# AED Pads for Conscious Patients?



## RedAirplane (Oct 28, 2015)

I was talking to a friend who recently ran a CP call.

He turned on the AED and put the pads on, with the logic that if the pt went into VT he would want to shock before the pt lost consciousness.

I was surprised because we're told specifically not to do that in EMT class. But upon talking to other people, it seems that many people do that for CP calls and it is somewhat accepted.

What are your thoughts?


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## Flying (Oct 28, 2015)

Not all chest pains are MIs. It's also a bit rich to be anticipating VF/VT without an ECG.
Also, does not your service consider the cost of pads?

I think it's flipping stupid.


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## ERDoc (Oct 28, 2015)

This sounds like someone is looking to justify using a toy that is not needed or appropriate or trying to make it look like they are a higher level than they are.


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## EMSComeLately (Oct 28, 2015)

The following assumes your friend is an EMT.  There are too many CP etiologies to throw on pads immediately.  It's not like you can use an AED for a synchronized cardioversion for VT with a pulse.  And, it'd still take time to get the AED to analyze once someone goes pulseless.  Your friend should focus on BLS practice and CAB along with AED at that time.

And if they weren't helping patient administer their own aspirin and nitro (all assumptions about patient confirmed) they also skipped other more important priorities over the AED.


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## chaz90 (Oct 28, 2015)

Yeah, I really don't see the sense in that. As an ALS provider, I put the pads on conscious STEMI patients and those with confirmed/deteriorating cardiac rhythms after I do an EKG.


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## ERDoc (Oct 28, 2015)

I'm curious if this provider removes the pad before taking the pt out of the ambulance and into the ER.


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## Ewok Jerky (Oct 28, 2015)

It's a reasonable move on an unstable patient, but not high on my list of priorities when there are lines to start, meds to give, reports to call in and such...talking about monitor pads not an aed though.


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## Tigger (Oct 28, 2015)

No. 

It's reasonable to place defib patches on the patient once the monitor shows something scary. But as an EMT with an AED, you can't see that and are just wasting expensive pads.


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## RedAirplane (Oct 28, 2015)

EMSComeLately said:


> The following assumes your friend is an EMT.  There are too many CP etiologies to throw on pads immediately.  It's not like you can use an AED for a synchronized cardioversion for VT with a pulse.  And, it'd still take time to get the AED to analyze once someone goes pulseless.  Your friend should focus on BLS practice and CAB along with AED at that time.
> 
> And if they weren't helping patient administer their own aspirin and nitro (all assumptions about patient confirmed) they also skipped other more important priorities over the AED.



They administered 325 mg ASA chewed and oxygen for a low SpO2, as well as controlled for shock with a space blanket given the cold/wet weather they were in. 
After that they used the AED pads.

It's not often that we get this type of call so neither myself nor our leadership was concerned with the waste of the pads-- my big question was medical validity.

Can an AED distinguish VT with a pulse and pulseless VT? If it can, then it makes no sense to use the pads since it won't shock the pt while s/he has a pulse. If it cannot, then I might see some use with an unstable patient (SVT or something), but I'd be well out of my comfort zone to try some stunt like that, so I probably wouldn't.


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## EMSComeLately (Oct 28, 2015)

RedAirplane said:


> They administered 325 mg ASA chewed and oxygen for a low SpO2, as well as controlled for shock with a space blanket given the cold/wet weather they were in.
> After that they used the AED pads.
> 
> It's not often that we get this type of call so neither myself nor our leadership was concerned with the waste of the pads-- my big question was medical validity.
> ...


The AED is only there to analyze for unsychronized shockable rhythms, i.e., pulseless vf/vt.

It's good to hear that other priorities were covered first.


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## TransportJockey (Oct 28, 2015)

RedAirplane said:


> They administered 325 mg ASA chewed and oxygen for a low SpO2, as well as controlled for shock with a space blanket given the cold/wet weather they were in.
> After that they used the AED pads.
> 
> It's not often that we get this type of call so neither myself nor our leadership was concerned with the waste of the pads-- my big question was medical validity.
> ...


If an AED read VT, it doesn't care if it has a pulse or not. It'll still say shock advised.


