# Chemical or Electrical Cardioversion?



## NPO (Apr 4, 2017)

Where do you personally draw the line? And if you're going with electrical therapy, do you premedicate?

I had my first SVT, and by all means, I could have shocked him, and no one would have batted an eye. I even had my narcotics out and open. But I decided to give 6mg of Adenosine a try, just to say I did it; I didn't expect it to work, but it did.

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

	
	
		
		

		
			





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## E tank (Apr 4, 2017)

Adenosine is way less hassle. The guy wasn't that unstable. Good use of that drug.

EDIT...People get "shocky" looking with tachyarrythmias because their cardiac output falls off and that means their venous return does too. In a low flow state, the time it would take to get to the heart, even with flushing, is delayed to the point where it can "burn out" before it has a chance to work. So you shock instead.


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## luke_31 (Apr 4, 2017)

You already answered your own question. If he is not symptomatic then go with drugs first. Don't get hung up with what the B/P is, especially when it's what you said it was. If he's not complaining of any other symptoms then the chest pain, I'd go for drugs first too.  The easiest way to decide pharmacology or electricity is by looking at the patient and going if I don't get this converted immediately will they go into arrest?  If yes by all means shock right away, also if you have time to draw up drugs to comfort the patient from the shock, then you have time to try adenosine first.


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## GMCmedic (Apr 4, 2017)

Truth is the answer is going to vary from medic to medic. 

I defended a new medic to the ER nurses once. He synchronized cardioverted SVT with chest pain that was otherwise stable. He wasnt wrong, he did exactly what ACLS teaches. 

For me, I need a whole picture. A chest pain and SOB complaint with SVT may get Adenisone. It really just depends on the patients apperance. Basically, If they look like theyre going to die they get electricity. AMS gets synchronized cardioversion everytime.

A-Fib with RVR and hypotension also gets synch cardioversion. 

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## hometownmedic5 (Apr 4, 2017)

Hemodynamic stability, mentation, associated complaints, and the gut sick/not sick opinion in the presence of a dysrythmia are my four qualifiers. 

You had tachycardia, hypotension, and chest pain. Definitely could have been cardioverted. Definitely could have been medicated. As is, neither would be wrong in my book. 

As for premedication, if I'm cardioverting, most likely they are too unstable to spend the time getting versed out and drawn, administering, and then waiting until it circulates to be effective. I'm happy to give you some fent after the fact if your discomfort is significant and you've improved hemodynamically. You certainly deserve it. 

This is a borderline case. Borderline cases are tough because there exists a strong, evidence based argument on both sides. These are the cases that cause huge problems because inevitably, someone will feel they are more "right", when they really aren't and won't let go. Even more so if this person is an FTO, Doctor, CQI guy etc.


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## Handsome Robb (Apr 4, 2017)

You wouldn't be wrong for cardioverting your patient but for me I'm going to use drugs every time and twice on Sunday unless they look like they're fixing to die, are ALOC/Unconscious, etc. 

In your dude I may have ended up sedating and cardioverting if he hadn't responded to repeated rounds of adenosine. 


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## NPO (Apr 4, 2017)

Handsome Robb said:


> In your dude I may have ended up sedating and cardioverting if he hadn't responded to repeated rounds of adenosine.


This is the route I was planning on going. Sounds like I was justified enough in treating my patient and not the monitor.

Anecdotally, the patient seemed to have some sort of mental disability, although, I didn't have any evidence of this, but he just seemed like it. He wasn't a very good historian, but as soon as we [the firefighter] pulled apart the defib pads, he got wide eyed and stared yelling "what are those for?! Don't put those on me!!" Which leads me to believe he may have traveled down this road before.


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## MackTheKnife (Apr 4, 2017)

NPO said:


> Where do you personally draw the line? And if you're going with electrical therapy, do you premedicate?
> 
> I had my first SVT, and by all means, I could have shocked him, and no one would have batted an eye. I even had my narcotics out and open. But I decided to give 6mg of Adenosine a try, just to say I did it; I didn't expect it to work, but it did.
> 
> ...


