# Pre-Hospital Anti-Dysrhythmics



## usalsfyre (Feb 11, 2010)

To avoid hi-jacking another thread, what is ya'lls opinion of prehospital anti-dysrhythmics? Useful or not?


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## Veneficus (Feb 11, 2010)

usalsfyre said:


> To avoid hi-jacking another thread, what is ya'lls opinion of prehospital anti-dysrhythmics? Useful or not?



Useful for what?


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## rmellish (Feb 11, 2010)

No, we've just been using them for fun all these years...


Is this a serious question?


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## usalsfyre (Feb 11, 2010)

Let me rephrase, poor question I appologize. 

Is the termination of ventricular tachydysrthmias via medication in a non-hemodynamicly comprimised patient by the field providers useful? Why or why not? Is approprite in some settings and not others, and if so when and where?


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## rmellish (Feb 11, 2010)

you mean converting a tachycardic rhythm in an otherwise stable patient? Not hypotensive, no AMS, no pulmonary edema? 

If it were me, I'd give O2 and transport. If they're truly asymptomatic then why mess with it?


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## Tal (Feb 11, 2010)

rmellish said:


> No, we've just been using them for fun all these years...
> 
> 
> Is this a serious question?



I think he asks if they work during the time before we reach the ICU. I think no, lidocaine and procor are slow acting, but importent to the prognosis.


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## MrBrown (Feb 11, 2010)

usalsfyre said:


> Is the termination of ventricular tachydysrthmias via medication in a non-hemodynamicly comprimised patient by the field providers useful? Why or why not? Is approprite in some settings and not others, and if so when and where?



No it is not and it is not something we do here, treat the patient and not the monitor.


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## fma08 (Feb 11, 2010)

If they are symptomatic *from the arrhythmia* and stable hemodynamically, not ALOC or anything, then yes, a pharmacological intervention is warranted.


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## mycrofft (Feb 11, 2010)

*Well sort of an answer, if you can include SVT/atrial fib.*

H&^L yes.

One of the reasons I'm more active here again (I know, mixed blessing) is that I needed a different beta blocker*. Got new meds ten days ago. Now I have a tachy but pretty darn regular baseline, versus being down to only about two of every three beats being near regular. Palpitations, positional dyspnea, postural swings gone, for now. I can sneeze without pain down my left arm.

So, I say yes, at least if the ventricular issue is rooted in the atrium.


*Sotalol


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## rmellish (Feb 11, 2010)

fma08 said:


> If they are symptomatic *from the arrhythmia* and stable hemodynamically, not ALOC or anything, then yes, a pharmacological intervention is warranted.



How else would they be symptomatic?


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## fma08 (Feb 11, 2010)

rmellish said:


> How else would they be symptomatic?



Little old lady who fell and broke her hip, symptomatic from the fall but is in a-fib? Not gonna start pushing cardizem for her.


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## rmellish (Feb 11, 2010)

fma08 said:


> If they are symptomatic *from the arrhythmia* and stable hemodynamically, not ALOC or anything, then yes, a pharmacological intervention is warranted.



And I would argue intervention is only necessary when pt is unstable or altered. Your post is contradictory. Aside from LOC and hemodynamics how else can you be symptomatic from an arrhythmia to the extent that it warrants intervention? 




fma08 said:


> Little old lady who fell and broke her hip, symptomatic from the fall but is in a-fib? Not gonna start pushing cardizem for her.



And I completely agree with you here. Must have misread the earlier post.


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## fma08 (Feb 11, 2010)

rmellish said:


> And I would argue intervention is only necessary when pt is unstable or altered. Your post is contradictory. Aside from LOC and hemodynamics how else can you be symptomatic from an arrhythmia to the extent that it warrants intervention?



Chest pain, shortness of breath, N/V, palpitations, weakness.

