88 y/o female with palpitations

[zzyzx]

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[zzyzx]

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[teedubbyaw]

Hey, you're the one describing her as asymptomatic. If you felt she was asymptomatic, again, why cardizem? I'm not knocking treatment, but I'm asking why.

 

[Aprz]

Are palpitations a reasonable symptom to push cardizem w/ a rate of 150? Meh. Is a rate of 150 high for an 88 y/o?

I have no idea. I would like to learn more about diltiazem (cardizem).

I believe it can also be given to treat atrial fibrillation with rapid ventricular response and fascicular ventricular tachycardia. It seems reasonable to me to administer it to treat a symptom caused one of those cardiac arrhythmias. I guess we should be thankful it is not in my scope, haha. Hopefully I knew more about it if it was in my scope of practice.

What's your threshold for diltiazem administration. Seems like that's something you'd administer to somebody symptomatic (eg palpation), but stable versus somebody who is hemodynamically unstable or at risk of rapidly deteriorating (eg rate of 300 with 1:1 atrial flutter).

I believe it comes packaged as 125 mg in 125 mL. I think you give it as 5 mg/hr and decrease/increase it in 2.5-5 mg/hr increments. I have no idea how to bolus it.

@teedubbyaw I don't think it was him who gave the cardizem. I thought it was the physician at the ER?

@zzyzx On the EKG Club on Facebook, we remove the name and date of the EKG. If it is not removed, they delete it. Although this isn't the EKG Club, I think it would be good to get into the habit of that. They do it in case there is anybody who is super old that would narrow down who it is with the help of the date I think.

 

[triemal04]

Asymptomatic. Does not compute.

Meh...I suppose that depends on how you feel about the fact that she has palpitations or how long she'll sustain a fast rate with minimal atrial kick (could be a long time, or it might not be) Or if you prefer to treat the problem or let others take care of it for you; honestly a very acceptable decision in some circumstances. This lady though...barring a non-cardiac cause for her tachycardia...she get's treated.

Still standing by my previous guess of AFlutter with 2:1 conduction. Now that you've given her a Ca channel blocker you're further messing with the AV node, causing it to flip around to 2:1 or 3:1.

Kind of concerned about v1 and v2 though. It could either be rate-induced ischemia, or maybe ischemia happened first and affected the AV node, causing this arrhythmia?

And? Why is this concerning to you? Both the change in conduction, which would be expected with the use of a calcium channel or beta-blocker, and the clear left ventricular hypertrophy?

 

[triemal04]

I have no idea. I would like to learn more about diltiazem (cardizem).

I believe it can also be given to treat atrial fibrillation with rapid ventricular response and fascicular ventricular tachycardia. It seems reasonable to me to administer it to treat a symptom caused one of those cardiac arrhythmias. I guess we should be thankful it is not in my scope, haha. Hopefully I knew more about it if it was in my scope of practice.

What's your threshold for diltiazem administration. Seems like that's something you'd administer to somebody symptomatic (eg palpation), but stable versus somebody who is hemodynamically unstable or at risk of rapidly deteriorating (eg rate of 300 with 1:1 atrial flutter).

I believe it comes packaged as 125 mg in 125 mL. I think you give it as 5 mg/hr and decrease/increase it in 2.5-5 mg/hr increments. I have no idea how to bolus it.

@teedubbyaw I don't think it was him who gave the cardizem. I thought it was the physician at the ER?

@zzyzx On the EKG Club on Facebook, we remove the name and date of the EKG. If it is not removed, they delete it. Although this isn't the EKG Club, I think it would be good to get into the habit of that. They do it in case there is anybody who is super old that would narrow down who it is with the help of the date I think.

Serious question: are you really a paramedic?

 

[Aprz]

My education is paramedic. I work as an EMT. My paramedic certification is pending.

 

[zzyzx]

@Aprz....thanks for your reply. To answer your question, diltiazem is the go-to drug for AF and A flutter, but the best way to answer your question in more detail is to simply direct you to Google the drug. Wikipedia is actually a fairly good resource, but you should research it further. Allnurses.com is a good resource as well as the nurses on that site have hands-on experience of using the medication.

I'll have to check out that Facebook ECG page.

 

[Tigger]

Serious question: are you really a paramedic?

More than a phew places out there that don't carry diltiazem, if they carry a calcium channel blocker at all...

 

[Aprz]

No calcium channel blockers here or in adjacent areas.

 

[Gurby]

And? Why is this concerning to you? Both the change in conduction, which would be expected with the use of a calcium channel or beta-blocker, and the clear left ventricular hypertrophy?

I was concerned about the ST elevation in v1 and v2, but you're right, this is a perfect textbook case of LVH with strain - I'm angry that I missed that! She meets the v1or2 + v5or6 > 35mm criteria, and if not for the flutter wave buried in the T waves in the lateral leads the morphology would be textbook.