You done good! Treat the patient, not the numbers.


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## MackTheKnife (Apr 4, 2017)

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


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## TXmed (Apr 4, 2017)

if you're concerned about pre-medication prior to cardioverting someone. if they dont have an IV just hit them with IM ketamine and hope it kicks in prior to them feeling the electricity. IM ketamine works far better than other IM pain medicine. I do this prior to IO'ing a semi-conscious patient that needs vascular access. works better than the lidocain flush.


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## StCEMT (Apr 4, 2017)

TXmed said:


> IM ketamine works far better than other IM pain medicine. I do this prior to IO'ing a semi-conscious patient that needs vascular access. works better than the lidocain flush.


I like this idea, haven't thought of that. Tucking this idea away.

OP. I agree with how you did it. If you dont have those bad tingly feelings and have easy access, then rock on.


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## NPO (Apr 4, 2017)

TXmed said:


> if you're concerned about pre-medication prior to cardioverting someone. if they dont have an IV just hit them with IM ketamine and hope it kicks in prior to them feeling the electricity. IM ketamine works far better than other IM pain medicine. I do this prior to IO'ing a semi-conscious patient that needs vascular access. works better than the lidocain flush.


I wish I had ketamime..

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## VentMonkey (Apr 4, 2017)

NPO said:


> I wish I had ketamime..


You read his memo, trust me I tried even though it was an answer I already knew.


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## NPO (Apr 4, 2017)

VentMonkey said:


> You read his memo, trust me I tried even though it was an answer I already knew.


Your efforts are appreciated. 

It needs to start at the state level. So I did some poking around...

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## VentMonkey (Apr 4, 2017)

NPO said:


> It needs to start at the state level. So I did some poking around...


Yes, this I already knew, but he said "suggestions". I had a few other items on their PM me if you'd like, he emailed me back that same day, and a day before his memo.


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## E tank (Apr 4, 2017)

TXmed said:


> if you're concerned about pre-medication prior to cardioverting someone. if they dont have an IV just hit them with IM ketamine and hope it kicks in prior to them feeling the electricity. IM ketamine works far better than other IM pain medicine. I do this prior to IO'ing a semi-conscious patient that needs vascular access. works better than the lidocain flush.



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


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## Carlos Danger (Apr 4, 2017)

The problem that I see with IM ketamine for cardioversion is that if you are giving a large enough dose of ketamine to have both a rapid onset and significant sedating effect, you are giving a pretty whopping dose, which not only may not be the best thing in someone with an irritable heart, but also means you have to deal with the side effects of a large dose of ketamine. 

If someone needs to be cardioverted emergently, frankly I don't worry much about sedation.


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## VentMonkey (Apr 4, 2017)

Randomly brief derail-

If anyone ever gets a chance to sit in on a TEE, it's well worth it. Just remembered seen one during CCP clinical and watched the cardiologists digging around while the CRNA pushed Propofol every so often to keep the patient sedated.

...sorry, back to the regularly scheduled thread.


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## hometownmedic5 (Apr 4, 2017)

Remi said:


> The problem that I see with IM ketamine for cardioversion is that if you are giving a large enough dose of ketamine to have both a rapid onset and significant sedating effect, you are giving a pretty whopping dose, which not only may not be the best thing in someone with an irritable heart, but also means you have to deal with the side effects of a large dose of ketamine.
> 
> If someone needs to be cardioverted emergently, frankly I don't worry much about sedation.


 
This is pretty much where I'm at. I don't electively cardiovert. If I'm going with Edison, you're wantonly unstable and need to be zapped right now. If you're stable enough for sedation, you're stable enough for medicine and I'm going to start there. If its not going well, you'll get your sedation in between adenosine doses, but if my evaluation says cardiovert now, i dont have time for meds. You can have some fentanyl later, once you're not quite so dying-ish. 

