# Scenerio 2



## Chris EMT J (Apr 4, 2022)

Male mid 50s CC of palpitations 
Pmx of AFib (uncontrolled and untreated) 
Vitals are as followed
HR 120 
BP 170/100 
O2 96% on RA 
RR 19 
BGL 115 
Temp 98.7f 
ECG suggest AFib with RVR 

Sample: palps, no allergies, no meds, AFib, last oral intake was a cup of coffee, events leading was walking home from coffee shop 

What would you do if you are the AEMT on the case and ETA 5min? 

Just a scenerio not a real patient but idea was inspired by experience


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## zacdav89 (Apr 4, 2022)

I would say nothing, you have afib thats not unstable that also has an unknown onset, d/t pt non compliance. Vitals as stable, set the er up for success start your iv and gather the rest of your assessment. No prehospital interventions needed.


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## Chris EMT J (Apr 4, 2022)

zacdav89 said:


> I would say nothing, you have afib thats not unstable that also has an unknown onset, d/t pt non compliance. Vitals as stable, set the er up for success start your iv and gather the rest of your assessment. No prehospital interventions needed.


Sounds good. On the cases that inspired this IVs were started and the ones with these BPs were given nitro. We also give aspirin alot for AFIB just to help with a prevention.


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## zacdav89 (Apr 4, 2022)

ChrisEMTA said:


> Sounds good. On the cases that inspired this IVs were started and the ones with these BPs were given nitro. We also give aspirin alot for AFIB just to help with a prevention.


I would counter what Benefit does those invernevtions bring to this patient? Pt has history of afib and is not Rate and rhythm controlled, so the clots are already there, and while the pt is hypertensive they don't appear to be in a hypertensive crisis and would get minimal to no benefit from the temporary pressure drop the nitro may provide


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## DesertMedic66 (Apr 5, 2022)

Absolutely no indication in the prehospital setting for aspirin or nitro. 

The patient has a history of a-fib and should be on preventive medications for that. A single dose of aspirin isn’t going to help. 

The patients BP is elevated but nothing that is extremely crazy. Sure, nitro may help bring his pressure down for a couple of minutes but we need to consider do we need to bring his BP down? He is not showing any signs of end organ damage so no we do not. Secondly, nitro has been reported to have rebound hypertension. There are also much better medications to utilize in a hypertensive emergency such as labetalol, esmolol, nicardipine. 

What are we gonna do for this patient? Absolutely nothing. Run a 12-lead and make sure there are no additional abnormalities and then a routine transport to the ED. I’m not gonna be starting an IV on him as there is a 95% chance he will be going into the lobby/triage at our local hospitals.


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## Tigger (Apr 5, 2022)

ChrisEMTA said:


> Sounds good. On the cases that inspired this IVs were started and the ones with these BPs were given nitro. We also give aspirin alot for AFIB just to help with a prevention.


What benefit do you expect any of these treatments to confer?


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## Chris EMT J (Apr 5, 2022)

Ok I am going to keep in mind for my future patients with AFib to not give aspirin or nitro. I have been doing it for preventing MI's and nitro for high blood pressure. I guess you guys are right may not actually be needed so thank you guys!


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## NomadicMedic (Apr 5, 2022)

ChrisEMTA said:


> Ok I am going to keep in mind for my future patients with AFib to not give aspirin or nitro. I have been doing it for preventing MI's and nitro for high blood pressure. I guess you guys are right may not actually be needed so thank you guys!


Curious, do you actually have protocols that call for ASA and NTG for these patients or were you just freelancing and giving meds because you felt like it?


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## Chris EMT J (Apr 5, 2022)

NomadicMedic said:


> Curious, do you actually have protocols that call for ASA and NTG for these patients or were you just freelancing and giving meds because you felt like it?


Honestly only protocol is if BP is considered a hypertensive urgency we give nitro. No actual protocol that says anything about a reg hypertension. Aspirin is also not by protocol but I have been giving it for AFIB because I have had patients that said they felt a little better and never had a patient die from aspirin with AFib so I just been giving aspirin by routine.


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## Tigger (Apr 6, 2022)

ChrisEMTA said:


> Honestly only protocol is if BP is considered a hypertensive urgency we give nitro. No actual protocol that says anything about a reg hypertension. Aspirin is also not by protocol but I have been giving it for AFIB* because I have had patients that said they felt a little better and never had a patient die from aspirin with AFib so I just been giving aspirin by routine.*


So we are clear, these are not good reasons to be giving medications. Aspirin is not used for pain or other symptom relief in cardiac patients. And saying "they didn't die" is not exactly a high bar for success either. 

Also it is a QA nightmare that you've been able to continually do this.


