# AFIB with RVR and wide complex??



## jfuent268 (Jul 11, 2015)

Hello everybody
I recently went on a call and wanted to share my experience and get some feedback/ opinions from others.

We responded to a 45 year old male patient with chest pain that began 1 hour prior to calling EMS. 

S: Chest pain, nausea, palpitations, shortness of breath
A: NKA
M: Lisinopril, Metformin, Albuterol
P: Asthma, Hypertension
L: NA
E: Got off work earlier from a call center and went home to rest.

O: Sudden
P: NA
Q: Crushing pain
R: Non radiating
S: 10/10
T: 1 hour prior to calling ems

As we arrive on scene we noted that the patient was in obvious distress, alert and oriented x 4, and skin was PWD.  He was placed on high flow 02 via non re-breather and a set of vitals were obtained. Blood pressure 220/110, pulse 220, respiratory rate 32, and SPO2 94% on room air with clear lung sounds.  The patient was placed on the monitor and a 12 lead EKG was obtained which showed a narrow complex tachycardia at a rate of over 200bpm which appeared to be irregular. An 18G iv was established in the left AC and 6mg of Adenosine were administered with no change.  An additional 12mg of adenosine were administered also with no change so we were convinced that whis was AFIB w/ RVR (Rate 200+).  The patient began to feel worse and was feeling very anxious at this point.  As we observed the monitor we began to note wide complexes which appeared to be runs of Ventricular Tachycardia.  These complexes were beginning to occur frequently.  We proceeded with putting the pads on the patient just to be prepared.  

The patient was then given 100 mg of Lidocaine IVP and the wide complexes were no longer seen but the patient was still tachycardic.  At this point we loaded the patient onto the ambulance and transported emergency traffic.  En route the patient was given 150 mg of Amiodarone as a drip over 10 minutes however the RVR persisted.  Upon contacting medical direction to notify them of our arrival they advised me not to perform synchronized cardioversion.  The patient remained the same and his heart rate was controlled at the hospital with cardizem.

Alright so that is pretty much it. I have uploaded the strips for your viewing pleasures and opinions.  Just a heads up our department does not carry cardizem.


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## TomB (Jul 11, 2015)

Looks like AF with runs of VT to me.


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## cannonball88 (Jul 11, 2015)

From my perspective, it appears you did things right. The only question I have is why switch to Cordarone when the Lidocaine was effective in stopping the runs of VT?


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## Handsome Robb (Jul 12, 2015)

I'm confused why you originally chose lidocaine but then followed it with an amiodorone drip rather than a lidocaine drip? It's not unheard of to change antidysrhythmics if the rhythm is refractory to the original drug however that's a pretty rapid progression through drugs. You're not going to reach and maintain therapeutic levels by giving only loading doses and not following with maintenance infusions.  

Pretty clear-cut case of AF with RVR. Do you carry calcium channel blockers? Seems as though the runs of VT began further along in this patient's progression, I'd be willing to bet it would be secondary to rate related ischemia causing irritability in the ventricles since it wasn't sustained and the rhythm is primarily atrial in nature. CCBs are contraindicated in VT however not if the VT is secondary to an atrial tachy-arrhythmia if I remember correctly. 

Also why the high flow O2 with room air SpO2 of 94%?


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## triemal04 (Jul 12, 2015)

jfuent268 said:


> Just a heads up our department does not carry cardizem.


Whew...good to know that I suppose.  Do you carry any calcium channel blockers or beta-blockers?  If not, why?

Why did you give adenosine?  All the strips you attached, including the 12-lead clearly show afib, not an unknown SVT or AVNRT.

What was your thought process on giving lidocaine?  It's certainly good for treating ventricular arrhythmia's, but in this case, and all cases, you should consider why that problem is occuring; in this case most likely it's due to the atrial fib at a high rate and probably the associated ischemia and demand on the heart.  Fix that and you'll likely fix the problem.  

Granted, without calcium channel blockers or beta-blockers your hands are tied.  This would be the patient you should be (and maybe did) thinking about cardioverting; from his meds there is no history of afib and it's a pretty defined onset so the risks are lower and the benefits are certainly there.  Might have been worthwhile to push harder for permission to cardiovert, though I don't know how your system is set up.  And it sounds like the guy did fine, so oh well.