Ketamine is now an optional med in Massachusetts(and my service has elected not to carry it), but they put it in the wrong protocol(behavioral sedation/chemical restraint), at the wrong dose; so to use it for anything else(if I had it) would need a mother may I call, and I really dont have time for that in this setting. It is my hope that, in a few years, it will become a mandatory medication, they will change the dosing to be less insane, and it will apply across multiple protocols.


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## StCEMT (Apr 4, 2017)

Just my $0.02, I don't really care about full sedation. If it dulls the pain, that's good enough for me. I've cardioverted without sedation and it looked like it sucked. If I can't, sorry bout ya, but if I can then I'd like to try. Like hometown said though, that's assuming they don't need me to start with cardioversion to begin with.


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## Aprz (Apr 4, 2017)

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

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


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## RocketMedic (Apr 4, 2017)

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


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## NomadicMedic (Apr 4, 2017)

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

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

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

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

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


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## CALEMT (Apr 4, 2017)

Handsome Robb said:


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



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


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## TXmed (Apr 4, 2017)

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


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## E tank (Apr 4, 2017)

NomadicMedic said:


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



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

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


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## Tigger (Apr 5, 2017)

MackTheKnife said:


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


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

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


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## GMCmedic (Apr 5, 2017)

CALEMT said:


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



Remember, real world =/= to ACLS. 

SVT with chest pain is unstable for ACLS skills

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## MackTheKnife (Apr 5, 2017)

E tank said:


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


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

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## Carlos Danger (Apr 6, 2017)

MackTheKnife said:


> Isn't a side effect of Special K bradycardia? Might be beneficial.
> 
> Sent from my XT1585 using Tapatalk


Tachycardia is much more common.


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## MackTheKnife (Apr 6, 2017)

Remi said:


> Tachycardia is much more common.


Thanx. I wasn't sure.

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## TomB (Apr 8, 2017)

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

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


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## TXmed (Apr 8, 2017)

I use etco2 as an additional means of justification


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## dutemplar (Apr 15, 2017)

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

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

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


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## Rialaigh (Apr 15, 2017)

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

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


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


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## Carlos Danger (Apr 15, 2017)

Rialaigh said:


> *sometimes less is more.*


Quoted for emphasis.


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## RocketMedic (Apr 15, 2017)

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


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## Eden (Apr 15, 2017)

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


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## E tank (Apr 15, 2017)

Eden said:


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



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


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## MackTheKnife (Apr 16, 2017)

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

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## E tank (Apr 16, 2017)

MackTheKnife said:


> I suppose you ask about SVT and WPW as to whether or not adenosine would work? I guess it would depend on whether or not the aberrant pathways are susceptible.
> 
> Sent from my XT1585 using Tapatalk



No, I ask because of missing that diagnosis and giving a CCB (or really anything that inhibits A-V node conduction) risks inducing a non-perfusing ventricular rhythm. That's what the science says and I was wondering if there was any real world experience with that here.


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## Eden (Apr 16, 2017)

E tank said:


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


I didn't run into one yet. Definitely something you want to make sure before administering a ccb.


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## Carlos Danger (Apr 16, 2017)

E tank said:


> No, I ask because of missing that diagnosis and giving a CCB (or really anything that inhibits A-V node conduction) risks inducing a non-perfusing ventricular rhythm. That's what the science says and I was wondering if there was any real world experience with that here.


Isn't that only in WPW with AF? I think normal WPW with retrograde conduction, node blockers are safe and effective.


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## E tank (Apr 16, 2017)

Remi said:


> Isn't that only in WPW with AF? I think normal WPW with retrograde conduction, node blockers are safe and effective.



Yep... you're right.  A fast irregular rhythm sometimes takes a closer look to be sure.  Just looking for folks' experience.


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## Carlos Danger (Apr 16, 2017)

E tank said:


> Yep... you're right.  A fast irregular rhythm sometimes takes a closer look to be sure.  Just looking for folks' experience.


 Certainly not something I have experience with, just recalling what I've read.


