moved onto cardioversion, successfully converting with 120 J. He went into a ventricular rhythm in the 55-65 bpm range, with a pressure somewhere over 70/50. Somewhere in there, we also pressure infused a liter of saline into him. Pt. survived to CCU admission, talking and breathing on his own. His pressure remained in the 70/50 range, and his SpO2 at 100% on nasal cannula.
> 
> Point of the story: I don't really know. Maybe it's that what really seems unstable to us really isn't all that abnormal. This guy states he had baseline vitals of 80/60, so his presenting BP wasn't that abnormally low. Sure, we delayed cardioversion by 3-4 minutes in an "unstable" patient, so what? Most of us out there in the field would have immediately though this patient is sure to die, this is not a perfusing rhythm. By the looks of it, it wasn't. But this pt. probably had this rhythm for the better part of two hours.
> 
> ...



Shocking. The hospital is able to do things that EMS cannot do. Possibly because it is a hospital. 

We get it.


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## MonkeyArrow (Apr 4, 2015)

Tigger said:


> Shocking. The hospital is able to do things that EMS cannot do. Possibly because it is a hospital.
> 
> We get it.


Just waiting for the next transport-or-work-on-scene-arrest debate (well, it's only me against everyone else) that comes up, when everyone says, "The hospital can't do anything that I can do in the field."


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## Nova1300 (Apr 4, 2015)

MonkeyArrow said:


> Had a case today in the ED of a man with previous cardiac Hx and an ICD with Vtach in the 120s. CC was chest pain and palpitations. He was talking and perfusing well on 2 L 02 home oxygen, but still in Vtach. EMS crews who brought him in couldn't find a IV after sticking him multiple times. In essence, he didn't get any treatment en route. At our facility, he received 2 PIVs upon arrival. Shortly thereafter, he decompensated and his SpO2 stats dropped. Even though he suddenly went from being "stable" to "unstable", we still took the time to give him *100 of Fent and 20 of etomidate* before cardioversion. He also was given successive 100 and 75 mg boluses of lidocaine by the EDP and cardiology, because the patient stated that it had worked for him before. The lido didn't work, and we moved onto cardioversion, successfully converting with 120 J. He went into a ventricular rhythm in the 55-65 bpm range, with a pressure somewhere over 70/50. Somewhere in there, we also pressure infused a liter of saline into him. Pt. survived to CCU admission, talking and breathing on his own. His pressure remained in the 70/50 range, and his SpO2 at 100% on nasal cannula.
> 
> Point of the story: I don't really know. Maybe it's that what really seems unstable to us really isn't all that abnormal. This guy states he had baseline vitals of 80/60, so his presenting BP wasn't that abnormally low. Sure, we delayed cardioversion by 3-4 minutes in an "unstable" patient, so what? Most of us out there in the field would have immediately though this patient is sure to die, this is not a perfusing rhythm. By the looks of it, it wasn't. But this pt. probably had this rhythm for the better part of two hours.
> 
> ...




Holy lord that's a lot of drug for a cardioversion.


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## PotatoMedic (Apr 4, 2015)

Not really.  Kinda on the high end for fentynal but not that bad.


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## Nova1300 (Apr 4, 2015)

FireWA1 said:


> Not really.  Kinda on the high end for fentynal but not that bad.



We may have to agree to disagree on this one.  But it brings up a good point.

Do you guys really feel an opiate is appropriate for cardioversion?  I will tell you, my answer is no.


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## PotatoMedic (Apr 5, 2015)

At most I would give 25-50mcg's, usually I would only sedate but I could see pain medication being given since it does hurt.

And all I was thinking was dosage of medications.  I can give up to 200mcg in trauma and 100mcg for medical. So again giving 100 for cardio version seems much but giving fentynal does not (to me) seem unreasonable.


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## Carlos Danger (Apr 5, 2015)

Nova1300 said:


> Holy lord that's a lot of drug for a cardioversion.


My thoughts exactly.


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## Nova1300 (Apr 5, 2015)

I think it's reasonable to give them.  The thought process and motivation for giving opiate is sound.  But let me tell you why I think it is not terribly useful, though this is anecdotal :
First is the brevity of the stimulus.  Although cardiversion is incredibly uncomfortable, it lasts a fraction of a second.  There is no residual pain.  But there is residual opiate now floating around.  Which is fine in stable patients. But patients in extremis from their rhythm frequently have hypoxia and hypercarbia.  And an opiate with no painful stimulus to treat becomes nothing more than a respiratory depressant, not something you want in a patient already hypoxic or hypercarbic. 

Secondly, and this is the part that is completely anecdotal, I think opiates are far more effective in some types of pain than others.  In general I have found that opiates are useful in pain caused by a constant stimulus, usually achy and dull.  I do not find opiates treat a sharp or sudden painful stimulus well.  And though I can't think of a word to describe the discomfort of cardiversion, I would relate it closely with sharp. 

I think effective sedation for cardioversion comes in two flavors: make them briefly unconscious or make them forget it happened.  And that involves _small_ doses of an induction agent or an amnestic.  Fentanyl is neither of those things.  That, combined with the potential respiratory effects of residual opiate in a patient with no pain to treat and the very real potential for deterioration is enough to keep opiates out of my arsenal for cardioversion.