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## Handsome Robb (Jul 12, 2015)

Oops didn't read the last little blurb


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## jfuent268 (Jul 12, 2015)

The high flow o2 was mostly for patient comfort since he was having trouble breathing.  I am aware this was because of the rapid heart rate. 
I do have verapamil but I forgot to mention we were out in an area that has no phone service and my medicaid direction requires a call to request this drug. 
My though process for lido was getting rid of the runs of vtach quickly and since lido can be given as a bolus instead of over 10 min like the amiodarone that's why I chose it.  Should I have started the lido drip in conjunction with the amiodarone drip??

I just figured there was no reason to since amiodarone is indicated for both afib wuth rvr and runs of vtach/malignant pvs's.

I see clearly that it is afib but I just wanted to make sure with the adenosine. ..it didnt hurt to try it haha. 

Thanks for the feedback guys.  This was my first call like this.  I was honestly a little nervous and the guy was deteriorating fast when we first arrived.


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## COmedic17 (Jul 13, 2015)

Unrelated- but I was working and trying to restrain a feisty pt and put myself into afib.  It's actually incredibly uncomfortable. I got extremely nauseous.


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## triemal04 (Jul 14, 2015)

jfuent268 said:


> The high flow o2 was mostly for patient comfort since he was having trouble breathing.  I am aware this was because of the rapid heart rate.


How was the extra oxygen going to make him comfortable?


> I do have verapamil but I forgot to mention we were out in an area that has no phone service and my medicaid direction requires a call to request this drug.


Understandable I suppose...but this is more something that the department and medical director should be working on; are you not in the US and don't have access to cardizem?  If you do, why carry verapamil instead?  Or not a beta-blocker?  Or both?  You say you didn't have phone service; not even a landline?  If you actually thought this patient was deteriorating fast, doing what is required to treat him in an appropriate way would be...well...appropriate. 


> My though process for lido was getting rid of the runs of vtach quickly and since lido can be given as a bolus instead of over 10 min like the amiodarone that's why I chose it.  Should I have started the lido drip in conjunction with the amiodarone drip??


Fair, but again, the cause of the irritability is what needs to be fixed; in this case the rapid afib.  Drips aren't overrated, but they are very often not needed.  The half-life of amiodarone is quite long; for most people, even with a prolonged transport (hours), the 150mg infusion will be enough.  Lidocaine doesn't have as long a half-life but the true need for a drip isn't that high; if the arrhythmia is still occuring after the first bolus it's probably because you didn't give enough, not because a drip is needed.


> I see clearly that it is afib but I just wanted to make sure with the adenosine. ..it didnt hurt to try it haha.


That was a joke, right?  I mean, nobody is so stupid as to actually think that is appropriate reasoning...right?  Giving a drug that you clearly know is not indicated because you think it won't hurt...hope you have a medical director with low expecations.


> Thanks for the feedback guys.  This was my first call like this.  I was honestly a little nervous and the guy was deteriorating fast when we first arrived.


While the patient did ok despite the things you did, and didn't do, if you were really that concerned about any sort of deterioration you should have been doing more to actually treat what was going on, versus just trying to treat whatever you saw on the monitor when it came up; in this case it would have been either getting order for verapamil, or cardioversion.


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## 9D4 (Jul 15, 2015)

triemal04 said:


> How was the extra oxygen going to make him comfortable?
> 
> Understandable I suppose...but this is more something that the department and medical director should be working on; are you not in the US and don't have access to cardizem?  If you do, why carry verapamil instead?  Or not a beta-blocker?  Or both?  You say you didn't have phone service; not even a landline?  If you actually thought this patient was deteriorating fast, doing what is required to treat him in an appropriate way would be...well...appropriate.
> 
> ...


Besides saying that if you can't get ahold of med control, I feel they would have a hell of lot more confidence if you treated the pt vs letting them deteriorate until you can grab a phone.