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## MackTheKnife (Apr 16, 2017)

E tank said:


> No, I ask because of missing that diagnosis and giving a CCB (or really anything that inhibits A-V node conduction) risks inducing a non-perfusing ventricular rhythm. That's what the science says and I was wondering if there was any real world experience with that here.


With an SVT that is actually WPW, how would you know? You wouldn't see a Delta wave with the tachycardia. Adenosine blocks AV node conduction temporarily. I ask whether or not it has an effect on the aberrant pathways associated with WPW.

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## E tank (Apr 17, 2017)

MackTheKnife said:


> With an SVT that is actually WPW, how would you know?



Right. Even with a "wide complex" tachycardia. Thats the question.  I'm asking for folks' experience with it. Doesn't sound like the question is too common in day to day practice. One of those things you read about more than seeing.


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## Tigger (Apr 18, 2017)

E tank said:


> Right. Even with a "wide complex" tachycardia. Thats the question.  I'm asking for folks' experience with it. Doesn't sound like the question is too common in day to day practice. One of those things you read about more than seeing.


I think it is still worth looking for delta waves in tachycardia. There is also some question as to whether or not adenosine is safe in WPW either. Most of the research I've found seems to indicate that it is safe however one of the medical directors is staunchly against. Not to mention a patient that we induced V-tach with. She was in a narrow complex SVT at 180 and in retrospect the delta waves were more than visible though I am not sure I would not do the same thing again.


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## VFlutter (Apr 18, 2017)

I have seen A fib w/ WPW go into VF after verapamil. Also have seen 1:1 A flutter eventually degrade into VF.


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## E tank (Apr 18, 2017)

Tigger said:


> I think it is still worth looking for delta waves in tachycardia. There is also some question as to whether or not adenosine is safe in WPW either. Most of the research I've found seems to indicate that it is safe however one of the medical directors is staunchly against. Not to mention a patient that we induced V-tach with. She was in a narrow complex SVT at 180 and in retrospect the delta waves were more than visible though I am not sure I would not do the same thing again.


 
I agree. Presumably, the delta wave contributes to the wider qrs. but depending on the morphology, like someone noted, it may not be really apparent without a closer look.


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## E tank (Apr 18, 2017)

Chase said:


> I have seen A fib w/ WPW go into VF after verapamil..



Wow...could you share the details?


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## Eden (Apr 18, 2017)

Chase said:


> I have seen A fib w/ WPW go into VF after verapamil. Also have seen 1:1 A flutter eventually degrade into VF.


 I've had a patient go to vt and self cardiovert to sinus in 2-3 minutes. She didnt feel it at all. But she didnt have a known accesory pathway.


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## Tigger (Apr 18, 2017)

Chase said:


> I have seen A fib w/ WPW go into VF after verapamil. Also have seen 1:1 A flutter eventually degrade into VF.


I think CCBs are pretty big no no in Afib WPW. If you block or slow AV nodal conduction, the accessory pathway is going to receive all those impulses and block none of them, which will (as stated) induce VF. Or at least that's how I came to figure it.


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## TomB (Apr 18, 2017)

I wrote a 2-part series on WPW. Part 1 looks at delta waves and Part 2 looks at the arrhythmias of WPW.

Part 1: https://www.ecgmedicaltraining.com/wolff-parkinson-white-wpw-syndrome-part-1/
Part 1: https://www.ecgmedicaltraining.com/wolff-parkinson-white-syndrome-part-2/

Realistically, orthodromic AVRT looks like SVT and antidromic AVRT looks like VT. 

Tom


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## VFlutter (Apr 20, 2017)

E tank said:


> Wow...could you share the details?



It was a patient being flown in from an outside hospital. A fib RVR with bursts into the 200s. Polymorphic irregular beats with clear pre-excitation.  Flight crew decided to give verapamil. Apparently sustained 250+ for a short time then went into VF and resuscitated. Strips were pretty impressive. Patient ended up on procanimide then ablation.


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