AFIB with RVR and wide complex??

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jfuent268

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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.
 

Attachments

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?
 
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%?
 
jfuent268 said:
Just a heads up our department does not carry cardizem.
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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.
 
Oops didn't read the last little blurb
 
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.
 
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.
 
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.
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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.
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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??
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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.
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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.
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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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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.

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.

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.

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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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%
Throat, neck or jaw discomfort 15%
Gastrointestinal discomfort 13%
Lightheadedness/dizziness 12%
Upper extremity discomfort 4%
ST segment depression 3%
First-degree AV block 3%
Second-degree AV block 3%
Paresthesia 2%
Hypotension 2%
Nervousness 2%
Arrhythmias 1%
Nonfatal myocardial infarction; life-threatening ventricular arrhythmia; third-degree AV block; bradycardia; palpitation; sinus exit block; sinus pause; sweating; T-wave changes; hypertension (systolic blood pressure > 200 mm Hg)
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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.
 
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.
 
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.
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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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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.
 
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.
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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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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

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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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.
 
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.
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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
 
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.
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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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