I was hoping the adenosine comment was a joke. I don't believe it is though. So just a quick reminder for him


> Flushing    44%
> Chest discomfort    40%
> Dyspnea or urge to breathe deeply    28%
> Headache    18%
> ...


those are the potential side effects of adenosine. Likely, the vtach was due to ischemia, as stated. If you care to take note however, ventricular arrhythmia is a listed side effect. 
We give drugs for the benefit. Risk vs benefit. There's a risk for every. Single. Drug. They are not harmless. 
I wouldn't to care to be in your shoes if that pt had deteriorated. "So you gave a non indicated drug, that you saw had no benefit, but didn't think it would 'hurt the pt'. PT then progressed into a lethal ventricular arrhythmia, which is a listed side effect of the drug you gave."
Food for thought.


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## Carlos Danger (Jul 15, 2015)

It's not uncommon for adenosine to be used as a diagnostic aid.....it's a very safe drug.


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## triemal04 (Jul 15, 2015)

I would hope you understand the difference between giving adenosine because you aren't able to definitively say what a particular arrhythmia is and are trying to help confirm/deny it, and giving it when, as stated, you are "clearly" sure what the rhythm is, which, by the included strips, would be an easy determination to make.


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## Carlos Danger (Jul 15, 2015)

triemal04 said:


> I would hope you understand the difference between giving adenosine because you aren't able to definitively say what a particular arrhythmia is and are trying to help confirm/deny it, and giving it when, as stated, you are "clearly" sure what the rhythm is, which, by the included strips, would be an easy determination to make.



Was this directed towards me?

If it was....I assure you that I am clear on all this.

I was just making a point to a previous post.


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## triemal04 (Jul 16, 2015)

Well...yeah sort of.  Since your comment didn't have anything to do with the OP's situation (or 9D4's comment) I felt it was appropriate to highlight the differences between the appropriate use of adenosine, and the inappropriate use of it.


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## Carlos Danger (Jul 16, 2015)

triemal04 said:


> Well...yeah sort of.  Since your comment didn't have anything to do with the OP's situation (or 9D4's comment) I felt it was appropriate to highlight the differences between the appropriate use of adenosine, and the inappropriate use of it.



I think my comment was relevant to both.

The OP may have written "I see clearly that it is afib but I just wanted to make sure with the adenosine", but given the fact that the sentence contains two contradictory statements, I would be willing to bet that what the OP really meant was "It looked a lot like AF but I wasn't 100% sure, so I figured some adenosine would help confirm and wouldn't hurt". And I think that is a valid and safe approach.


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## triemal04 (Jul 16, 2015)

Okidoki...


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## Melbourne MICA (Aug 6, 2015)

Sorry I'm getting chills hearing calcium channel blockers and adenosine mentioned in the context of VT and Afib.

http://circep.ahajournals.org/content/6/3/e34.long

http://journals.lww.com/em-news/Ful...se_Calcium_Channel_Blockers_in_a_Wide.12.aspx

If deteriorating then perhaps sedation and cardioversion whether SVT or Afib/VT -works for both of course. Bit hairy going from adenosine to lidocaine to amiodarone.

MM


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## Carlos Danger (Aug 6, 2015)

Melbourne MICA said:


> Sorry I'm getting chills hearing calcium channel blockers and adenosine mentioned in the context of VT and Afib.
> 
> http://circep.ahajournals.org/content/6/3/e34.long
> 
> ...



I agree. I'm just saying that adenosine has a legit role as a diagnostic aid. It sounds to me like what the OP was using it for, because he wasn't really 100% what he had on his hands.


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## Melbourne MICA (Aug 6, 2015)

Remi said:


> I agree. I'm just saying that adenosine has a legit role as a diagnostic aid. It sounds to me like what the OP was using it for, because he wasn't really 100% what he had on his hands.



Can't say I agree whatsoever in the notion of using powerful anti-arrhythmics as "diagnostic tools". This suggests experimentation and is in my view, unethical. As for rhythm interpretation - I appreciate this can be daunting and often far from obvious in the field with a time critical patient on your hands to boot, but honestly - is this really that difficult a rhythm to recognise?  - Uncontrolled Afib with runs of unsustained VT? I would have thought anyone using Adenosine, Lidocaine and Amiodarone MUST be able to recognise this rhythm or rhythms like it to be safely using these very powerful drugs in the first place. Guarantee this patient would have been cardioverted in the ED had he been a walk in. Passing thought - that BP reading - 220/110 with a HR of 200+??

