# Adenosine Question



## EMSrush (Nov 7, 2010)

Hey guys-
I have a question that I'd love to get some feedback on...

I worked with a preceptor who told me that he had a PT several years ago whom, after receiving Adenosine, went into asystole and never came out of it. The preceptor explained that the PT was throwing PVC's (>25/min) with an underlying NSR. He further explained that, "...when I gave the Adenosine, I took away his ventricles, which was all that the PT had left...".

I'm not sure if I agree with this explanation. His treatment that he administered doesn't necessarily sound like it was inappropriate to me...? Anyone??


----------



## fma08 (Nov 7, 2010)

EMSrush said:


> Hey guys-
> I have a question that I'd love to get some feedback on...
> 
> I worked with a preceptor who told me that he had a PT several years ago whom, after receiving Adenosine, went into asystole and never came out of it. The preceptor explained that the PT was throwing PVC's (>25/min) with an underlying NSR. He further explained that, "...when I gave the Adenosine, I took away his ventricles, which was all that the PT had left...".
> ...



:blink: That's about all I have to say for your preceptor.

1. Adenosine does not work on the ventricles.
2. Adenosine isn't indicated for PVC's
3. Asystole is a side effect of adenosine.
4. If the pt. is in NSR with PVC's, the ventricles are not all the pt. has left.


----------



## Shishkabob (Nov 7, 2010)

Either you heard wrong, or.....Stay far far away from that medic.....


----------



## EMSrush (Nov 7, 2010)

*Note: I'm so sorry... I had been reading a bunch of different forums, and I wrote "Adenosine" instead of "Lidocaine". First thread response helped me realize my mistake. Big difference, sorry about that... Will edit original post. LOL.*

Hey guys-
I have a question that I'd love to get some feedback on...

I worked with a preceptor who told me that he had a PT several years ago whom, after receiving Lidocaine, went into asystole and never came out of it. The preceptor explained that the PT was throwing PVC's (>25/min) with an underlying NSR. He further explained that, "...when I gave the Lidocaine, I took away his ventricles, which was all that the PT had left...".

I'm not sure if I agree with this explanation. His treatment that he administered doesn't necessarily sound like it was inappropriate to me...? Anyone??


----------



## fma08 (Nov 7, 2010)

EMSrush said:


> *Note: I'm so sorry... I had been reading a bunch of different forums, and I wrote "Adenosine" instead of "Lidocaine". First thread response helped me realize my mistake. Big difference, sorry about that... Will edit original post. LOL.*
> 
> Hey guys-
> I have a question that I'd love to get some feedback on...
> ...



1. Lidocaine does work on the ventricles
2. Lidocaine is indicated for PVC's (although they are pushing away from giving it except in severe cases according to my understanding)
3. If the pt. is in NSR with PVC's, the ventricles are not all the pt. has left.
4. Can't make a determination without seeing the pt. or lots more information.


----------



## EMSrush (Nov 7, 2010)

fma08 said:


> 3. If the pt. is in NSR with PVC's, the ventricles are not all the pt. has left.



That was my very first thought.


----------



## the Happy Medic (Nov 7, 2010)

We no longer carry Lidocaine, but when we did the question came back to how "bad" the PVCs were.

If the logic was that the lidocaine will slow other impulses to match the PVCs, then were we really helping a sick heart?

With so much new focus on testing these interventions we've relied on, we're finding more and more that many of our medications have little, if any, effect.

I nearly spit out my coffee on that first post though!  Adenosine for PVCs...I thought it was a trick question at first.


----------



## EMSrush (Nov 7, 2010)

the Happy Medic said:


> We no longer carry Lidocaine, but when we did the question came back to how "bad" the PVCs were.
> 
> If the logic was that the lidocaine will slow other impulses to match the PVCs, then were we really helping a sick heart?
> 
> ...