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## EMSComeLately (Oct 28, 2015)

TransportJockey said:


> If an AED read VT, it doesn't care if it has a pulse or not. It'll still say shock advised.


True..it only knows electrical, but not mechanical pulse...an obvious but easy to forget point.


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## LACoGurneyjockey (Oct 28, 2015)

RedAirplane said:


> They administered 325 mg ASA chewed and oxygen for a low SpO2, as well as controlled for shock with a space blanket given the cold/wet weather they were in.
> After that they used the AED pads.
> 
> It's not often that we get this type of call so neither myself nor our leadership was concerned with the waste of the pads-- my big question was medical validity.
> ...



Whether you can or not, DO NOT TRY AND USE AN AED TO DEFIB A PATIENT WITH A PULSE (SVT, VT w/ a pulse, CP/MI). You have an AED for pulseless patients. An unsynchronized cardioversion (defibrillation) of V Tach with a pulse can very well send your patient into cardiac arrest. That's bad. 
I remember a horror story of bystanders applying an AED to a patient who collapsed. He then had a seizure, and the AED detected VF and shocked him... 3 times. They're not fool proof. You, as an EMT, need to not only be smarter than the machine, but know when to use it and when not to.


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## redundantbassist (Oct 28, 2015)

RedAirplane said:


> He turned on the AED and put the pads on, with the logic that if the pt went into VT he would want to shock before the pt lost consciousness.



Wait.. did this guy seriously suggest performing an unsynchronised cardioversion on a fully concious, unseated patient with an AED? I would be very wary of this employee and would keep a close eye on him during calls.


RedAirplane said:


> I was surprised because we're told specifically not to do that in EMT class.



Even so, if someone is so stupid and lacking in common sense that they need this to be specified to them, they should not be working with patients.


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## Tigger (Oct 28, 2015)

RedAirplane said:


> Can an AED distinguish VT with a pulse and pulseless VT? If it can, then it makes no sense to use the pads since it won't shock the pt while s/he has a pulse. If it cannot, then I might see some use with an unstable patient (SVT or something), but I'd be well out of my comfort zone to try some stunt like that, so I probably wouldn't.


Use AEDs for what they are for. Do not make things more difficult.


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## EpiEMS (Oct 28, 2015)

For fun: http://gatheringofeagles.us/2013/Saturday/Gallagher-AEDCaseReport.pdf
A little gathering of eagles case presentation for you all.

More on topic, though, applying AED pads to a conscious well perfused patient is more likely than not contraindicated.


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## Eddie263 (Oct 28, 2015)

If you weren't trained to do something, don't do it. Theres a reason cardioversion is an ALS skill. Not only does it require a shock but meds as well.


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## NomadicMedic (Oct 28, 2015)

LACoGurneyjockey said:


> I remember a horror story of bystanders applying an AED to a patient who collapsed. He then had a seizure, and the AED detected VF and shocked him... 3 times. They're not fool proof. You, as an EMT, need to not only be smarter than the machine, but know when to use it and when not to.



That sounds like urban legend to me. There is no way an AED will recognize a simple seizure as VF in a patient with a normal QRS and shock a patient three times. Not gonna happen.


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## Gurby (Oct 28, 2015)

redundantbassist said:


> Wait.. did this guy seriously suggest performing an unsynchronised cardioversion on a fully concious, unseated patient with an AED? I would be very wary of this employee and would keep a close eye on him during calls.



Somewhat related...

I saw this in the hospital during my medic clinical time, though with an actual monitor not an AED.  Guy comes in having an MI.  They do a 12 lead, throw the pads on, and while everyone is standing around talking he goes into VF.  Somebody notices it and is like hey VF!  Shock.  Guy comes to, he's like ow that hurt.  VF again!  "Sorry buddy"...  Zap!  Guy comes to again, is not appreciating our efforts.  He probably went into VF and then got shocked out of it 5 times and was more or less conscious the entire time, before they got some amiodarone in him and shipped him off to the cath lab.  Pretty sure he had a good outcome when all was said and done, but he was pretty lucky to have coded in the ED and not 10 minutes earlier in the back of the BLS ambulance that brought him in.