Sorry this sounds harsh but this case is textbook intensive care stuff in the field.

MM


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## Carlos Danger (Aug 6, 2015)

Melbourne MICA said:


> Can't say I agree whatsoever in the notion of using powerful anti-arrhythmics as "diagnostic tools". This suggests experimentation and is in my view, unethical.



You may disagree with it, but it is a widely accepted use for adenosine. 

Do you view other diagnostic procedures - CT or stress testing, for instance - as experimentation and therefore unethical, as well?

I am not defending the OP's clinical decision making, nor am I arguing against cardioversion in the scenario presented (that's what I probably would have done). I'm just pointing out that this is a legitimate use for this drug.


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## teedubbyaw (Aug 6, 2015)

Adenosine has long been used to help identify certain rhythms...I.e slowing it down to see if P waves exist.


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## Melbourne MICA (Aug 6, 2015)

Remi said:


> You may disagree with it, but it is a widely accepted use for adenosine.
> 
> Do you view other diagnostic procedures - CT or stress testing, for instance - as experimentation and therefore unethical, as well?
> 
> I am not defending the OP's clinical decision making, nor am I arguing against cardioversion in the scenario presented (that's what I probably would have done). I'm just pointing out that this is a legitimate use for this drug.



With all due respect, that is a straw man argument. There is no parallel between a non-invasive procedure like CT and drugs where both effects and side effects may prove catastrophic if not used in the right setting, for the right purpose.

I agree Adenosine is used diagnostically: http://www.ncbi.nlm.nih.gov/pubmed/1711962 and is short acting. But it still has a half life where any number of devastating effects may occur. And you can't take it out or stop its actions once it goes in the vein. Going into asystole and cardiac arrest is the same whether your treatment causes it to happen in twenty minutes or in 30secs. And as the above article implies, it is only used diagnostically in the hospital environment under controlled conditions with the goal of revealing the underlying and hidden cardiac aberrancy  and establishing the safest and most effective short and long term management pathway.

And its efficacy can be assessed retrospectively as well. For example, I've seen an ED physician skillfully applying a tilt test for a patient with SVT, who had been given adenosine to see whether she was posturally challenged. She was - as soon as her legs were dependent and her BP fell even marginally the conditions/sensitivity/pathology that initiated the SVT in the first place were reactivated and she went straight back into SVT despite the initial reversion. The ED doc then moved to verapamil for a  more potent and lasting effect. This worked perfectly without risk to the patient  - he had all the back up he needed: any medication, resource, test, person or drug required and monitoring occurred in controlled conditions. And his management included taking the results of his testing and treatment and referring them to a specialist for long term management as well.

I'm not trying to be adversarial but patient advocacy is the mandate of all paramedics - we only ever do what is absolutely necessary within the boundaries and limitations of the uncontrolled pre-hospital environment and our own skill sets, body of knowledge and authority to treat. And in many ways this means we have to be even better at identifying the problem correctly in the first place. At least in this case, it was not appropriate to use adenosine diagnostically. This rhythm should have been correctly interpreted by an IC paramedic with authority to use anti-arrhythmics.

MM


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## Carlos Danger (Aug 6, 2015)

Melbourne MICA said:


> With all due respect, that is a straw man argument. There is no parallel between a non-invasive procedure like CT and drugs where both effects and side effects may prove catastrophic if not used in the right setting, for the right purpose.



It is not a straw man at all. Many diagnostic tests carry risk. You can't say "adenosine shouldn't be used diagnostically because it carries risk" but then dismiss the risk inherent in a dobutamine stress test in a sick patient. Even simple, routine lab tests carry risk - many patients every year are harmed by over treatment resulting from errant or abnormal but clinically irrelevant lab results.

Adenosine is a safe drug: http://www.ncbi.nlm.nih.gov/m/pubmed/19623049/


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## Melbourne MICA (Aug 8, 2015)

Remi said:


> It is not a straw man at all. Many diagnostic tests carry risk. You can't say "adenosine shouldn't be used diagnostically because it carries risk" but then dismiss the risk inherent in a dobutamine stress test in a sick patient. Even simple, routine lab tests carry risk - many patients every year are harmed by over treatment resulting from errant or abnormal but clinically irrelevant lab results.
> 
> Adenosine is a safe drug: http://www.ncbi.nlm.nih.gov/m/pubmed/19623049/



For a start, don't misquote me and then put quotation marks around the statement to give a false impression. This is what I said, quote: At least in this case, it was not appropriate to use adenosine diagnostically". "At least in this case". And I probably shouldn't have even said it that way either. I also clearly gave legitimate reasoning for the underlying ethical  and clinical proposition not to use drugs in the field for diagnostic purposes especially this "safe" drug".