Ha... I felt pretty silly myself when I re-read my original posting. I know school has taken a bit of a toll on me, but geez! :glare:

As a newbie, if it had been my call, it would have been hard for me to gauge how "bad" the PVC's were.. but I would probably look to see if the PT is symptomatic, rather than rely on frequency. The service I did my ride outs with does still carry Lido... I didn't realize it was being phased out in other regions. I knew Amiodarone was starting to be pushed a bit more, but didn't realize Lido was being phased out.


----------



## Aidey (Nov 7, 2010)

I have heard of a similar case. The pt was in bijeminy at around 60, including the PVCs (they were perfusing). When they gave him lidocaine the PVCs stopped but the sinus rate stayed the same (30), and then they had to treat him for unstable bradycardia. He didn't code, but they made him a lot worse.


----------



## Smash (Nov 7, 2010)

It used to be trendy to treat PVCs.  Then we realized that we weren't helping anyone and we were sometimes making people worse.  In some areas it's even a touch controversial as to whether we should even be using amiodarone in conscious VT in the field.  The thinking is, if it is unstable, cardiovert it, if it isn't, take it to hospital.

I think TomB could probably add more to that discussion than I could though.


----------



## mgr22 (Nov 8, 2010)

Those wide complexes were probably ventricular escape beats, not PVCs (there was likely nothing premature about them). Yes, lidocaine would be bad in that situation.


----------



## EMSrush (Nov 8, 2010)

mgr22 said:


> Those wide complexes were probably ventricular escape beats, not PVCs (there was likely nothing premature about them). Yes, lidocaine would be bad in that situation.



Hmm... I had never even considered that. :unsure: And if they were indeed escape beats, that would not be something we would want to treat, because the heart needed that beat to maintain. And that might explain why his PT had the reaction that he did. Am I close...?


----------



## usalsfyre (Nov 8, 2010)

Treating well tolerated, non-life threatening arrythmias in the field is fraught with peril. Your best bet, outside of maybe adenosine for SVT is to let the guys with 3-4 years of residency plu 1-2 years of fellowship sort is all out.


----------



## mgr22 (Nov 8, 2010)

EMSrush said:


> Hmm... I had never even considered that. :unsure: And if they were indeed escape beats, that would not be something we would want to treat, because the heart needed that beat to maintain. And that might explain why his PT had the reaction that he did. Am I close...?



You didn't say how symptomatic the patient was before the lido. If he/she had been perfusing well despite those PVCs, I'd be wondering why an antiarrhythmic was administered prehospitally.


----------



## vquintessence (Nov 8, 2010)

I second usalyfyre.

A lot is missing from your description of events, most likely due to the vague recollection of events from your preceptor.  But beating a dead horse to death... treating something that's there (ie. PVCs) but is ostensibly asymptomatic at the moment, is mind boggling.

Do you treat the ankle fx w/ gross deformity and (+)distal CMS with fentanyl 100 mcg, versed 2.5 mg and then attempt to realign the extremity?

Take your preceptors situation however, and add numerous syncopal events w/ generalized weakness and pallor; now what?  Would any of you intervene?  If so, with what?


----------



## EMSrush (Nov 8, 2010)

mgr22 said:


> You didn't say how symptomatic the patient was before the lido. If he/she had been perfusing well despite those PVCs, I'd be wondering why an antiarrhythmic was administered prehospitally.



That was one of the first questions I asked my preceptor... and I didn't get much of a response. I didn't push the issue, but it definitely gave me something to chew on. -_-


----------



## Sugi (Nov 10, 2010)

EMSrush said:


> *Note: I'm so sorry... I had been reading a bunch of different forums, and I wrote "Adenosine" instead of "Lidocaine". First thread response helped me realize my mistake. Big difference, sorry about that... Will edit original post. LOL.*
> 
> Hey guys-
> I have a question that I'd love to get some feedback on...
> ...



Were they R on T PVC's? Maybe the asystole didnt have anything to do with the lido... Maybe the R on T pvc's threw the pt into a fine vfib? I know its a bit of a stretch, but I've never heard of lido causing asystole before... I guess you could have pushed like 100mL instead of 100mg (though I would be interested to know where you got that packaging from haha)

Which brings me to a point that I had... Alot of people on this thread said lido is more hurtful than helpful. What about for R on T PVC's?