All clinical signs indicating that there could be something going on with the heart e.g. and MI, that would be causing the arrhythmia, in which case, the arrhythmia itself is an unneeded stress on the heart which I would want to treat immediately. Not only for the patient's comfort, or reducing the stress on the heart, but also to hopefully convert to a normal rhythm, or one where I can get a quality XII to check for underlying problems. Not to mention, just because they are stable now, doesn't mean they won't become unstable quickly. I'm not sure how I'd justify allowing a patient to remain in a potentially dangerous rhythm to the point of needing electrical therapy when I could have prevented it in the first place with the appropriate pharmacological therapy.


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## MrBrown (Feb 12, 2010)

Compromise from a dysrhythmia should include severe chest pain, shortness of breath, pulmonary edema, ALOC, hypotension etc and should be in the setting of sustianed ectopy or abnormal rhythm.

Some guy with a bit of chest tightness from one or two PVCs is not a problem, somebody who is semi conscious from sustianed VT is.


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## fma08 (Feb 12, 2010)

MrBrown said:


> Compromise from a dysrhythmia should include severe chest pain, shortness of breath, pulmonary edema, ALOC, hypotension etc and should be in the setting of sustianed ectopy or abnormal rhythm.
> 
> Some guy with a bit of chest tightness from one or two PVCs is not a problem, somebody who is semi conscious from sustianed VT is.



That's the thing, pre-hospital pharmacological interventions for arrhythmia should remain a viable option because it depends on the patient. I remember a vivid encounter from a patient while I was in medic school who seemed to be in V-tac with a pulse. Ran through the ACLS algorithm and ended up needing cardioversion, but doesn't mean that pharmacological interventions were not warranted, (which were due to symptomatic yet hemodynamically stable).


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## MrBrown (Feb 12, 2010)

We have amiodarone but audits have shown its being a little overused in patients who may have had a dysrhythmia but are not significantly compromised so it was resting somehwere sort of halfway between useful and prophylactic

I certianly would not withold amiodarone/cardioversion or atropine/pacing if it was indicated but in a stable patient who is not compromised I do not see the need.

From the memo



> This procedure is to be used when the patient is either in VT or in another tachydysrhythmia that is causing significant cardiac compromise. Significant cardiac compromise ... requires more than ‘a bit of chest tightness’ and more than ‘a bit of shortness of breath’.
> 
> In general we are seeing amiodarone overused in this setting and the pendulum needs to ‘swing a little away’ from using amiodarone for fast AF unless there is significant cardiac compromise associated with it.
> Note: amiodarone should only be very rarely used in the setting of a regular narrow complex SVT.
> ...


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## bmc911 (Feb 12, 2010)

i think it dpends on many factors and we all know every case is different. it also depends on ones definition os symptomatic. some believe if there is a cardiac realted complaint ie:chest pain, pressure, palpitations, etc, this would be symptomatic. other only consider symptomatic to be related to vitals. 

a-fib at 140-160 theres usually no reason to go crazy and get aggressive with antiarrythmics, a-fib 180+ plus theres no reason to wait til it is symptomtic or hemodynamically unstable. however with these you have to consider causes and treat those before throwin meds at it, as with any treatment.

v-tach is a fatal rythym when it is sustained and whether symptomatic or not. it will be symptomatic and unstable if untreated. now im not talking about patients with runs of v-tach, im refering to patients in a consistent v-tach. runs of v-tach treat the patient not the monitor and again for both consider underlying causes and treat first if possible.


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## LondonMedic (Feb 28, 2010)

rmellish said:


> how else would they be symptomatic?


If you have to ask that question do you think you should be in a position to hand out the pink heart pills?


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## FLEMTP (Feb 28, 2010)

fma08 said:


> Little old lady who fell and broke her hip, symptomatic from the fall but is in a-fib? Not gonna start pushing cardizem for her.



This is where a greater history and assessment will come into play. If I get the little old lady that fell and broke her hip, and is in an a-fib with RVR, im going to treat the obvious items first.. im going to give narcotics for pain and versed for muscle spasms and sedation... some fluids to see if her rate comes down, some oxygen of course, but if she sustains her rate... you'd better believe im going to be treating the underlying a-fib. You dont know unless you do some good homework if the patient fell secondary to being dizzy, maybe due to the decrease in her cardiac output from the combination of the a-fib and the rapid ventricular response. She also may have fell several days ago, and has not taken her medication. 

