Anti-Arrhythmics Hemodynamically Stable VTach

[Aprz]

I'm not a Paramedic or Paramedic student. I'm just curious since I over heard a conversation at the station, and decided to join in.

A paramedic intern responded to a 9-1-1 call where a mid-40s body builder was complaining about his AICD/pacer (the intern said it was both a defibrillator and pacer per patient, he did not see pacing spikes when the thing shocked the patient) shocking him. Unfortunately, I do not remember his cardiac history, but the paramedic intern explained to me that he had a history of using a lot of steroids, and that eventually lead to him having to get an AICD/pacer because of that "he has a bad heart". The only complain the body builder had was the AICD/pacer was shocking him, he denied chest pain, denied palpitations, wasn't mentally altered, not short of breath, good complexion, etc. Like I said, according to the Paramedic intern, his only complaint was his AICD shocking him. The Paramedic intern did a 3-lead and saw VTach. He then did a 12-lead, which according to him, the only significant thing in there was VTach.

Thinking about Smash's post with amiodarone post-ROSC, I was thinking about this... what are our goals with this patient? I was thinking to myself "Great, if he's hemodynamically stable, should I shock him? Should I push an anti-arrhythmic?" I figured that the AICD/pacer is only shocking him, it's not even converting the rhythm according to the intern, and we also have our own shocking equipment if we need to shock him ourselves, why not disable the AICD/pacer? I am not entirely sure if AICDs/pacer could be turned off, but I was thinking if we could.... why not turn it off, don't give an anti-arrhythmic, and try to determine why he's experience vtach while transporting to the hospital? It's not that I am entirely scared to treat VTach, but the fact that it's the only thing we can see on the ECG (I didn't get to see the strips and 12-lead so I can't say that it is VTach, but let's just say it is).... I'm just suspicious it's not VTach, or that an anti-arrhythmic is gonna help. Per intern, when I asked if the lido he pushed benefited the patient, he said "yeh, it slowed it down", I didn't verify if that converted the rhythm, or just simply slowed it down.

The question is... should an anti-arrhythmic be given to this patient (the intern used lidocaine)? Was my thought even rationale/reasonable?

 

[Handsome Robb]

You can disable pacers/AICDs with a magnet. Most if not all patients are given a magnet when it is placed. The rhythm must have been very fast to hide all the pacer spikes if that was indeed what was happening which is possible, Id still think the amperage on the pacer would be more than that of the cardiac rhythm.

Even if the patient was hemodynamically stable v-tach needs to be treated. I'd hang 150 mgs of amiodorone in a 100ml bag of NS and give it over 10 minutes. Now if the amio tanked his bp and he became symptomatic I'd cardiovert him. My monitor is going to deliver more joules than an internal defibrillator, although it does have to surpass much more resistance than an internal one. VT and SVT look similar but it isn't super difficult to discern one from the other.

 

[MSDeltaFlt]

If the AICD is firing you must first find out if it is firing for the right reasons and not dysfunctional. If confirmed firing for right reasons, then your pt was not hemodynamically stable irregardless of his BP and not complaining of chest pain. His HR and/or rhythm warranted it. So yes. Give the anitarrhythmic: ventricular or otherwise. Because if you don't then he will eventually convert to the most stable rhythm of all.

 

[TomB]

Disable tachy therapy with a ring magnet (if you don't have a magnet then sedate the patient). Make sure it's a regular wide complex tachyardia and not AF with BBB since AF is the most common reason for inappropriate ICD shocks. Whether or not to give an antiarrhythmic is a judgment call. I'm not a fan of prehospital antiarrhythmics but this is one circumstance where it might be worth it especially if you can't disable tachy therapy in the field. ICD shocks are traumatizing to the patient and it depletes the battery life of the device. If the patient deteriorates and you need to cardiovert make sure your pads are placed perpendicular to the axis formed by the ICD power plant and the heart.

 

[usafmedic45]

mid-40s body builder was complaining about his AICD/pacer (the intern said it was both a defibrillator and pacer per patient, he did not see pacing spikes when the thing shocked the patient) shocking him. Unfortunately, I do not remember his cardiac history, but the paramedic intern explained to me that he had a history of using a lot of steroids, and that eventually lead to him having to get an AICD/pacer because of that "he has a bad heart".

Yeah....welcome to one of the cardiomyopathies.