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## Chris EMT J (Apr 6, 2022)

Tigger said:


> So we are clear, these are not good reasons to be giving medications. Aspirin is not used for pain or other symptom relief in cardiac patients. And saying "they didn't die" is not exactly a high bar for success either.
> 
> Also it is a QA nightmare that you've been able to continually do this.


Your right. I shouldn't just give meds to prevent. And by "didn't die" meant they didn't have any problems. I am going to keep it in mind for future AFib patients. Thanks for your input.


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## mgr22 (Apr 6, 2022)

ChrisEMTA said:


> Your right. I shouldn't just give meds to prevent. And by "didn't die" meant they didn't have any problems. I am going to keep it in mind for future AFib patients. Thanks for your input.


It's good that you have an open mind, but your generalizations make me think your scope of practice is more than you can handle right now.

Tigger mentioned QA. Does your agency do any of that?


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## DrParasite (Apr 6, 2022)

DesertMedic66 said:


> Secondly, nitro has been reported to have rebound hypertension.


I have never heard of this... where did you see those reports?


DesertMedic66 said:


> I’m not gonna be starting an IV on him as there is a 95% chance he will be going into the lobby/triage at our local hospitals.


That patient is going to the lobby/triage? wow, your hospitals must have much more liberal standards for what patients should go to triage.  Even if he has a history of it, that doesn't mean the ambulance should just leave him in a chair in the lobby.

As for the other items that OP mentioned, I'm a little worried, and think he/she might not be ready to handle EMT-A... your treatment plan has me a little worried...


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## DesertMedic66 (Apr 6, 2022)

DrParasite said:


> I have never heard of this... where did you see those reports?
> 
> That patient is going to the lobby/triage? wow, your hospitals must have much more liberal standards for what patients should go to triage.  Even if he has a history of it, that doesn't mean the ambulance should just leave him in a chair in the lobby.
> 
> As for the other items that OP mentioned, I'm a little worried, and think he/she might not be ready to handle EMT-A... your treatment plan has me a little worried...


I’ll have to see where I can find the info for rebound hypertension. Its not something I have looked into at all. 

Our hospitals will send 95% of stable patients who do not actively need any BLS or ALS interventions to the lobby if it is a busy day, which it always is. We have been asked to pull unnecessary IVs out so the patient can go to triage. We have one hospital that has put patients who we have started an IV and gave Fentanyl in the lobby.


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## NomadicMedic (Apr 6, 2022)

ChrisEMTA said:


> Honestly only protocol is if BP is considered a hypertensive urgency we give nitro. No actual protocol that says anything about a reg hypertension. Aspirin is also not by protocol but I have been giving it for AFIB because I have had patients that said they felt a little better and never had a patient die from aspirin with AFib so I just been giving aspirin by routine.



I am very curious to see a protocol for a hypertensive emergency that specifies NTG administration. And as has been mentioned, the ASA is to help inhibit platelet aggregation in cases of ACS. If an EMT ever tells me they give ASA for symptom relief, I immediately recognize there’s a fundamental education gap. I think AEMTs playing fast and loose with protocols I’d a dangerous practice. It illustrates the lack of knowledge that may accompany the certification level and why AEMTs are considered a bad fit in many systems.

I don’t know what the OPs experience level is, but this example of practice is bad news bears.


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## Chris EMT J (Apr 6, 2022)

NomadicMedic said:


> I am very curious to see a protocol for a hypertensive emergency that specifies NTG administration. And as has been mentioned, the ASA is to help inhibit platelet aggregation in cases of ACS. If an EMT ever tells me they give ASA for symptom relief, I immediately recognize there’s a fundamental education gap. I think AEMTs playing fast and loose with protocols I’d a dangerous practice. It illustrates the lack of knowledge that may accompany the certification level and why AEMTs are considered a bad fit in many systems.
> 
> I don’t know what the OPs experience level is, but this example of practice is bad news bears.


Oh.....I am sorry. I do like learning and advancing my education thru practice so I will just follow strict protocol. I do want to be clear I am open minded and want to hear any tips for future practice Sincerely I am open to change. Feel free to leave any other tips in future scenerios


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## Tigger (Apr 6, 2022)

DesertMedic66 said:


> I’ll have to see where I can find the info for rebound hypertension. Its not something I have looked into at all.
> 
> Our hospitals will send 95% of stable patients who do not actively need any BLS or ALS interventions to the lobby if it is a busy day, which it always is. We have been asked to pull unnecessary IVs out so the patient can go to triage. We have one hospital that has put patients who we have started an IV and gave Fentanyl in the lobby.


Too bad they can’t just leave the lines in. We take people to triage with lines in and meds on board regularly. Same with low amounts of O2. If you walk into our hospitals with a subacute complaint you will likely be seen within twenty minutes by a provider and have labs drawn. Then you go sit in triage with the line in maybe getting fluid until there is a bed or you get discharged. 

Wild how different it can be.


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