From my own experiences here, paramedics will tend to engage in this kind of behaviour sometimes because they haven't figured out something they most probably should have in the first place - and with all due respect to the paramedic involved here - like an interpretation of an ECG an intensive care paramedic should be able to analyse, for example. They also go "diagnostic" because they don't apply a patient advocacy philosophy to their decision making the attitude being - " I can't figure out what's going on, lets try this drug and see what happens". Its a hawkish approach to care that puts the paramedics position before the patients.

And what happens when that approach doesn't work the first time? How many times do you keep applying the next layer of this approach before you stop? In what circumstances/patient conditions does the paramedic decide its not Ok to employ this approach? It's a can of worms that doesn't recognise the simple fact that the only person who EVER suffers from mistakes, omissions, oversights in medicine is the patient.

Besides, I'm yet to see anywhere in my own protocols for all the conditions we treat ( and I would venture in your own) where it says "if not sure what the rhythm or problem is apply "x" mg of drug A see what happens, then "x" ugm of drug B if that doesn't work, then.... etc., etc.   There are no guidelines like that even for the docs who employ diagnostic procedures.

Like I said, I'm not arguing about the use of pharmacologically based diagnostic procedures. I already agreed this is done routinely, where required and that this carries risks as the use of ALL drugs does -effects and side effects. You can clearly see I said as much. I also said I'm not trying to be adversarial or even argumentative. I just think its important if we are going to discuss field craft in open forums such as these that these kind of issues are canvassed as the "whys" of our practice are just as important as the technical "whats".

MM


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## Carlos Danger (Aug 8, 2015)

Melbourne MICA said:


> For a start, don't misquote me and then put quotation marks around the statement to give a false impression. This is what I said, quote: At least in this case, it was not appropriate to use adenosine diagnostically". "At least in this case". And I probably shouldn't have even said it that way either. I also clearly gave legitimate reasoning for the underlying ethical  and clinical proposition not to use drugs in the field for diagnostic purposes especially this "safe" drug".



I did not intend to misrepresent your statements with my improper use of quotations. Please forgive my lack of literary discipline. Anyone who read the two-page discussion could easily see that you didn't actually write what I put in quotes.

The fact remains that you described the use of adenosine to diagnose the origin of a tachycardia as unsafe and improper. I simply disagreed and pointed out that it is actually a common use of the drug, and that the drug is very safe for that purpose, as proven in the literature.

Again, I did not defend the OP's decision making or his use of adenosine in the specific scenario that he posted.


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## Melbourne MICA (Aug 9, 2015)

Remi said:


> I did not intend to misrepresent your statements with my improper use of quotations. Please forgive my lack of literary discipline. Anyone who read the two-page discussion could easily see that you didn't actually write what I put in quotes.
> 
> The fact remains that you described the use of adenosine to diagnose the origin of a tachycardia as unsafe and improper. I simply disagreed and pointed out that it is actually a common use of the drug, and that the drug is very safe for that purpose, as proven in the literature.
> 
> Again, I did not defend the OP's decision making or his use of adenosine in the specific scenario that he posted.



Thanks for your honesty Remi and like I said I'm not trying to be difficult or be a smartass either for that matter. But I can't let you off completely without saying you are still being a bit slippery if you don't mind me putting it that way  although we have consensus on your last sentence/point. I have stated more than once that diagnostic approaches using (potentially dangerous) drugs like antiarrhythmics INTHE FIELD are not appropriate. I never said they weren't in hospital situations and even explained in detail why they are done there. The proof of the pudding is in our guidelines - at least the ones in Australia. We have no diagnostic protocols - especially for cardiac conditions - just symptomatic management and Rx based on rhythm interpretation (12 lead). This may not be the case in the US although I certainly haven't seen any guidelines/protocols along these lines. (I've looked at bucket loads of them for some burns research I've been doing over the last four years).