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## Brandon O (Apr 5, 2015)

You're worried about duration of effect even for fent?


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## Carlos Danger (Apr 5, 2015)

Brandon O said:


> You're worried about duration of effect even for fent?



Why not? Even though it's short acting compared to other opioids, it lasts infinitely longer than the stimulus of cardioversion.

I would give it post-procedure IF they were having pain, but that usually isn't needed.


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## Nova1300 (Apr 5, 2015)

Remi said:


> Why not? Even though it's short acting compared to other opioids, it lasts infinitely longer than the stimulus of cardioversion.
> 
> I would give it post-procedure IF they were having pain, but that usually isn't needed.



This.  Opiates without a pain stimulus to treat can quickly become a nuisance in a sick patient without an airway. 

I think the case against fentanyl is even stronger in patients with atrial fibrillation.  Many of these patients are already on some form of anti arrhythmic and often other drugs which are monopolizing the cytochromes in the liver.  Combined with the hypoperfusion of the kidney, which eliminates a good bit of fentanyl unchanged, that duration of action may not be quite as short as you think.


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## MonkeyArrow (Apr 5, 2015)

I will add that the patient given those meds was bagged by the RT for about 5 minutes after the cardioversion. No adverse effects were seen and the patient's saturation remained high throughout. He was awake and talking shortly. Again, n=1.


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## Nova1300 (Apr 5, 2015)

MonkeyArrow said:


> I will add that the patient given those meds was bagged by the RT for about 5 minutes after the cardioversion. No adverse effects were seen and the patient's saturation remained high throughout. He was awake and talking shortly. Again, n=1.



 And that is what we call induction of general anesthesia without an airway in a patient with a full stomach.


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## Carlos Danger (Apr 5, 2015)

MonkeyArrow said:


> I will add that the patient given those meds was bagged by the RT for about 5 minutes after the cardioversion. No adverse effects were seen and the patient's saturation remained high throughout. He was awake and talking shortly. Again, n=1.



You don't consider needing to be ventilated an adverse effect?


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## MonkeyArrow (Apr 5, 2015)

Remi said:


> You don't consider needing to be ventilated an adverse effect?


No, because it was expected. The RT and the ED doc were already there expecting to have to manage the airway. I guess it could be considered an adverse effect. So maybe I should rephrase and say no unexpected results.


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## TheLocalMedic (Apr 6, 2015)

Nova1300 said:


> And that is what we call induction of general anesthesia without an airway in a patient with a full stomach.



Definitely agree with you.


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## Carlos Danger (Apr 6, 2015)

MonkeyArrow said:


> No, because it was expected. The RT and the ED doc were already there expecting to have to manage the airway. I guess it could be considered an adverse effect. So maybe I should rephrase and say no unexpected results.



I just don't see a need to induce general anesthesia (which is exactly what 20 of etomidate and 100 of fentanyl is) and take on all the risks that come along with it for cardioversion. There's just no reason to get someone so deep that they need respiratory support. I also think that if you _are_ going to do that, then anesthesia should be involved. 

Fentanyl by itself is very safe and easy to use. But when you start mixing it with GABA agonists, especially in hemodynamically compromised patients, and especially in those who are on lots of other meds, things can get really.....interesting. 

I'm not questioning the judgement of the folks who made the decision to put this guy all the way to sleep - maybe they had a good reason in this case. But as a routine practice, it just isn't necessary, and is probably not the safest practice.


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## RedAirplane (Apr 15, 2015)

I'm a BLS guy hanging out in the wrong forum... But I'm surprised to learn that you shock things besides VF and pulsless VT. Is there a brief explanation of this I can find somewhere?


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## DesertMedic66 (Apr 15, 2015)

Ishan said:


> I'm a BLS guy hanging out in the wrong forum... But I'm surprised to learn that you shock things besides VF and pulsless VT. Is there a brief explanation of this I can find somewhere?


We shock VT with pulses and SVT (in patients who are unstable) because their hearts are not able to maintain perfusion in those rhythms. It's like hitting the reset button.


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## gotbeerz001 (Apr 15, 2015)

Ishan said:


> I'm a BLS guy hanging out in the wrong forum... But I'm surprised to learn that you shock things besides VF and pulsless VT. Is there a brief explanation of this I can find somewhere?


Google "synchronized cardioversion"... Basically a lower dose of a well-timed shock for someone not dead... Yet.


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## jwk (Apr 22, 2015)

MonkeyArrow said:


> No, because it was expected. The RT and the ED doc were already there expecting to have to manage the airway. I guess it could be considered an adverse effect. So maybe I should rephrase and say no unexpected results.


Not sure where you are in GA, but your ER doc needs remedial education on the different levels of sedation.  What he did definitely crosses way over the sedation line, which is all that is indicated for cardioversion, and into general anesthesia.  I would seriously question the clinical judgement of that physician if he truly thinks this is acceptable practice.  I don't know any hospital that grants "general anesthesia" privileges to ER docs.


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