Every situation is different. I've said it before and I'll say it again.. people here seem to want a cookbook answer for an outside the box problem. Many of the scenarios I see here people seem to want to get a definitive blanket answer... and that's just not a sound way of thinking when it comes to medicine.

I will absolutely treat any dysrhythmia if and when it is appropriate for the patient. If they present with cardiac chest pain and/or cardiac type symptoms, anything above a mild shortness of breath, dizziness, palor, nausea, diaphoresis, altered LOC, hypotension, etc and I believe strongly and can back up my belief with facts, then im going to treat with electricity. 

If they present in a dysrythmia and they appear to be pretty stable, but the situation still calls for it then I will treat with cardizem, lopressor, amiodarone, lidocaine, or which ever medication is appropriate for the situation. 

Now, stable in one situation might be unstable in another, once again, there is no blanket statement or blanket answer for all situations. Assess, re-assess and treat appropriately.. and ALWAYS be prepared to defend your actions with sound medical facts. If you cannot justify what or why you are doing whatever it is you are doing, then DONT DO IT. 

If its a matter of lack of comfort, lack of knowledge or lack of skill and/or use of the skill.. then shame on you for not maintaining your minimum standards of competency for the job you are hired to do... and you are doing your patient a dis-service. 

You folks might disagree with me, but my job is to begin treatment on these people when they call us and take them someplace for definitive follow up care. just giving people a fast ride to the ER is not acceptable to me.


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## Melbourne MICA (Mar 6, 2010)

*ATR's*

For the original poster - converting tachydysrhytmias before they lead to cardiac arrest has always seemed like a good idea to me. (Tongue in cheek sarcasm here only -).

MM


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## trevor1189 (Mar 6, 2010)

> it also depends on ones definition os symptomatic.



I'm just a basic here, but symptomatic would include palipations/fluttering/pressure whatever your patient may call it.

This goes right back to the definition of signs and symptoms from EMT class.

Signs- Quantitative observations that can have a value placed on them.
Symptoms- Qualitative observations provided to you by your patient.

Some people in this thread seem to be confusing symptomatic with the qualitative measurements like the hypotension in the hemodynamically unstable person. Qualitative observations are inherently difficult to comprehend which is why we try to quantify them like the 1-10 pain scale. However, you have to remember symptomatic would include the SYMPTOMS. If your patient is in SVT with a rate of 180 and says my heart feels funny, then they are symptomatic and deserve to be treated. Am I wrong on that?

So I voted yes because the adenosine for SVT immediately popped into my head.


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## Melbourne MICA (Mar 7, 2010)

trevor1189 said:


> I'm just a basic here, but symptomatic would include palipations/fluttering/pressure whatever your patient may call it.
> 
> This goes right back to the definition of signs and symptoms from EMT class.
> 
> ...



Yes and no. Remember treatment, especially in EMS may be definitive or symptomatic. There may also be a time frame attached - time critical eg. There may also be compelling evidence that pre-hospital intervention is not necessary even if symptomatic except where immediate life threat exists or perhaps a compelling history of rapid deterioration. And histories may be revealing or unhelpful as can be the pts themselves.

Tachyarrhythmias need to be reverted (or revert), no question... or is there? A pt may be in an SVT but have only mild symptoms and more importantly, no haemodynamic compromise. In terms of anecdotal stuff, I'm sure plenty of the guys can recount pts who have had extended acute or acute on chronic episodes of a tachyarrhythmia, like SVT or yes even VT, who have mild symptoms or no symptoms at all or alternately the dysrrhythmia has a protracted lifespan. I've personally seen a sixty something year old chap with full blooded VT which lasted all day and overnight and he looked happy as Larry. I visited him in his ward whilst he was sipping tea and eating dinner still in VT.