----------



## MrBrown (Nov 10, 2010)

Smash said:


> It used to be trendy to treat PVCs.



It used to be trendy to roll around in blue jumpsuits with "PARAMEDIC" on the back in yellow letters with lots of gold chains and an afro, drive a high top caddy with orange lights and struggle to carry in the Lifepak 4 and tacklebox full of drugs and glass IV bottles too ....


----------



## EMSrush (Nov 10, 2010)

Sugi said:


> Were they R on T PVC's? Maybe the asystole didnt have anything to do with the lido... Maybe the R on T pvc's threw the pt into a fine vfib? I know its a bit of a stretch, but I've never heard of lido causing asystole before... I guess you could have pushed like 100mL instead of 100mg (though I would be interested to know where you got that packaging from haha)
> 
> Which brings me to a point that I had... Alot of people on this thread said lido is more hurtful than helpful. What about for R on T PVC's?



I wish I knew more about it the actual situation. He was a bit of a difficult preceptor, mainly because he'd get a bit crazy during some of the calls we went on. Stress, maybe? I don't know. I don't stress easily, as it's not my emergency or my style. 

As soon as I asked him to elaborate on the lido issue just a little bit, he seemed to shut down. I didn't want him to think I was being a smart ***, so I dropped it. My biggest concern was that he might have been treating something that the PT may have been tolerating quite well. But as a newbie, I knew better than to preach to a 30 year EMS veteran.


----------



## MrBrown (Nov 10, 2010)

EMSrush said:


> But as a newbie, I knew better than to preach to a 30 year EMS veteran.



Incorrect.  If you know (or think) he is doing something wrong you have the right to question him.  Just because he did a two bit course thirty years ago and has one year of experience repeated thirty times does not mean he knows best.


----------



## EMSrush (Nov 10, 2010)

MrBrown said:


> Incorrect.  If you know (or think) he is doing something wrong you have the right to question him.  Just because he did a two bit course thirty years ago and has one year of experience repeated thirty times does not mean he knows best.



If he is in the act of doing something wrong in my presence, yes. 
A story from heck-knows-how-many years ago? Nope. I wasn't even there, didn't see it, can't judge. This was merely a story, and who knows what factors in this story have changed from the occurrence to the telling. I can, however, use it as a personal learning point for myself, which is what I've done.


----------



## usalsfyre (Nov 10, 2010)

Sugi said:


> Were they R on T PVC's? Maybe the asystole didnt have anything to do with the lido... Maybe the R on T pvc's threw the pt into a fine vfib? I know its a bit of a stretch, but I've never heard of lido causing asystole before... I guess you could have pushed like 100mL instead of 100mg (though I would be interested to know where you got that packaging from haha)
> 
> Which brings me to a point that I had... Alot of people on this thread said lido is more hurtful than helpful. What about for R on T PVC's?



R on T phenomenon will manifest itself with VTach (pulseless or perfusing) or Vfib. If pulseless, defibrilate. If perfusing Vtach is present then you have to determine whether it warrants electrical therapy. If Vtach is well tolerated I still would think long and hard before treating it.


----------



## 18G (Nov 10, 2010)

> If Vtach is well tolerated I still would think long and hard before treating it.



And what happens if your delay in treating the Vtach causes it to deteriorate into Vfib which it is prone to do?

I've never seen a protocol that allowed EMS providers to allow a patient to remain in Vtach. Why would you want to let a patient in a potentially lethal, suboptimal rhythm such as Vtach?


----------



## Aidey (Nov 10, 2010)

Where I interned the protocol was that if the patient was unstable they could use Lidocaine or cardiovert. If the patient was stable they had to call for orders for the Lido. The hospitals never gave permission because they used Amiodarone, the end result is that we had a patient in monomorphic v-tach for the majority of the transport. He would convert out for about 30 seconds when we did vagal maneuvers, but he was in the v-tach most of the time. 

Pulse of like 80 and irregular, BP of 130/80. Pt was in his 70s and couldn't figure out what all the fuss was. He said he felt good enough to take us out dancing (my preceptor was female also).


