AFIB with RVR and wide complex??

[teedubbyaw]

Adenosine has long been used to help identify certain rhythms...I.e slowing it down to see if P waves exist.

 

[Melbourne MICA]

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.

With all due respect, that is a straw man argument. There is no parallel between a non-invasive procedure like CT and drugs where both effects and side effects may prove catastrophic if not used in the right setting, for the right purpose.

I agree Adenosine is used diagnostically: http://www.ncbi.nlm.nih.gov/pubmed/1711962 and is short acting. But it still has a half life where any number of devastating effects may occur. And you can't take it out or stop its actions once it goes in the vein. Going into asystole and cardiac arrest is the same whether your treatment causes it to happen in twenty minutes or in 30secs. And as the above article implies, it is only used diagnostically in the hospital environment under controlled conditions with the goal of revealing the underlying and hidden cardiac aberrancy and establishing the safest and most effective short and long term management pathway.

And its efficacy can be assessed retrospectively as well. For example, I've seen an ED physician skillfully applying a tilt test for a patient with SVT, who had been given adenosine to see whether she was posturally challenged. She was - as soon as her legs were dependent and her BP fell even marginally the conditions/sensitivity/pathology that initiated the SVT in the first place were reactivated and she went straight back into SVT despite the initial reversion. The ED doc then moved to verapamil for a more potent and lasting effect. This worked perfectly without risk to the patient - he had all the back up he needed: any medication, resource, test, person or drug required and monitoring occurred in controlled conditions. And his management included taking the results of his testing and treatment and referring them to a specialist for long term management as well.

I'm not trying to be adversarial but patient advocacy is the mandate of all paramedics - we only ever do what is absolutely necessary within the boundaries and limitations of the uncontrolled pre-hospital environment and our own skill sets, body of knowledge and authority to treat. And in many ways this means we have to be even better at identifying the problem correctly in the first place. At least in this case, it was not appropriate to use adenosine diagnostically. This rhythm should have been correctly interpreted by an IC paramedic with authority to use anti-arrhythmics.

MM

 

[Carlos Danger]

With all due respect, that is a straw man argument. There is no parallel between a non-invasive procedure like CT and drugs where both effects and side effects may prove catastrophic if not used in the right setting, for the right purpose.

It is not a straw man at all. Many diagnostic tests carry risk. You can't say "adenosine shouldn't be used diagnostically because it carries risk" but then dismiss the risk inherent in a dobutamine stress test in a sick patient. Even simple, routine lab tests carry risk - many patients every year are harmed by over treatment resulting from errant or abnormal but clinically irrelevant lab results.

Adenosine is a safe drug: http://www.ncbi.nlm.nih.gov/m/pubmed/19623049/

 

[Melbourne MICA]

It is not a straw man at all. Many diagnostic tests carry risk. You can't say "adenosine shouldn't be used diagnostically because it carries risk" but then dismiss the risk inherent in a dobutamine stress test in a sick patient. Even simple, routine lab tests carry risk - many patients every year are harmed by over treatment resulting from errant or abnormal but clinically irrelevant lab results.

Adenosine is a safe drug: http://www.ncbi.nlm.nih.gov/m/pubmed/19623049/

For a start, don't misquote me and then put quotation marks around the statement to give a false impression. This is what I said, quote: At least in this case, it was not appropriate to use adenosine diagnostically". "At least in this case". And I probably shouldn't have even said it that way either. I also clearly gave legitimate reasoning for the underlying ethical and clinical proposition not to use drugs in the field for diagnostic purposes especially this "safe" drug".

From my own experiences here, paramedics will tend to engage in this kind of behaviour sometimes because they haven't figured out something they most probably should have in the first place - and with all due respect to the paramedic involved here - like an interpretation of an ECG an intensive care paramedic should be able to analyse, for example. They also go "diagnostic" because they don't apply a patient advocacy philosophy to their decision making the attitude being - " I can't figure out what's going on, lets try this drug and see what happens". Its a hawkish approach to care that puts the paramedics position before the patients.