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## LACoGurneyjockey (Oct 29, 2015)

DEmedic said:


> That sounds like urban legend to me. There is no way an AED will recognize a simple seizure as VF in a patient with a normal QRS and shock a patient three times. Not gonna happen.


Not an urban legend, a call that the other crew in my station ran. After talking with the ER doc, his conclusion was based on the labs there was no way he could have arrested. Several bystanders on scene reported shocking 3 times with the AED. Take it or leave it, but it's not some war story I heard in EMT class.


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## ERDoc (Oct 29, 2015)

I've seen 12-leads that had leads that looked like VT when a pt was shaking their arm or leg.  I can't recall if it showed up in any of the precordial leads, which is what an AED would be looking at.


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## NomadicMedic (Oct 29, 2015)

I still don't buy it. I've got a friend at Physio. I'll send him an email tomorrow. If anyone would know, it would be him.


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## wxemt (Nov 2, 2015)

My local protocol is to place pads on conscious STEMI patient.  That being said, the monitor doesn't go into AED mode unless the patient codes.


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## triemal04 (Nov 2, 2015)

wxemt said:


> My local protocol is to place pads on conscious STEMI patient.  That being said, the monitor doesn't go into AED mode unless the patient codes.


The difference between someone having an MI and someone complaining of chest pain is vast.  Requiring every STEMI to have pads placed is overkill, but far better than blindly placing them on someone who utters the magic words "chest pain."  

It's kind of like giving everyone who says "pain" narcotics...but I digress...


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## Akulahawk (Nov 3, 2015)

wxemt said:


> My local protocol is to place pads on conscious STEMI patient.  That being said, the monitor doesn't go into AED mode unless the patient codes.


I have yet to see an EMS monitor that switches to AED mode all by itself. There's monitor mode and there's AED/Defib mode. Some monitors even have "Pace" mode. Even the AED monitors have to specifically put into AED mode before they'll do anything other than show a rhythm.


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## wxemt (Nov 3, 2015)

Akulahawk said:


> I have yet to see an EMS monitor that switches to AED mode all by itself. There's monitor mode and there's AED/Defib mode. Some monitors even have "Pace" mode. Even the AED monitors have to specifically put into AED mode before they'll do anything other than show a rhythm.



Exactly.  Outside of the cost of the pads, pre -applying the pads to an unstable STEMI patient really has no cons that I can see.  This is of course assuming a proficient EMT.


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## CALEMT (Nov 3, 2015)

wxemt said:


> My local protocol is to place pads on conscious STEMI patient.  That being said, the monitor doesn't go into AED mode unless the patient codes.



Whats the justification to applying pads to every STEMI pt? Not every STEMI codes in the field or in the hospital for that matter. Seems like a waste to me.


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## wxemt (Nov 3, 2015)

CALEMT said:


> Whats the justification to applying pads to every STEMI pt? Not every STEMI codes in the field or in the hospital for that matter. Seems like a waste to me.



Not every STEMI patient codes, but those go into vfib arrest benefit from immediate defibrillation.  Not exactly the same thing, but I would compare it somewhat to leaving the pads on after ROSC (i.e. in case the patient codes again).


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## CALEMT (Nov 3, 2015)

wxemt said:


> Not every STEMI patient codes, but those go into vfib arrest benefit from immediate defibrillation.  Not exactly the same thing, but I would compare it somewhat to leaving the pads on after ROSC (i.e. in case the patient codes again).



True, but what is the percentage of STEMI pt's that go into vfib during the time you have pt care? I'm not trying to argue, protocols are protocols. It just seems like a unnecessary protocol in my opinion. 

Leaving the pads on after ROSC is different that placing them on an active STEMI. After all you did just shock the heart back into a rhythm, chances are fairly decent that the pt may code again. No guarantee that a STEMI will code on you during the duration of the call.


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## wxemt (Nov 3, 2015)

CALEMT said:


> True, but what is the percentage of STEMI pt's that go into vfib during the time you have pt care? I'm not trying to argue, protocols are protocols. It just seems like a unnecessary protocol in my opinion.
> 
> Leaving the pads on after ROSC is different that placing them on an active STEMI. After all you did just shock the heart back into a rhythm, chances are fairly decent that the pt may code again. No guarantee that a STEMI will code on you during the duration of the call.