----------



## MrBrown (Nov 10, 2010)

If the patient is in VT which is well tolerated Brown would be hanging up some amiodarone to try and break it.  Should that fail its time for cardioversion.

The only rhythms not treated here are well tolerated haemodynamically uncompromising AF, sinus tach or sinus brady, PVCs and blocks.  

Obviously somebody who is pale, grey, has a GCS of 9 and a third degree block is going to get treated.


----------



## Aidey (Nov 10, 2010)

He got Amiodarone at the hospital. The problem was that they were not carrying it on the ambs yet, and the hospitals did like people using lido becuase it meant they couldn't give the Amiodarone right away. The protocol didn't allow for unstable cardioversion without orders. We could have tried to get orders, but we wouldn't have. They didn't believe us that he was in v-tach, so I doubt we would have gotten orders. 

When we walked in the door with about 10 feet of EKG paper the doc looked at it and said "Oh, that is actually V-tach".


----------



## EMSrush (Nov 10, 2010)

Aidey said:


> When we walked in the door with about 10 feet of EKG paper the doc looked at it and said "Oh, that is actually V-tach".



I love it... :wacko:


----------



## usalsfyre (Nov 10, 2010)

18G said:


> And what happens if your delay in treating the Vtach causes it to deteriorate into Vfib which it is prone to do?
> 
> I've never seen a protocol that allowed EMS providers to allow a patient to remain in Vtach. Why would you want to let a patient in a potentially lethal, suboptimal rhythm such as Vtach?



I didn't say don't treat it under any circumstances, just think about it based on your situation. If I have a patient hit R on T 7 minutes out, by the time I wait for the 12 lead to process, pull out the Amiodarone, mix it, spike the bag, set the pump (and yes ALL medicated infusions should be on a pump) and connect it we're going to be darn close to the ED. An ED which is not moving and has gobs more room and people if things go south after administering a potentially lethal drug for well tolerated condition. As well as more complete treatment and assesment options to determine if Amiodarone is even the right choice. If I'm a half hour out, the equation changes considerably.

Plus, stable, well tolerated Vtach normally doesn't degenerate into Vfib without physical signs of hemodynamic instabilty first. Which is what we call a clue. If the patient shows signs of potential or actual hemodynamic instability they need emergent cardioversion, _mùy pronto_.


----------



## Cawolf86 (Nov 11, 2010)

18G said:


> And what happens if your delay in treating the Vtach causes it to deteriorate into Vfib which it is prone to do?
> 
> I've never seen a protocol that allowed EMS providers to allow a patient to remain in Vtach. Why would you want to let a patient in a potentially lethal, suboptimal rhythm such as Vtach?



Never? In LA County, perfusing VT is simply monitored for signs of poor perfusion. 

http://ems.dhs.lacounty.gov/ManualsProtocols/BHTG/BHTG-D3.pdf


----------



## 18G (Nov 11, 2010)

LA County must have some mediocre protocols....

In PA for stable wide-complex tachycardia we can give Lidocaine or Amiodarone. If we suspect SVT with aberrancy then we can give adenosine... all above the command line. 

If unstable than we cardiovert with three options for sedation (versed, ativan, and valium).


----------



## usalsfyre (Nov 11, 2010)

18G said:


> LA County must have some mediocre protocols....
> 
> In PA for stable wide-complex tachycardia we can give Lidocaine or Amiodarone. If we suspect SVT with aberrancy then we can give adenosine... all above the command line.
> 
> If unstable than we cardiovert with three options for sedation (versed, ativan, and valium).



So I don't work under LA County protocols. My protocols don't even have a "command line" so to speak, they're made up of decision points with very, very few interventions needing prior physician contact. I don't believe my adult cardiac guidelines even have any of those. So I can treat stable Vtach as I see fit. The question is not whether I CAN it's whether I SHOULD. That question should be considered very, very carefully prior to screwing around with the cardiovascular system of someone who is tolerating a given rhythm well.


----------