If he's in VT, the pacer is shocking him appropriately. You should tell your "intern" to STFU. If the patient is complaining, asking him whether he'd prefer those 20-50 joule internal shocks or a 200-300 joule external one should help shut him up. Lidocaine or amiodarone would be appropriate in this situation so far as I am concerned.

 

[tssemt2010]

Yeah....welcome to one of the cardiomyopathies.

If he's in VT, the pacer is shocking him appropriately. You should tell your "intern" to STFU. If the patient is complaining, asking him whether he'd prefer those 20-50 joule internal shocks or a 200-300 joule external one should help shut him up. Lidocaine or amiodarone would be appropriate in this situation so far as I am concerned.

i was thinkin the same thing, i think 150 of amiodarone would be fine in this situation, hopefully he was stable vtac throughout the transport because alot of people dont sustain vtac long before they crap out on you, never had a patient in v-tach with a pacemaker so idk how that would work

 

[TomB]

Sustained monomorphic VT is a not-uncommon finding in a patient with an ICD. Often the patient presents with a wide complex tachycardia at a rate of < 150 with an ICD that is not firing. The oral antiarrhythmics (one presumes) keeps the rate of the VT slightly lower than the lower rate "shock" limit of the device. This is confusing for a lot of paramedics because they think "if the patient is in VT why isn't it shocking?" It would be interesting to know whether or not this happens by design. In other words, was VT induced in the EP lab at the time of implantation and the patient was not pulseless with it? It's hard to know. Just a dilemma for a paramedic to deal with when the time comes, but at least you don't have the added pressure of multiple ICD shocks. I've seen cases where the patient was shocked 13 or 14 times in a row and tachy therapy was finally disabled. I personally think tachy therapy should be disabled immediately if the shocks are not terminating the VT. It's Einstein's definition of insanity (doing the same thing over and over and expecting a different result). The shocks are not benign events.

 

[MSDeltaFlt]

As a caveat to this thread, if you could test this body builder's urine (or any other body builder's UDS), you'd be amazed at what you'll find. These guys CAN (not all) be as much of a drug abuser as the local Meth head we pick up on the streets. Some are addicted to amphetamines, narcotics, along with steroids, sterols, GRAMS of caffeine and other stimulants. Some grow resistant strains of bacteria from chronic use of unclean techniques of injection of steroids. All for the sake of getting that "perfect" body look: size/mass/cut/tan etc.

This is why I'm willing to bet hard cash as just how critical this guy was and he probably didn't even know it.

FYI.

 

[Aprz]

Usafmedic, to clarify something, I'm a not a Paramedic (so no intern), and I was talking with a paramedic intern. Was just experimenting with the thought in my head and talking with the intern about it saying how I thought turning off the ICD would've been better and my rationale which was "it's not working/not converting the rhythm" and being hesitant with using an anti-arrhythmic when the only two things we see is it's shocking him and VTach per intern. I didn't get to see the strips and 12-lead to confirm it was VTach and to share with you guys.

Somebody else I talked with agreed that that ICD is better left on because external shocking is gonna cause more cell deaths and they'll have a longer healing process, and they would've had an amiodarone drip if they could.

 

[jjesusfreak01]

Related question. I've read that we give Mag Sulfate with Torsades patients because it decreases the irritability of the ventricles (ie, its an antiarrhythmic) that increases the chance of conversion upon shocking the patient. Does the same hold for amiodarone? That is, do we give it in arrest situations because it increases the chance that we'll get a successful conversion down the line?

 

[systemet]

As a caveat to this thread, if you could test this body builder's urine (or any other body builder's UDS), you'd be amazed at what you'll find. These guys CAN (not all) be as much of a drug abuser as the local Meth head we pick up on the streets. Some are addicted to amphetamines, narcotics, along with steroids, sterols, GRAMS of caffeine and other stimulants. Some grow resistant strains of bacteria from chronic use of unclean techniques of injection of steroids. All for the sake of getting that "perfect" body look: size/mass/cut/tan etc.

This is a really good point. I'm no body builder, but I used to lift weights at a gym where the local bodybuilders hung out. It was great, because they had lots of free weights, and scared away most of the casual work out crowd, so the gym was almost empty, even in peak hours. No waiting for equipment.

But the stories I would over hear. Wow. Guys injecting thyroid hormone, insulin-like growth factor, and so on. I like pharmacology a lot. I find it really interesting, but I wouldn't have thought of half the things these guys were trying.

Another aspect to this, is that two of the largest groups of steroid users, by occupation, must be firefighters and cops. [I have no evidence whatsoever to support this, just my entirely subjective opinion.]

