Adenosine Question

[EMSrush]

Incorrect. If you know (or think) he is doing something wrong you have the right to question him. Just because he did a two bit course thirty years ago and has one year of experience repeated thirty times does not mean he knows best.

If he is in the act of doing something wrong in my presence, yes.
A story from heck-knows-how-many years ago? Nope. I wasn't even there, didn't see it, can't judge. This was merely a story, and who knows what factors in this story have changed from the occurrence to the telling. I can, however, use it as a personal learning point for myself, which is what I've done.

 

[usalsfyre]

Were they R on T PVC's? Maybe the asystole didnt have anything to do with the lido... Maybe the R on T pvc's threw the pt into a fine vfib? I know its a bit of a stretch, but I've never heard of lido causing asystole before... I guess you could have pushed like 100mL instead of 100mg (though I would be interested to know where you got that packaging from haha)

Which brings me to a point that I had... Alot of people on this thread said lido is more hurtful than helpful. What about for R on T PVC's?

R on T phenomenon will manifest itself with VTach (pulseless or perfusing) or Vfib. If pulseless, defibrilate. If perfusing Vtach is present then you have to determine whether it warrants electrical therapy. If Vtach is well tolerated I still would think long and hard before treating it.

 

[18G]

If Vtach is well tolerated I still would think long and hard before treating it.

And what happens if your delay in treating the Vtach causes it to deteriorate into Vfib which it is prone to do?

I've never seen a protocol that allowed EMS providers to allow a patient to remain in Vtach. Why would you want to let a patient in a potentially lethal, suboptimal rhythm such as Vtach?

 

[Aidey]

Where I interned the protocol was that if the patient was unstable they could use Lidocaine or cardiovert. If the patient was stable they had to call for orders for the Lido. The hospitals never gave permission because they used Amiodarone, the end result is that we had a patient in monomorphic v-tach for the majority of the transport. He would convert out for about 30 seconds when we did vagal maneuvers, but he was in the v-tach most of the time.

Pulse of like 80 and irregular, BP of 130/80. Pt was in his 70s and couldn't figure out what all the fuss was. He said he felt good enough to take us out dancing (my preceptor was female also).

 

[MrBrown]

If the patient is in VT which is well tolerated Brown would be hanging up some amiodarone to try and break it. Should that fail its time for cardioversion.

The only rhythms not treated here are well tolerated haemodynamically uncompromising AF, sinus tach or sinus brady, PVCs and blocks.

Obviously somebody who is pale, grey, has a GCS of 9 and a third degree block is going to get treated.

 

[Aidey]

He got Amiodarone at the hospital. The problem was that they were not carrying it on the ambs yet, and the hospitals did like people using lido becuase it meant they couldn't give the Amiodarone right away. The protocol didn't allow for unstable cardioversion without orders. We could have tried to get orders, but we wouldn't have. They didn't believe us that he was in v-tach, so I doubt we would have gotten orders.

When we walked in the door with about 10 feet of EKG paper the doc looked at it and said "Oh, that is actually V-tach".

 

[EMSrush]

When we walked in the door with about 10 feet of EKG paper the doc looked at it and said "Oh, that is actually V-tach".

I love it... :wacko:

 

[usalsfyre]

And what happens if your delay in treating the Vtach causes it to deteriorate into Vfib which it is prone to do?

I've never seen a protocol that allowed EMS providers to allow a patient to remain in Vtach. Why would you want to let a patient in a potentially lethal, suboptimal rhythm such as Vtach?

I didn't say don't treat it under any circumstances, just think about it based on your situation. If I have a patient hit R on T 7 minutes out, by the time I wait for the 12 lead to process, pull out the Amiodarone, mix it, spike the bag, set the pump (and yes ALL medicated infusions should be on a pump) and connect it we're going to be darn close to the ED. An ED which is not moving and has gobs more room and people if things go south after administering a potentially lethal drug for well tolerated condition. As well as more complete treatment and assesment options to determine if Amiodarone is even the right choice. If I'm a half hour out, the equation changes considerably.

Plus, stable, well tolerated Vtach normally doesn't degenerate into Vfib without physical signs of hemodynamic instabilty first. Which is what we call a clue. If the patient shows signs of potential or actual hemodynamic instability they need emergent cardioversion, mùy pronto.

 

[Cawolf86]

And what happens if your delay in treating the Vtach causes it to deteriorate into Vfib which it is prone to do?

I've never seen a protocol that allowed EMS providers to allow a patient to remain in Vtach. Why would you want to let a patient in a potentially lethal, suboptimal rhythm such as Vtach?

Never? In LA County, perfusing VT is simply monitored for signs of poor perfusion.

http://ems.dhs.lacounty.gov/ManualsProtocols/BHTG/BHTG-D3.pdf

 

[18G]

LA County must have some mediocre protocols....

In PA for stable wide-complex tachycardia we can give Lidocaine or Amiodarone. If we suspect SVT with aberrancy then we can give adenosine... all above the command line.

If unstable than we cardiovert with three options for sedation (versed, ativan, and valium).

 

[usalsfyre]

LA County must have some mediocre protocols....

In PA for stable wide-complex tachycardia we can give Lidocaine or Amiodarone. If we suspect SVT with aberrancy then we can give adenosine... all above the command line.

If unstable than we cardiovert with three options for sedation (versed, ativan, and valium).

So I don't work under LA County protocols. My protocols don't even have a "command line" so to speak, they're made up of decision points with very, very few interventions needing prior physician contact. I don't believe my adult cardiac guidelines even have any of those. So I can treat stable Vtach as I see fit. The question is not whether I CAN it's whether I SHOULD. That question should be considered very, very carefully prior to screwing around with the cardiovascular system of someone who is tolerating a given rhythm well.