Oh I definitely agree that it is likely unnecessary for 9/10 STEMI patients.  I guess the powers at be see the cost of the pads as being out weighed by the potential benefit in the small percentage of patients that go into a shockable rhythm.

Question for others that have this same protocol.  Do you also have CCR and CPR protocols?  Both of these seems to be on the newer edge of things and I am just curious if these two sets of protocols typically exist together.


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## ERDoc (Nov 3, 2015)

Even in the ER, STEMIs get pads.  You have someone with a very unhappy myocardium which is more likely to go into a bad rhythm.


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## NomadicMedic (Nov 3, 2015)

Over the last year I transported 5 STEMIs, 2 of them arrested. Pads may be expensive, but charging that LP and firing off the shock in just a couple of seconds... Priceless.


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## chaz90 (Nov 3, 2015)

Yeah, I continue to put pads on every STEMI patient. Fortunately my agency doesn't seem to mind.


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## redundantbassist (Nov 4, 2015)

DEmedic said:


> Over the last year I transported 5 STEMIs, 2 of them arrested. Pads may be expensive, but charging that LP and firing off the shock in just a couple of seconds... Priceless.


Just out of curiosity, how have the results been?


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## Jim37F (Nov 4, 2015)

Our defib pads are Multi Function Electrodes, used for defib, pacing, and cardioversion. The only times I've seen them put on a conscious patient were for things like SVT, or we had a conscious V-Tach patient a week or so ago who we put pads on but otherwise I can count the number of times on one hand I've seen the MFE's put on conscious patients in the last two years I've been here


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## NomadicMedic (Nov 4, 2015)

redundantbassist said:


> Just out of curiosity, how have the results been?



I'm assuming you mean the arrests? Both resuscitated while en route. One coded repeatedly in the ED prior to PCI and could not be revived, the other made it to PCI and I heard he was discharged with a CPC 1. The other STEMIs I transported all made it into PCI (as far as I know).


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## SixEightWhiskey (Nov 4, 2015)

AED = Automated External Defibrillator

Defibrillation and cardioversion are not the same thing. Put the AED on people in cardiac arrest. It's a pretty straight forward concept.

Not sure exactly how your system works, but if a person is getting nitro/ASA and has chest pain and has a low SPO2, there should probably be a paramedic (or at least a request for one) involved in the story somewhere. They can determine whether the conscious cardiac patient requires therapy pads applied or not.


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## Flying (Nov 4, 2015)

SixEightWhiskey said:


> Not sure exactly how your system works, but if a person is getting nitro/ASA and has chest pain and has a low SPO2, there should probably be a paramedic (or at least a request for one) involved in the story somewhere. They can determine whether the conscious cardiac patient requires therapy pads applied or not.


I believe the system in this scenario is BLS first response, with transporting dual medics.


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## SixEightWhiskey (Nov 4, 2015)

Flying said:


> I believe the system in this scenario is BLS first response, with transporting dual medics.


That's reasonable. I'd rather have the BLS do the other regular BLS stuff in that scenario though and have a good report ready for whenever they do get ALS, and then the medics can decide whether to put the pads on or not if they need to provide some sort of electrical therapy.


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## RedAirplane (Nov 4, 2015)

Flying said:


> I believe the system in this scenario is BLS first response, with transporting dual medics.



Correct.


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## RedAirplane (Nov 4, 2015)

SixEightWhiskey said:


> That's reasonable. I'd rather have the BLS do the other regular BLS stuff in that scenario though and have a good report ready for whenever they do get ALS, and then the medics can decide whether to put the pads on or not if they need to provide some sort of electrical therapy.



This is a bit of a game of telephone, because I'm recounting something I heard that happened and was curious about it. 

For the bottom line, if you assume that AED pads are a dime a dozen and that this wouldn't happen UNTIL an assessment, ASA, vitals, etc were done, would you ever want a BLS provider to do this? Conversely, is it just useless, or is it harmful?