By the way I''ve posted a thread on hydrogel burns dressings. Looking for some feedback as I've also just had a paper published on the subject in the International Wound Journal - a systematic review of the evidence base for hydrogels. I'm trying to upload it but keep getting an error message. 

I appreciate the frank discussion. Thanks. I won't argue points just for the sake of it.

kind regards

MM


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## jfuent268 (Jan 9, 2017)

triemal04 said:


> How was the extra oxygen going to make him comfortable?
> 
> Understandable I suppose...but this is more something that the department and medical director should be working on; are you not in the US and don't have access to cardizem?  If you do, why carry verapamil instead?  Or not a beta-blocker?  Or both?  You say you didn't have phone service; not even a landline?  If you actually thought this patient was deteriorating fast, doing what is required to treat him in an appropriate way would be...well...appropriate.
> 
> ...





triemal04 said:


> How was the extra oxygen going to make him comfortable?
> 
> Understandable I suppose...but this is more something that the department and medical director should be working on; are you not in the US and don't have access to cardizem?  If you do, why carry verapamil instead?  Or not a beta-blocker?  Or both?  You say you didn't have phone service; not even a landline?  If you actually thought this patient was deteriorating fast, doing what is required to treat him in an appropriate way would be...well...appropriate.
> 
> ...





triemal04 said:


> How was the extra oxygen going to make him comfortable?
> 
> Understandable I suppose...but this is more something that the department and medical director should be working on; are you not in the US and don't have access to cardizem?  If you do, why carry verapamil instead?  Or not a beta-blocker?  Or both?  You say you didn't have phone service; not even a landline?  If you actually thought this patient was deteriorating fast, doing what is required to treat him in an appropriate way would be...well...appropriate.
> 
> ...



I thought this was a learning/share your opinion enviorment. 
You must be one of those guys who thinks he knows everything yet does nothing. I bet you spend your days judging people instead of giving advice. 
Pathetic!


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## StCEMT (Jan 10, 2017)

Well at least this wasn't another 4 year necro


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## Underoath87 (Jan 10, 2017)

jfuent268 said:


> I thought this was a learning/share your opinion enviorment.
> You must be one of those guys who thinks he knows everything yet does nothing. I bet you spend your days judging people instead of giving advice.
> Pathetic!



It took you 18 months to come up with that reply?


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## NomadicMedic (Jan 10, 2017)

Underoath87 said:


> It took you 18 months to come up with that reply?



Took 18 months to get salty.


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## CWATT (Jan 16, 2017)

For anyone who knows - could you please explain the etiology for why Adenosine is contraindicated by AFib?  My understanding is that Adenosine acts primarially on the AV node, so wouldn't the rhythm just revert to AFib if given?


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## Alan L Serve (Jan 17, 2017)

Patient needed a Beta Blocker or Calcium Channel Blocker. Not sure why you gave Adenosine or Amiodarine in the presence of AFib w/RVR. Do you carry Metroprolol? Should have given that.


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## captaindepth (Jan 17, 2017)

CWATT said:


> For anyone who knows - could you please explain the etiology for why Adenosine is contraindicated by AFib?  My understanding is that Adenosine acts primarially on the AV node, so wouldn't the rhythm just revert to AFib if given?



The contraindication comes from the possibility of there being an accessory pathway as an alternate route for electrical impulses other than the AV node. If the AV node is transiently blocked and electrical impulses travel through an accessory pathway lethal arrhythmias can propagate through the ventricles. Atrial fibrillation  can have an atrial rate of 300-500 "bpm" but the ventricular rate is controlled by the AV node. So if the AV node is blocked the signals can travel through the accessory pathway and lead to ventricular fibrillation.


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## Underoath87 (Jan 17, 2017)

You guys realize this thread is like 2 years old, right?


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## VentMonkey (Jan 17, 2017)




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## Summit (Jan 17, 2017)

CWATT said:


> For anyone who knows - could you please explain the etiology for why Adenosine is contraindicated by AFib?  My understanding is that Adenosine acts primarially on the AV node, so wouldn't the rhythm just revert to AFib if given?