 

[Nervegas]

The question is... should an anti-arrhythmic be given to this patient (the intern used lidocaine)? Was my thought even rationale/reasonable?

Yes, an anti-arrhythmic should be given, lidocaine wouldn't have been my first choice, as he had the AICD/Pacemaker and that is a contraindication for lido. Amio 150mg over 10 minutes would be my first choice, followed by a cardioversion if he becomes more unstable. Expedite transport to a cardiac capable hospital, as they will be able to get the readout from the AICD and also handle the underlying issue.

 

[Aprz]

Yes, an anti-arrhythmic should be given, lidocaine wouldn't have been my first choice, as he had the AICD/Pacemaker and that is a contraindication for lido. Amio 150mg over 10 minutes would be my first choice, followed by a cardioversion if he becomes more unstable. Expedite transport to a cardiac capable hospital, as they will be able to get the readout from the AICD and also handle the underlying issue.

Would you disbale the AICD if you could then since it sounds like you're planning on shocking him yourself if he worsens. So far you know that the AICD hasn't been converting the rhythm. Where this Paramedic works, amiodarone isn't available. Would you push lido if it's all you had?

 

[medicsb]

Yes, an anti-arrhythmic should be given, lidocaine wouldn't have been my first choice, as he had the AICD/Pacemaker and that is a contraindication for lido. Amio 150mg over 10 minutes would be my first choice, followed by a cardioversion if he becomes more unstable. Expedite transport to a cardiac capable hospital, as they will be able to get the readout from the AICD and also handle the underlying issue.

Wait, since when is AICD/pacemaker a contraindication for lidocaine?

 

[Nervegas]

Wait, since when is AICD/pacemaker a contraindication for lidocaine?

I remember reading about it someplace, I don't think its an absolute contra but more a soft one, as in, if you dont carry amio, use lido type situation.

Would you disbale the AICD if you could then since it sounds like you're planning on shocking him yourself if he worsens. So far you know that the AICD hasn't been converting the rhythm. Where this Paramedic works, amiodarone isn't available. Would you push lido if it's all you had?

Yes, have the magnet to disable the AICD if needed. And Yes, lido would be my second choice since I have amio available. If Lido is your go to anti-arrythmic then by all means, use it. Lido isnt absolutely contra-indicated by the pacemaker, but Amio is the preferred choice.

 

[KellyBracket]

Hot off the presses

I tried to edit this down. Just came out in the last issue of Circulation
{Circulation. 2011; 124: e411-e414}

Ventricular arrhythmias in patients with implanted defibrillators.

Ventricular tachycardia (VT) and ventricular fibrillation (VF) are important causes of mortality and morbidity in a wide variety of heart diseases. ... The occurrence of VT or VF is associated with increased mortality and heart failure hospitalizations in ICD patients, despite effective termination of the arrhythmia. VT or VF is associated with heart disease severity and, in some patients, is a marker for deterioration or intercurrent illness. Whether short VT or VF episodes and the hemodynamic and neurohormonal responses they may elicit contribute directly to adverse outcomes is not known. Frequent or incessant VT can cause hemodynamic deterioration, and death from uncontrollable VT occasionally occurs. ICD shocks in response to VT can damage myocardial cells and elicit sympathetic responses. ICD shocks have been associated with mortality in post hoc analyses of ICD trials, but whether there is a direct causal relationship of shocks to cardiac mortality and heart failure remains a controversial topic.

Patients With Arrhythmia Symptoms or ICD-Detected Arrhythmia
A patient who reports arrhythmia symptoms or a perceived shock should be promptly evaluated with an ICD interrogation to determine whether the event was truly a ventricular arrhythmia, rather than an inappropriate ICD therapy in response to rapid atrial fibrillation, or electric noise from a lead malfunction, which warrants further intervention. Those who have had VT or VF will broadly fall into 1 of 3 groups. The first are typically stable with modest heart disease and preserved functional capacity, who return to a stable state following ICD termination of an arrhythmia. The VT or VF episode is an isolated event, and a substantial extension of survival is likely. The second group comprises patients for whom the VT/VF event signifies an unfavorable change in their previously stable clinical status. ... The third group are patients who have severe heart disease and a poor prognosis. ...