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## chaz90 (Nov 4, 2015)

RedAirplane said:


> This is a bit of a game of telephone, because I'm recounting something I heard that happened and was curious about it.
> 
> For the bottom line, if you assume that AED pads are a dime a dozen and that this wouldn't happen UNTIL an assessment, ASA, vitals, etc were done, would you ever want a BLS provider to do this? Conversely, is it just useless, or is it harmful?



I don't think it's actually harmful in any way, but still a wholly unindicated intervention. 

If we're talking about a completely non-harmful but not indicated intervention, I could perform 12 lead EKGs 3x a day on my dad. He has no personal history of heart disease, is relatively healthy, and isn't complaining of anything. On the other hand, he's in his late 50s, slightly hypertensive, has some family history of cardiac problems, some MIs don't present with typical symptoms, and maybe I would someday catch some early pre-acute signs of ischemia and allow prompt and helpful intervention. The number needed to treat for the possible benefits of this therapy though is so tiny as to make it unreasonable, so no one would dream of doing this. Same applies towards placing AED pads on all chest pain patients. In the absence of any other diagnostic criteria, the number of "chest pain" patients who will arrest to a shockable rhythm in the presence of the BLS crew is so small as to make this unreasonable.


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## SixEightWhiskey (Nov 5, 2015)

Exactly! it's not indicated for the scenario presented. It's that simple. Also, the OP said something alone the lines of "so they can be shocked before they lose consciousness" as a reason. Typically if someone goes into VT/VF arrest, they're going to lose consciousness because they have just died! And even if they get an AED defibrillation and their heart starts beating again, they may very well remain unconscious. 

Again, an AED is indicated for someone who is unresponsive, apneic and pulseless. Throwing it on everybody who has a chest pain/cardiac complaint is an incredible amount of overkill and is unwarranted.


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## RedAirplane (Nov 5, 2015)

SixEightWhiskey said:


> Exactly! it's not indicated for the scenario presented. It's that simple. Also, the OP said something alone the lines of "so they can be shocked before they lose consciousness" as a reason. Typically if someone goes into VT/VF arrest, they're going to lose consciousness because they have just died! And even if they get an AED defibrillation and their heart starts beating again, they may very well remain unconscious.
> 
> Again, an AED is indicated for someone who is unresponsive, apneic and pulseless. Throwing it on everybody who has a chest pain/cardiac complaint is an incredible amount of overkill and is unwarranted.



The exact logic of my colleague was to address a pulse-producing VT (such as SVT).


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## chaz90 (Nov 5, 2015)

RedAirplane said:


> The exact logic of my colleague was to address a pulse-producing VT (such as SVT).


Yikes. Even worse. 

SVT (supraventricular tachycardia) is by definition a category of tachycardias originating above the ventricles and thereby excluding VT. 

Cardioversion with proper sync is not possible on an AED. Cardioversion is explicitly not a BLS or layperson skill, and your friend could face legal charges if he knowingly performed this and the patient had a poor outcome...I'd tell him to avoid this at all costs and not even consider it.


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## Flying (Nov 5, 2015)

RedAirplane said:


> The exact logic of my colleague was to address a pulse-producing VT (such as SVT).


Tell your bud to stop practicing medicine without a license.

I can also get really excited about doing more with the few tools given, but come on.


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## SixEightWhiskey (Nov 5, 2015)

RedAirplane said:


> The exact logic of my colleague was to address a pulse-producing VT (such as SVT).


These rhythms require ALS intervention.


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## NomadicMedic (Nov 5, 2015)

SixEightWhiskey said:


> These rhythms require ALS intervention.[/QUOT]
> 
> Unless you're @DrParasite and believe that the best treatment is simply "throw 'em in a BLS truck and take 'em to the hospital"


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## gotbeerz001 (Nov 5, 2015)

RedAirplane said:


> The exact logic of my colleague was to address a pulse-producing VT (such as SVT).


SVT is not a variant of VT...
Maybe he thinks it means "super ventricular tachycardia"


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## ERDoc (Nov 5, 2015)

We should probably prophylactically intubate all of our pts since, you know, they could all stop breathing too.