The doc treated him - ordinarily VT is of course considered a lethal arrhythmia. It didn't revert him but the salient point was when they sat back and looked at the situation - he was doing fine - not compromised in any way especially haemodynamically, the most important consideration with all cardiac events. Eventually the pts VT just...stopped...by itself.

You have to way up all the factors and the situation as a whole. The main thing is, don't fret about it but keep a keen eye on things. Monitor and observe. Intervene when the pt is compromised (or when you anticipate it). Symptoms can be managed judiciously and as needed often with just basics or simple pharmacotherapy.

None of this stuff is cut and dried - that's half the fun - flying by the seat of your pants out there on the raggedy edge but keeping up the facade of a cool exterior - "wow - the relative says - I was stressed to the max and you guys were just so calm about it all".

All good stuff. Enjoy.

MM


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## Veneficus (Mar 7, 2010)

Melbourne MICA said:


> You have to way up all the factors and the situation as a whole. The main thing is, don't fret about it but keep a keen eye on things. Monitor and observe. Intervene when the pt is compromised (or when you anticipate it). Symptoms can be managed judiciously and as needed often with just basics or simple pharmacotherapy.
> 
> None of this stuff is cut and dried - that's half the fun - flying by the seat of your pants out there on the raggedy edge but keeping up the facade of a cool exterior - "wow - the relative says - I was stressed to the max and you guys were just so calm about it all".




This should be part of every prehopital textbook ever written. But the thread unfortunately demonstrates the "if....then" mentality of US EMS.(and some parts of medicine as a whole) The idea of a complex condition can be narrowed down to a simple treatment algorythm where yes/no questions show you which arrow you need to follow to "solve the problem." As if it was that simple.

But it is what keeps the academy style EMS mills in the US in business. It could be a bud light commercial... "We salute you Mr. saves lives by following instructions the janitor could carry out ambulance driver."

pardon my cynicism.


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## MrBrown (Mar 7, 2010)

Case in point (kind of)

Went to a 20 year old this morning (on 0.5/27 sleep mind you) c/o palpations and burning feeling in chest.  

Hx smoked a little bit of pot about 7hrs ago 

3 lead showed ST at 150 w/o ectopy while 12 lead showed the same by my reasoning but also printed "Borderline ECG: Sinus Tachycardia, Right Atrial Enlargement" or something like that.  

I was not with an Intensive Care Officer and we left her at home.  

Now how many people out there would spin out and start loading her up on oxygen, aspirin and maybe some nitrates, be calling up for Intensive Care and taking her to the hospital?


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## Melbourne MICA (Mar 7, 2010)

Veneficus said:


> This should be part of every prehopital textbook ever written. But the thread unfortunately demonstrates the "if....then" mentality of US EMS.(and some parts of medicine as a whole) The idea of a complex condition can be narrowed down to a simple treatment algorythm where yes/no questions show you which arrow you need to follow to "solve the problem." As if it was that simple.
> 
> But it is what keeps the academy style EMS mills in the US in business. It could be a bud light commercial... "We salute you Mr. saves lives by following instructions the janitor could carry out ambulance driver."
> 
> pardon my cynicism.



The way things often are you have every right to some cynicism - but not too much. At the end of the day we must all teach the "gentle" art of ambulance care - that's' the bits about dealing with people the right way and using knowledge and technologies as tools but not as the sum total of our services. 

Managing a tachyarrhythmia is in most respects no different from managing a minor problem. It still requires a plan of action based on common sense, a sound grasp of the situation based on information (not speculation or assumptions) and a logical and empathic thought process.

And it must *ALWAYS* revolve around a patient advocacy focus.

The only difference between a stubbed toe and a VT is what tools you employ to give the person (that be the pt) the best chance at recovering to normal health and well-being.  And it doesn't have to be the EMS suit who tuns the final key for the "this way to your recovery" door. Sometimes we just point them in the right direction and make sure they go to the *right* door in the first place.

MM

PS Thanks for the kind remarks Veneficus.


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## MrBrown (Mar 7, 2010)

90% of ambulance practice is people management, 9% is basic, fundamentals of care and 1% is drugs and complex intensive care.