Sorry but I have to strongly disagree with you on not providing treatment

Regarding treatment, I don't think there's any question that she should be treated - the question is whether we as EMT's should be doing it in the field with a 10min/30min/1hr transport time (by the EKG's you posted, it looks like here she was . My protocols say I can give diltiazem if heartrate is greater than 150, patient is symptomatic but stable. So she does meet the criteria, but I'd like to know more of her medical history and medications before making that call.

If she is prescribed diltiazem or a similar drug I probably push it happily. If her symptoms are chest pain, SOB, etc, rather than "palpitations, this happens sometimes it's just my AFib acting up", I'm a lot more eager to push it.

I'm definitely going to keep a close eye on her, but with a transport time under 15 minutes or so and patient as described, I probably just start a line, saline KVO (careful of fluid overload), repeat 12-lead en route, make sure I know about it right away if her symptoms change. If we're 20+ minutes out from the hospital, I think I lean more towards treating. How long this has been going on factors in, too - if it started 12 hours ago I'm less concerned than I would be if she just felt it start 15 minutes ago and called 911.

Do you agree/disagree with that reasoning?

 

[triemal04]

More than a phew places out there that don't carry diltiazem, if they carry a calcium channel blocker at all...

My education is paramedic. I work as an EMT. My paramedic certification is pending.

Not really implying anything, just curious is all. Cardizem/diltiazem is a very basic, common medication. It's so common in fact that it is, and has been for some time, part of ACLS. I know there are places that don't use it; I just find it curious that someone who should have taken ACLS, is a paramedic, and has a high interest in EKG's doesn't know the basics about a standard drug that is used to treat cardiac arrhythmia's.

 

[Carlos Danger]

150 is very fast for an 88 y/o.

I would treat that even if asymptomatic.

 

[triemal04]

I was concerned about the ST elevation in v1 and v2, but you're right, this is a perfect textbook case of LVH with strain - I'm angry that I missed that! She meets the v1or2 + v5or6 > 35mm criteria, and if not for the flutter wave buried in the T waves in the lateral leads the morphology would be textbook.

Beware of imitators! The big bad imitators! Also, while you absolutely should not use the computer's interpretation as gospel and base your plan off of it (IF, and that's a big IF, if you are competant at interpreting 12-leads that is) I don't see anything wrong with using it as a second opinion if you are working alone; just don't let it sway you if it doesn't make sense. In the same vein, it's worth trying to figure out why it comes up with the conclusions it does; could be that you missed something, or could be due to an error, but worth thinking about. In this case, bet that would have been the nudge to remember that LVH can cause benign elevation.

Regarding treatment, I don't think there's any question that she should be treated - the question is whether we as EMT's should be doing it in the field with a 10min/30min/1hr transport time (by the EKG's you posted, it looks like here she was . My protocols say I can give diltiazem if heartrate is greater than 150, patient is symptomatic but stable. So she does meet the criteria, but I'd like to know more of her medical history and medications before making that call.

If she is prescribed diltiazem or a similar drug I probably push it happily. If her symptoms are chest pain, SOB, etc, rather than "palpitations, this happens sometimes it's just my AFib acting up", I'm a lot more eager to push it.

I'm definitely going to keep a close eye on her, but with a transport time under 15 minutes or so and patient as described, I probably just start a line, saline KVO (careful of fluid overload), repeat 12-lead en route, make sure I know about it right away if her symptoms change. If we're 20+ minutes out from the hospital, I think I lean more towards treating. How long this has been going on factors in, too - if it started 12 hours ago I'm less concerned than I would be if she just felt it start 15 minutes ago and called 911.

Do you agree/disagree with that reasoning?

Like I said, this lady, barring a non-cardiac cause for her tachycardia, should get treated. Are you WRONG to not do so? No, not really, but I wouldn't say that it is the best option. She's mildly symptomatic; if she were truly asymptomatic, you wouldn't be there, and her rate is higher than it should be. High enough to cause problems on it's own? Depends on the specific person but maybe not, at least not in the short-term; medium term or long-term is a different story. But, she also has lost her atrial kick due to the fib/flutter, which, coupled with less ventricular filling time due to the tachycardia could cause her to have problems quicker than if she was in a sustained sinus tachycardia for one reason or another. A slower ventricular rate would be beneficial in this instance. It's also worth taking into account how long you think she'll maintain herself, AND how long it'll take for the ER to start their treatement.

For me, she get's treated.

For someone who doesn't and has GOOD reasons not to...maybe not wrong, but not really right either.

 

[teedubbyaw]

Beware of imitators! The big bad imitators! Also, while you absolutely should not use the computer's interpretation as gospel and base your plan off of it (IF, and that's a big IF, if you are competant at interpreting 12-leads that is) I don't see anything wrong with using it as a second opinion if you are working alone; just don't let it sway you if it doesn't make sense. In the same vein, it's worth trying to figure out why it comes up with the conclusions it does; could be that you missed something, or could be due to an error, but worth thinking about. In this case, bet that would have been the nudge to remember that LVH can cause benign elevation.