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## Jim37F (Nov 5, 2015)

ERDoc said:


> We should probably prophylactically intubate all of our pts since, you know, they could all stop breathing too.


I was just about to say put a traction splint on everyone with a slip and fall or fender bender


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## RedAirplane (Nov 5, 2015)

I'll take ownership of the SVT bit. He said VT with a pulse, and I'm the idiot who thought that meant SVT.


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## gotbeerz001 (Nov 5, 2015)

RedAirplane said:


> I'll take ownership of the SVT bit. He said VT with a pulse, and I'm the idiot who thought that meant SVT.


No biggie, bro. 
Props for claiming your mistake; lesser folks would have let it roll.


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## triemal04 (Nov 5, 2015)

ERDoc said:


> We should probably prophylactically intubate all of our pts since, you know, they could all stop breathing too.


....wait...we aren't supposed to be doing that?  Uh-oh...


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## CALEMT (Nov 5, 2015)

Jim37F said:


> I was just about to say put a traction splint on everyone with a slip and fall or fender bender



I was going to say full c spine but most of EMS already does that.


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## NomadicMedic (Nov 5, 2015)

I give everyone150 of amiodorone, because arrhythmia.


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## chaz90 (Nov 5, 2015)

DEmedic said:


> I give everyone150 of amiodorone, because arrhythmia.


Pulmonary toxicity be damned!


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## NomadicMedic (Nov 6, 2015)

chaz90 said:


> Pulmonary toxicity be damned!



Eh, just throw em in a BLS truck and go to the hospital.


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## DPM (Nov 6, 2015)

Outside of pacing, I've put pads on a chest pain PT once in the absence of STEMI. In that case the PT was borderline bradycardic (rate ~ 65), looked terrible, though no MI on the monitor, and I was pleasantly surprised that he didn't code. I thought I would pacing before pretty soon, but the PT was an EMR Ski patroller, and I think the adrenalin burst from me putting the pads on is what got his heart rate up.


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## DrParasite (Nov 16, 2015)

DEmedic said:


> Unless you're @DrParasite and believe that the best treatment is simply "throw 'em in a BLS truck and take 'em to the hospital"


I never said that, nor would I, but nice try.  better luck next time.


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## Bosco836 (Dec 22, 2015)

chaz90 said:


> Cardioversion with proper sync is not possible on an AED.



I used to think this too, but apparently Cardiac Science is now including an algorithm for Cardioversion on some of their AEDs. http://www.cardiacscience.com/cardi...oluntary_device_correction_resources/6677.pdf   --> See page 17 for further reference.

As an aside, there was an interesting article in JEMS about a school nurse who performed synchronized cardioversion on a conscious patient using this particular AED and the ramifications associated with it.  
http://www.jems.com/articles/print/...ads-nurse-to-shock-concious-boy-with-aed.html


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## luke_31 (Dec 22, 2015)

Bosco836 said:


> As an aside, there was an interesting article in JEMS about a school nurse who performed synchronized cardioversion on a conscious patient using this particular AED and the ramifications associated with it.
> http://www.jems.com/articles/print/...ads-nurse-to-shock-concious-boy-with-aed.html


Talk about lucky. The AED may have been designed to work for the cardioversion, but shouldn't have been used for this patient at all.


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## Bosco836 (Dec 22, 2015)

luke_31 said:


> Talk about lucky. The AED may have been designed to work for the cardioversion, but shouldn't have been used for this patient at all.



Completely agree.  I get the impression that the provider identified in the article had no idea what was actually going on.  In the alternative, more appropriate treatments should have been considered prior to attempting to electrically cardiovert (Assuming that such a procedure is even within the providers scope).  

What amazes me is that these AED units - presumably for use by lay people - actually are equipped with such a feature in the first place.


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## EpiEMS (Dec 22, 2015)

Bosco836 said:


> What amazes me is that these AED units - presumably for use by lay people - actually are equipped with such a feature in the first place.



I had quickly read the article on the train, so pardon my misinterpretation -- but doesn't it seem like it was contraindicated to apply it to begin with? It's not as if the machine can identify LOC.

If anything, seems like a good feature to have for that truly unstable patient.


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