Monomorphic VT Versus Polymorphic VT/VF
Details of the arrhythmia episode that can be retrieved from the ICD... VT can be monomorphic, ... or polymorphic ... that usually degenerates rapidly to VF if it does not terminate promptly. It is important to recognize, however, that arrhythmia detection algorithms in ICDs primarily define the VT rate (usually expressed as cycle length) and cannot discriminate between various ventricular arrhythmia types. The ICD is typically configured for a VF zone for fast VTs (eg, >220/min) and 1 or 2 VT zones for slower arrhythmias. A fast monomorphic VT with a rate falling into the VF zone is often erroneously reported to the clinician as VF, whereas a polymorphic VT with a rate that falls in a designated VT zone may be reported as VT. Review of the stored electrograms is required to distinguish the difference. ...
Sustained monomorphic VT is usually due to reentry in a region of myocardial scar in patients with structural heart disease. ... Scars are a durable arrhythmia substrate, such that the likelihood of a VT recurrence following the initial episode of scar-related VT can exceed 20% per year. ICDs, however, often can terminate monomorphic VTs by applying a burst of pacing (antitachycardia pacing,) that is painless. Appropriate ICD programming to allow this option is therefore important. A shock is applied if antitachycardia pacing fails, accelerates VT, or causes VT to transition to VF.

Polymorphic VT indicates a continually changing ventricular activation sequence, often associated with a changing arrhythmia substrate. Acute myocardial ischemia and metabolic derangements are the major concerns... Polymorphic VT is often associated with disorders ... such as the acquired and congenital long-QT syndromes and Brugada syndrome. Myocardial hypertrophy and failure predispose to these arrhythmias. ... Antitachycardia pacing is unlikely to be effective for terminating polymorphic VT. Thus, the diagnostic and therapeutic considerations for polymorphic VTs are different than those for scar-related monomorphic VTs.

Therapy to Reduce VT
Episodes of VT that cause symptoms or perceptible hemodynamic effects usually warrant therapy to reduce or prevent recurrences, although an impact of antiarrhythmic therapy on mortality has yet to be proven. ... In patients with significant structural heart disease, β-blockers and amiodarone are the common pharmacological options. Amiodarone combined with a β-blocker was more effective than sotalol or an alternative β-blocker. Amiodarone has well-known noncardiac toxicities and was associated with increased mortality in patients with class III heart failure who did not have ICDs. The most common cardiac adverse effect of amiodarone is bradycardia, which has the potential to impair ventricular function by increasing ventricular pacing from the ICD in patients who do not otherwise require pacing.

For patients with monomorphic VT, catheter ablation is often an option.... Outcomes for VT due to nonischemic cardiomyopathies and arrhythmogenic RV cardiomyopathy are less well studied. The arrhythmia substrate is more variable and more likely to require epicardial ablation, which requires more specific expertise and is associated with additional risk. In postinfarction patients with frequent, recurrent VT, procedure-related mortality is ≈3%, but most deaths are attributable to continued uncontrollable VT when the procedure fails. Catheter ablation can be life-saving in patients with incessant VT or very frequent VT, often referred to as electrical storms. Catheter ablation is not usually an option for treating infrequent, polymorphic VT...

Further Needs
Many issues require further study. ... Arrhythmia control without improvement in cardiac function has limited benefit, and often arrhythmia control cannot be achieved. End-of-life care for this population is challenging and guidance to physicians and families is needed.

The relation of ventricular arrhythmias to mortality and heart failure suggests that therapies that prevent VT/VF might improve outcome, but all therapies have the potential for adverse effects that could negate benefit. ...

The availability of home-monitoring systems for ICD patients will further inform our understanding of the relation between ventricular arrhythmias, cardiac remodeling, and mortality as heart disease evolves....

 

[medicjosh]

VT and AICD in the ED

So as a medic I still shadow docs in the ED relatively frequently to get a different type of exposure and to keep learning some good stuff.

Earlier this week a patient was driven to the ED by family due to his AICD firing. The pt had contacted his cardiologist en route to the hospital so the arrhythmia services were awaiting the patients arrival. They were able to interrogate his AICD which revealed 9 episodes of VT and the patient had two more runs of VT with shocks in the ED within the first 10 minutes of the patients arrival. Now here's what really threw me:

Once the the nurses established IV access the NP from the arrhythmia services order a 300mg amiodarone bolus! I questioned the NP why she ordered the cardiac arrest dose rather than the 150mg drip over 10 min as he was hemodynamically stable. Her response was that if it weren't for his AICD you treat him essentially as if he had pulseless VT.

Does anyone have any experience with this type of a scenario where the cardiac arrest dose is administered to a hemodynamically stable pt with an AICD firing? Any literature on the topic?