And what happens when that approach doesn't work the first time? How many times do you keep applying the next layer of this approach before you stop? In what circumstances/patient conditions does the paramedic decide its not Ok to employ this approach? It's a can of worms that doesn't recognise the simple fact that the only person who EVER suffers from mistakes, omissions, oversights in medicine is the patient.

Besides, I'm yet to see anywhere in my own protocols for all the conditions we treat ( and I would venture in your own) where it says "if not sure what the rhythm or problem is apply "x" mg of drug A see what happens, then "x" ugm of drug B if that doesn't work, then.... etc., etc. There are no guidelines like that even for the docs who employ diagnostic procedures.

Like I said, I'm not arguing about the use of pharmacologically based diagnostic procedures. I already agreed this is done routinely, where required and that this carries risks as the use of ALL drugs does -effects and side effects. You can clearly see I said as much. I also said I'm not trying to be adversarial or even argumentative. I just think its important if we are going to discuss field craft in open forums such as these that these kind of issues are canvassed as the "whys" of our practice are just as important as the technical "whats".

MM

 

[Carlos Danger]

For a start, don't misquote me and then put quotation marks around the statement to give a false impression. This is what I said, quote: At least in this case, it was not appropriate to use adenosine diagnostically". "At least in this case". And I probably shouldn't have even said it that way either. I also clearly gave legitimate reasoning for the underlying ethical and clinical proposition not to use drugs in the field for diagnostic purposes especially this "safe" drug".

I did not intend to misrepresent your statements with my improper use of quotations. Please forgive my lack of literary discipline. Anyone who read the two-page discussion could easily see that you didn't actually write what I put in quotes.

The fact remains that you described the use of adenosine to diagnose the origin of a tachycardia as unsafe and improper. I simply disagreed and pointed out that it is actually a common use of the drug, and that the drug is very safe for that purpose, as proven in the literature.

Again, I did not defend the OP's decision making or his use of adenosine in the specific scenario that he posted.

 

[Melbourne MICA]

I did not intend to misrepresent your statements with my improper use of quotations. Please forgive my lack of literary discipline. Anyone who read the two-page discussion could easily see that you didn't actually write what I put in quotes.

The fact remains that you described the use of adenosine to diagnose the origin of a tachycardia as unsafe and improper. I simply disagreed and pointed out that it is actually a common use of the drug, and that the drug is very safe for that purpose, as proven in the literature.

Again, I did not defend the OP's decision making or his use of adenosine in the specific scenario that he posted.

Thanks for your honesty Remi and like I said I'm not trying to be difficult or be a smartass either for that matter. But I can't let you off completely without saying you are still being a bit slippery if you don't mind me putting it that way although we have consensus on your last sentence/point. I have stated more than once that diagnostic approaches using (potentially dangerous) drugs like antiarrhythmics INTHE FIELD are not appropriate. I never said they weren't in hospital situations and even explained in detail why they are done there. The proof of the pudding is in our guidelines - at least the ones in Australia. We have no diagnostic protocols - especially for cardiac conditions - just symptomatic management and Rx based on rhythm interpretation (12 lead). This may not be the case in the US although I certainly haven't seen any guidelines/protocols along these lines. (I've looked at bucket loads of them for some burns research I've been doing over the last four years).

By the way I''ve posted a thread on hydrogel burns dressings. Looking for some feedback as I've also just had a paper published on the subject in the International Wound Journal - a systematic review of the evidence base for hydrogels. I'm trying to upload it but keep getting an error message.

I appreciate the frank discussion. Thanks. I won't argue points just for the sake of it.

kind regards

MM

 

[jfuent268]

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.

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.

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.

I thought this was a learning/share your opinion enviorment.
You must be one of those guys who thinks he knows everything yet does nothing. I bet you spend your days judging people instead of giving advice.
Pathetic!

 

[StCEMT]

Well at least this wasn't another 4 year necro

 

[Underoath87]

I thought this was a learning/share your opinion enviorment.
You must be one of those guys who thinks he knows everything yet does nothing. I bet you spend your days judging people instead of giving advice.
Pathetic!

It took you 18 months to come up with that reply?

 

[NomadicMedic]

It took you 18 months to come up with that reply?

Took 18 months to get salty.

