# ACLS be damned!!!



## Veneficus (Oct 6, 2010)

So today I cardioverted a patient with a flutter at a rate of 55. 

I will put this down on the same list of experiences as pacing vtach with pulse of 180.

I find a strange sort of pride in knowing that somebody over in Dallas is probably having nightmares about it.


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## abckidsmom (Oct 6, 2010)

LOL!  Did you do it in an ambulance or an EP lab?


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## Smash (Oct 6, 2010)

Veneficus said:


> So today I cardioverted a patient with a flutter at a rate of 55.
> 
> I will put this down on the same list of experiences as pacing vtach with pulse of 180.
> 
> I find a strange sort of pride in knowing that somebody over in Dallas is probably having nightmares about it.



It's always nice to keep people on their toes!  Flutter with such a slow ventricular response is interesting, do you have a strip you can share?


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## Veneficus (Oct 7, 2010)

abckidsmom said:


> LOL!  Did you do it in an ambulance or an EP lab?



Cardio ward.

The goal was to try and restore NSR in order to eliminate the need for a pacemaker because the patient had all kinds of issues that would make implanting one difficult. 

Don't have a strip. on my way there now, if the guy is still there, i will try to get one.


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## Aidey (Oct 7, 2010)

Any pharmacological options used?


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## terrible one (Oct 7, 2010)

Care to share anymore info on both of these pt's? 
I find it interesting cardioverting a slow Aflutter and Pacing a Vtach.


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## Shishkabob (Oct 7, 2010)

I can understand cardioverting A-flutter, not really a shocker... but pacing Vtach at 180?


I need to hear that story.


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## Aidey (Oct 7, 2010)

I think it is a little unusual becuase of the conduction ratio. A perfusing pulse of 55bpm isn't exactly alarming. I'm curious why the V-Tach was paced and not cardioverted.


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## MrBrown (Oct 7, 2010)

How much ketamine did he get? 

Whatever he is having I want double


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## usalsfyre (Oct 7, 2010)

There is a treatment for VT called overdrive pacing. Perhaps this is what Veneficus is refering to.  It was taught in the first ACLS class I attended, then when somebody figured out most monitor/defib combos (you know, what people run the first 20min of a cardiac emergency with) weren't capable of performing it, it got dropped.

The basic idea was that you paced the patient at a rate faster than the rate the ectopic foci to gain control of the myocardium. Once your pacer is in control, you slow the rate down to something a little more acceptable to you and the patient. 

Keep in mind most EMS pacers won't pace above the rate of your average VT. Also keep in mind I haven't discussed this more deeply than in passing in about 8 years, have never done or seen it, and have never researched whether it actually works or not because it's never been in my scope and I've always had synchronized cardioversion available if I absolutely needed to convert VT. YMMV, taxes and tags are extra, ect, ect. 

Hopefully the OP or at least someone who knows more about overdrive pacing will chime in.


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## Veneficus (Oct 7, 2010)

sorry, no strip. Didn't get near that pt today.

Pacing Vtach. 

This was when I was working on a truck full time. We responded to a guy with a acute onset of dizziness and feeling faint. As I recall he was right on the line of stable or untable, so I called med control because he had a pacemaker, but the vtach was not paced, there was no sign the pacer was working. 

In collaboration with med control it was decided his pacemaker likely failed, so we would try using TCP until his internal one could be properly repaired/replaced. It worked wonderfully.

Cardioverting aflutter at 55. 

the patient was a 80 y/o male, had more history than I really want to type right now, but it came down to the chief cardio attending deciding it was worth a shot to try and save the guy a trip to theatre.

He had aflutter, HR (51-55) alternating between 3:1 and 4:1 conduction. He was stable in both mental status and BP, 121/79. He was removed from PO warfarin and placed on 48 hour heparin.

PT was sedated by the anesthesia service, versed and fent. And sync cardioverted him at 50J biphasic, and 100J twice, trying to stay at or below 100 to minimize damage to the myocardium. Ultimately the effort failed and it was decided he would get a pacemaker today. As i said, I didn't get to see him.  

Did see a SAM patient with pulmonary edema, resolved by 500cc fluid bolus. I do so like seeing unusual patients. My black cloud i still intact and operating as normal.


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## Shishkabob (Oct 7, 2010)

Hmph... I just gave Lido to my non-paced VT :lol:


Ahhh, medicine.


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## socalmedic (Oct 7, 2010)

hmm, i am wondering if they tried cardizem on your flutter. To me i think cardizem is a wonder drug. I have seen it used on a whole host of rhythms and never seen it fail to control it, A-fib, A-flutter, SVT, even a Sinus tach.


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## Veneficus (Oct 7, 2010)

socalmedic said:


> hmm, i am wondering if they tried cardizem on your flutter. To me i think cardizem is a wonder drug. I have seen it used on a whole host of rhythms and never seen it fail to control it, A-fib, A-flutter, SVT, even a Sinus tach.



he was there for several days before I was, if they didn't try it, I would think because of his history. Honestly I can't remember it all it was so extensive, and I know for sure desperation was setting in.


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## socalmedic (Oct 7, 2010)

sounds good to me, i cant think of a reason they wouldnt have tried it already. i just love to arm chair these things.


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## Akulahawk (Oct 7, 2010)

Overdrive pacing... that harkens back about 10 years for me... Learned about it, haven't done it though. Basically though, most people think about pacing when the rate's too slow... but as shown above, it can work to slow someone's rate down too! 

Thanks for the reminder about overdrive TCP.


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## Charmeck (Oct 14, 2010)

I would be interested to see A-flutter at 55.


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## MrBrown (Oct 15, 2010)

Your anaesthesia service needs better drugs ... and that black cloud of yours is to go with your black ninja outfit


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## JPINFV (Oct 15, 2010)

Charmeck said:


> I would be interested to see A-flutter at 55.



Hmm... A-flutter with 1st degree AV block maybe?


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## Hockey (Oct 15, 2010)

JPINFV said:


> Hmm... A-flutter with 1st degree AV block maybe?



Ehhh...I dunno about that..I guess its possible


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## JPINFV (Oct 15, 2010)

There's no reason I can't see why not. A-flutter is a macro-rentry circuit moving around the tricuspid valve annulus in the right atrium. The other is an AV-node delay. The 2 big questions is just how rare having both would be and would the refractory period of the AV node be slow enough to get the speed down to the 50s.


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## anestheticmedic (Nov 23, 2010)

My medic teacher override paced and got to the ER and the doc pulled the pads off, pulse soared and he quickly put them back on. I wasn't tought it either. That's all I know of it


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## Aidey (Nov 23, 2010)

Charmeck said:


> I would be interested to see A-flutter at 55.





JPINFV said:


> Hmm... A-flutter with 1st degree AV block maybe?




A-Flutter with a 5:1 conduction would be 50bpm wouldn't it?


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## BluesMedic (Dec 17, 2010)

usalsfyre said:


> There is a treatment for VT called overdrive pacing. Perhaps this is what Veneficus is refering to.  It was taught in the first ACLS class I attended, then when somebody figured out most monitor/defib combos (you know, what people run the first 20min of a cardiac emergency with) weren't capable of performing it, it got dropped.
> 
> The basic idea was that you paced the patient at a rate faster than the rate the ectopic foci to gain control of the myocardium. Once your pacer is in control, you slow the rate down to something a little more acceptable to you and the patient.
> 
> ...



     I have heard of this also and from what I remember, you are right on how it works.  I agree with you and others that it is not used in the pre-hospital setting because of the "normal" monitors we use not being able to pace at that rate.


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