What the patient needs often does not come in bullet point format in a little spiral bound book.


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## usalsfyre (Mar 7, 2010)

Melbourne, 

You made my point more perfectly than I could. It wasn't a "should we be treating lethal unstable dysrhythmias" thread, obviously, we should. This was more of a "should we be treating hemodynamaicly stable relatively non-symptomatic dysrhthmias or waitinging and letting the guys in white coats who make big money playing with calipers evaluate it?"

If ER docs often defer treatment to cadiologist in this type of patient then why are we rushing to push drugs? If they're unstable, electricity followed by the pharmocological treatment of your choice. Otherwise, ask yourself, are you playing over your head?


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## Melbourne MICA (Mar 7, 2010)

*SVT's*



usalsfyre said:


> Melbourne,
> 
> You made my point more perfectly than I could. It wasn't a "should we be treating lethal unstable dysrhythmias" thread, obviously, we should. This was more of a "should we be treating hemodynamaicly stable relatively non-symptomatic dysrhthmias or waitinging and letting the guys in white coats who make big money playing with calipers evaluate it?"
> 
> If ER docs often defer treatment to cadiologist in this type of patient then why are we rushing to push drugs? If they're unstable, electricity followed by the pharmocological treatment of your choice. Otherwise, ask yourself, are you playing over your head?



I think analysis of such situations has to go even further than the stable or unstable pt or even the pt who has a history of SVT's or is a first offender if I can put it that way. 

When we are making decisions, that is, making a committent to a course of action, the analysis that guides it must be thorough, precise, logical and intuitive. 

So what are we really saying here?

1. Your anaylsis contains information derived from an examination of *all* the readily available facts (such as past/present med history, circumstances of the event, drugs, physiological/psychological mitigators) which is pertinent and relevent - hence thorough;

2. Precise in so far as the technical details are well established and isolated - a good 12lead, yep its SVT, obs reveal whatever, S&S's - the pt fits in one of your protocol boxes pretty well, there is a well established and reasonable treatment plan which goes with such cases - you've crunched the numbers, joined the dots and crossed the technical T's.

3. Your analysis is not random, an alternative therapy secondary neuronal pathway outcome, its fits the matrix of prevailing and well established medical practice - its a sound, well rounded and reasonable piece of medical _*logic*_ - based on common sense and the fact that most grownups can be expected to think stright when needed and would come to a similar conclusion if in your situation.

4. Use your sense of intuition - another way of saying drawing on experiences.Never overlook the value or input of your past experiences or those of the pt/family/rellies etc. Past experiences are memory patterns burned onto your brains hard drive. They are a by-product of analyses already done by your brain and there to be utilised and exploited. Thats' why, after exposure, practice and time (how your memories are created) many of your actions are automatic - the right Iv, O2, monitor, the right drug etc etc. You can carry out these fucntions without thought.And don't forget, (because your brain *never *does) the old grey matter hard drive is also re-writeable. 

Your memorised thought patterns are an overlay you can apply to any event. And when you put the tracing paper of the past memories over todays event you will notice subtle or not so subtle differences which will alter that established thought matrix for the next time a similar situation arises. But the original is still there. Not only that but the grey bits up there are so good they can marry up seemingly unrelated memory patterns from other experiences with todays and compute a new and perhaps radically different brains eye view of what is happening and what you should do about it.

The changes you note with each new event are another memory pattern in and of themselves and there to remind you that each event is unique and individual - a warning not to stereotype your practice or rely soley on your autopilot. Always be sure to take the controls of the plane no matter how much you trust the ground controller or the autopilot. 

To be on-topic for the discussion here's a little example.

A elderly pt is in SVT with mild symptoms and no haemodynamic compromise, obs are good and she has been in her normal health recently. You have a bit of travel time to the ED but not too far away. Treat or not?

No replies asked for just food for thought.

MM

PS.Seems like going around in a circle but are we?
AMI, CCF, Cardiomyopathy, new HT and cardiac meds.
PPS. Not trying to be Doctor MM here - just saying how I look at things if it helps all/any of us.


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