 

[CWATT]

For anyone who knows - could you please explain the etiology for why Adenosine is contraindicated by AFib? My understanding is that Adenosine acts primarially on the AV node, so wouldn't the rhythm just revert to AFib if given?

 

[Alan L Serve]

Patient needed a Beta Blocker or Calcium Channel Blocker. Not sure why you gave Adenosine or Amiodarine in the presence of AFib w/RVR. Do you carry Metroprolol? Should have given that.

 

[captaindepth]

For anyone who knows - could you please explain the etiology for why Adenosine is contraindicated by AFib? My understanding is that Adenosine acts primarially on the AV node, so wouldn't the rhythm just revert to AFib if given?

The contraindication comes from the possibility of there being an accessory pathway as an alternate route for electrical impulses other than the AV node. If the AV node is transiently blocked and electrical impulses travel through an accessory pathway lethal arrhythmias can propagate through the ventricles. Atrial fibrillation can have an atrial rate of 300-500 "bpm" but the ventricular rate is controlled by the AV node. So if the AV node is blocked the signals can travel through the accessory pathway and lead to ventricular fibrillation.

 

[Underoath87]

You guys realize this thread is like 2 years old, right?

 

[VentMonkey]

 

[Summit]

For anyone who knows - could you please explain the etiology for why Adenosine is contraindicated by AFib? My understanding is that Adenosine acts primarially on the AV node, so wouldn't the rhythm just revert to AFib if given?

Yes. So the question is why give it if we know what the rythmn is and the med won't work.

However, if you aren't sure it is Afib with RVR... then you could give it for diagnostic purposes.

 

[CWATT]

I think I've realized my error here... is this rhythm considered Narrow Complex or Wide Complex?

 

[Alan L Serve]

Adenosine as a diagnostic tool for diagnosing Afib? That's just bonkers and possibly lethal.

The biggest dangers with adenosine are seen in two groups of patients: 1) those with atrial fibrillation or atrial flutter, and 2) those in sinus tachycardia and not PSVT.
Numerous studies in the literature report serious rhythm degeneration and even death when adenosine has been inadvertently given to patients with either atrial fibrillation or atrial flutter. Adenosine can convert relatively stable atrial flutter with 2:1 conduction and a heart rate of 150 to 1:1 conduction with a heart rate of 300 and cause rapid clinical decompensation.10
...

Thus, an absolute contraindication to adenosine exists in patients who have either atrial flutter or an irregular rhythm in atrial fibrillation.

http://www.jems.com/articles/print/...patient-cardiac-rhythm-important-ems-ade.html

Please don't ever do that. Imagine sitting on the witness stand as an injury/wrongful death attorney is grilling you about your creative and reckless use of Adenosine in AFib. You almost never see those words "absolute contraindication" but there they are.

 

[CWATT]

Adenosine as a diagnostic tool for diagnosing Afib? That's just bonkers and possibly lethal.



Please don't ever do that. Imagine sitting on the witness stand as an injury/wrongful death attorney is grilling you about your creative and reckless use of Adenosine in AFib. You almost never see those words "absolute contraindication" but there they are.

Just to stir the pot a little more on using adenosine diagnostically, Heart & Stroke Foundation in the Pediatric Advanced Life Support (PALS) manual (2011 edition) on p.130 it state under Indications:

"May be helpful in disgtinguishing atrial flutter from SVT"

The Heart & Stroke also say in their Advanced Cardiac Life Support (ACLS) manual (2016 edition) for Wide Complex Tachycardias:

"If the rhythm etiology cannot be determined and is regular in its rate and monomorphic recent evidence suggests that IV adenosine is relatively safe for both treatment and diagnosis" p.145


**also, I'm still looking for clarification on whether this is considered a narrow or wide QRS complex. (Sorry for the newb question - I'm a new EMT and having a bit of difficulty determining where we consider the isostatic baseline to be with the rhythm the OP posted) - that is, if what I'm seeing is a delta-wave or T-wave.

 

[CWATT]

I've found the answer to my own question for why Adenosine is contraindicated with AFib, so I thought I'd share if anyone else was wondering the same.