Yes. So the question is why give it if we know what the rythmn is and the med won't work.

However, if you aren't sure it is Afib with RVR... then you could give it for diagnostic purposes.


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## CWATT (Jan 17, 2017)

I think I've realized my error here...    is this rhythm considered Narrow Complex or Wide Complex?


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## Alan L Serve (Jan 17, 2017)

Adenosine as a diagnostic tool for diagnosing Afib? That's just bonkers and possibly lethal.



> The biggest dangers with adenosine are seen in two groups of patients: 1) those with atrial fibrillation or atrial flutter, and 2) those in sinus tachycardia and not PSVT.
> Numerous studies in the literature report serious rhythm degeneration and even death when adenosine has been inadvertently given to patients with either atrial fibrillation or atrial flutter. Adenosine can convert relatively stable atrial flutter with 2:1 conduction and a heart rate of 150 to 1:1 conduction with a heart rate of 300 and cause rapid clinical decompensation.10
> ...
> 
> ...



Please don't ever do that. Imagine sitting on the witness stand as an injury/wrongful death attorney is grilling you about your creative and reckless use of Adenosine in AFib. You almost never see those words "absolute contraindication" but there they are.


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## CWATT (Jan 17, 2017)

Alan L Serve said:


> Adenosine as a diagnostic tool for diagnosing Afib? That's just bonkers and possibly lethal.
> 
> 
> 
> Please don't ever do that. Imagine sitting on the witness stand as an injury/wrongful death attorney is grilling you about your creative and reckless use of Adenosine in AFib. You almost never see those words "absolute contraindication" but there they are.



Just to stir the pot a little more on using adenosine diagnostically, Heart & Stroke Foundation in the Pediatric Advanced Life Support (PALS) manual (2011 edition) on p.130 it state under Indications:

"May be helpful in disgtinguishing atrial flutter from SVT"

The Heart & Stroke also say in their Advanced Cardiac Life Support (ACLS) manual (2016 edition) for Wide Complex Tachycardias:

"If the rhythm etiology cannot be determined and is regular in its rate and monomorphic recent evidence suggests that IV adenosine is relatively safe for both treatment and diagnosis"  p.145


**also, I'm still looking for clarification on whether this is considered a narrow or wide QRS complex. (Sorry for the newb question - I'm a new EMT and having a bit of difficulty determining where we consider the isostatic baseline to be with the rhythm the OP posted) - that is, if what I'm seeing is a delta-wave or T-wave.


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## CWATT (Jan 17, 2017)

I've found the answer to my own question for why Adenosine is contraindicated with AFib, so I thought I'd share if anyone else was wondering the same.


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## Alan L Serve (Jan 17, 2017)

CWATT said:


> Just to stir the pot a little more on using adenosine diagnostically, Heart & Stroke Foundation in the Pediatric Advanced Life Support (PALS) manual (2011 edition) on p.130 it state under Indications:
> 
> "May be helpful in disgtinguishing atrial flutter from SVT"
> 
> ...


The rhythm posted surely was not regular. It had very clear Afib as demonstrated by the goofy-looking p-waves but also a polymorphic characteristic of the narrow QRS complexes.

Those who advocate for using Adenosine when it's so clearly absolutely contraindicated....gulp.


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## NomadicMedic (Jan 17, 2017)

Pretty clearly afib.


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## Alan L Serve (Jan 17, 2017)

DEmedic said:


> View attachment 3414
> 
> 
> Pretty clearly afib.


Hard to see how anyone could interpret it otherwise or why they would ever use Adenosine or even consider the use of Adenosine for diagnostic purposes. The dx is super obvious. Fast rate + Afib = rate control and pressure support. Let them synch cardiovert in the ED.


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## BassoonEMT (Feb 2, 2017)

Two year old threads are the BEST threads!


I always took "adenosine as a diagnostic tool" to be more of a well known backup plan.

By that I mean "well this looks like SVT, lets give the adenosine". Heart slows, revealing a rhythm with no p waves, and more irregular than originally seen, and then tachs up again.  The adenosine wasn't the resolving treatment, but you've now used it to diagnose that the rhythm is a-fib, and can treat accordingly.
But maybe that's just me.

But yes this was definitely a-fib from the start.


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