Like I said, this lady, barring a non-cardiac cause for her tachycardia, should get treated. Are you WRONG to not do so? No, not really, but I wouldn't say that it is the best option. She's mildly symptomatic; if she were truly asymptomatic, you wouldn't be there, and her rate is higher than it should be. High enough to cause problems on it's own? Depends on the specific person but maybe not, at least not in the short-term; medium term or long-term is a different story. But, she also has lost her atrial kick due to the fib/flutter, which, coupled with less ventricular filling time due to the tachycardia could cause her to have problems quicker than if she was in a sustained sinus tachycardia for one reason or another. A slower ventricular rate would be beneficial in this instance. It's also worth taking into account how long you think she'll maintain herself, AND how long it'll take for the ER to start their treatement.

For me, she get's treated.

For someone who doesn't and has GOOD reasons not to...maybe not wrong, but not really right either.

So, she's in a period of afib/aflutter again. Are you seeing any clinical signs of her diminished atrial kick? Will you in an hour from now? And again, is 150 'really' high for an 88yo?

When I worked in a cardiac monitoring facility tracing ekg's of at home pt's, this was one of the most common things to see, and very rarely would a pt become symptomatic. Missed medication dosages were a big cause. Rhythm would reset and the pt would go back to watching TV. I don't like seeing rates that high in an 88yo, but it's not a red flag in this particular pt as far as I can gather.

5 minute transport time, I'll get the best history I can for the doc and not push cardizem. When I'm an hour from the hospital, she'll get drugs pushed.

 

[triemal04]

So, she's in a period of afib/aflutter again. Are you seeing any clinical signs of her diminished atrial kick? Will you in an hour from now? And again, is 150 'really' high for an 88yo?
I know what I think; it's why I would treat this lady. What do YOU think, and WHY?

When I worked in a cardiac monitoring facility tracing ekg's of at home pt's, this was one of the most common things to see, and very rarely would a pt become symptomatic. Missed medication dosages were a big cause. Rhythm would reset and the pt would go back to watching TV. I don't like seeing rates that high in an 88yo, but it's not a red flag in this particular pt as far as I can gather.
And you would, I'm sure be digging into her recent history. But based on this scenario, with let's say no missed meds and no non-cardiac causes, why would you not treat this woman? If she had already waited for this to stop on it's own (as is not uncommon for people to do) why would you continue to wait? By not a red flag I gather you're calling this a benign finding? Interesting.

5 minute transport time, I'll get the best history I can for the doc and not push cardizem. When I'm an hour from the hospital, she'll get drugs pushed0
So you're of "let someone else deal with it" mindset? How long do you think it'll be once she reaches the ER before she get's the appropriate med? Real question and something everyone should think about and know if possible..

Replies in red.

Everyone reading this gets to make the decision about what type of paramedic they want to be. There certainly are times when it is more appropriate to NOT treat someone in the field even though you technically can...and there are certainly times when it IS appropriate, even if that means you need to dig a little further. The choice falls to the individual.

 

[Gurby]

How long do you think it'll be once she reaches the ER before she get's the appropriate med?

This is something I should consider more often - sometimes it takes the doctor a while to come see the patient, and even longer for the nurses to come treat.

 

[teedubbyaw]

Replies in red.

Everyone reading this gets to make the decision about what type of paramedic they want to be. There certainly are times when it is more appropriate to NOT treat someone in the field even though you technically can...and there are certainly times when it IS appropriate, even if that means you need to dig a little further. The choice falls to the individual.

I like how you turn a constructive discussion into putting words into my mouth. Yes, benign and let someone else deal with it is how I roll.

tootles.

 

[triemal04]

I like how you turn a constructive discussion into putting words into my mouth. Yes, benign and let someone else deal with it is how I roll.

tootles.

I'm not putting words into your mouth, and if this isn't what you think by all means please explain what you do; in fact I even asked if you would do that in the last post.

So far you've said that the lady is asymptomatic, not having any type of red-flags, and that you wouldn't treat her. If you DON'T think that this is a benign problem, could you elaborate more on what you think it is and WHY you wouldn't treat her? All I can come up with so far from what you've said is because you've seen some people spontaneously convert. And as you've said so that you wouldn't do it with a short transport time...apologies, but that does certainly sound like you are dumping the work onto someone else.

If you've got a different reason I'd love to hear it.

 

[triemal04]

This is something I should consider more often - sometimes it takes the doctor a while to come see the patient, and even longer for the nurses to come treat.

It's worth keeping in mind; even at the best ER's there will be a lag from when you arrive to when the patient actually starts being treated. While it'll vary from place to place and will depend on what is going on/what needs to be done there will always be a gap.