Chemical or Electrical Cardioversion?

[NPO]

Where do you personally draw the line? And if you're going with electrical therapy, do you premedicate?

I had my first SVT, and by all means, I could have shocked him, and no one would have batted an eye. I even had my narcotics out and open. But I decided to give 6mg of Adenosine a try, just to say I did it; I didn't expect it to work, but it did.

The man called 911 complaining of chest pain, but he appeared in no significant distress. He was alert, oriented, and ambulatory on scene. His rate was 220, with a BP of about 85/50. I know this meets every indicator to move straight to electrical therapy, but given how non-symptomatic he appeared, I couldn't move past at least trying Adenosine first.

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[E tank]

Adenosine is way less hassle. The guy wasn't that unstable. Good use of that drug.

EDIT...People get "shocky" looking with tachyarrythmias because their cardiac output falls off and that means their venous return does too. In a low flow state, the time it would take to get to the heart, even with flushing, is delayed to the point where it can "burn out" before it has a chance to work. So you shock instead.

 

[luke_31]

You already answered your own question. If he is not symptomatic then go with drugs first. Don't get hung up with what the B/P is, especially when it's what you said it was. If he's not complaining of any other symptoms then the chest pain, I'd go for drugs first too. The easiest way to decide pharmacology or electricity is by looking at the patient and going if I don't get this converted immediately will they go into arrest? If yes by all means shock right away, also if you have time to draw up drugs to comfort the patient from the shock, then you have time to try adenosine first.

 

[GMCmedic]

Truth is the answer is going to vary from medic to medic.

I defended a new medic to the ER nurses once. He synchronized cardioverted SVT with chest pain that was otherwise stable. He wasnt wrong, he did exactly what ACLS teaches.

For me, I need a whole picture. A chest pain and SOB complaint with SVT may get Adenisone. It really just depends on the patients apperance. Basically, If they look like theyre going to die they get electricity. AMS gets synchronized cardioversion everytime.

A-Fib with RVR and hypotension also gets synch cardioversion.

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[hometownmedic5]

Hemodynamic stability, mentation, associated complaints, and the gut sick/not sick opinion in the presence of a dysrythmia are my four qualifiers.

You had tachycardia, hypotension, and chest pain. Definitely could have been cardioverted. Definitely could have been medicated. As is, neither would be wrong in my book.

As for premedication, if I'm cardioverting, most likely they are too unstable to spend the time getting versed out and drawn, administering, and then waiting until it circulates to be effective. I'm happy to give you some fent after the fact if your discomfort is significant and you've improved hemodynamically. You certainly deserve it.

This is a borderline case. Borderline cases are tough because there exists a strong, evidence based argument on both sides. These are the cases that cause huge problems because inevitably, someone will feel they are more "right", when they really aren't and won't let go. Even more so if this person is an FTO, Doctor, CQI guy etc.

 

[Handsome Robb]

You wouldn't be wrong for cardioverting your patient but for me I'm going to use drugs every time and twice on Sunday unless they look like they're fixing to die, are ALOC/Unconscious, etc.

In your dude I may have ended up sedating and cardioverting if he hadn't responded to repeated rounds of adenosine.


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[NPO]

In your dude I may have ended up sedating and cardioverting if he hadn't responded to repeated rounds of adenosine.

This is the route I was planning on going. Sounds like I was justified enough in treating my patient and not the monitor.

Anecdotally, the patient seemed to have some sort of mental disability, although, I didn't have any evidence of this, but he just seemed like it. He wasn't a very good historian, but as soon as we [the firefighter] pulled apart the defib pads, he got wide eyed and stared yelling "what are those for?! Don't put those on me!!" Which leads me to believe he may have traveled down this road before.


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[MackTheKnife]

Where do you personally draw the line? And if you're going with electrical therapy, do you premedicate?

I had my first SVT, and by all means, I could have shocked him, and no one would have batted an eye. I even had my narcotics out and open. But I decided to give 6mg of Adenosine a try, just to say I did it; I didn't expect it to work, but it did.

The man called 911 complaining of chest pain, but he appeared in no significant distress. He was alert, oriented, and ambulatory on scene. His rate was 220, with a BP of about 85/50. I know this meets every indicator to move straight to electrical therapy, but given how non-symptomatic he appeared, I couldn't move past at least trying Adenosine first.

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You done good! Treat the patient, not the numbers.

 

[MackTheKnife]

You "done good"! Treat the patient, not the monitor or the numbers.

 

[TXmed]

if you're concerned about pre-medication prior to cardioverting someone. if they dont have an IV just hit them with IM ketamine and hope it kicks in prior to them feeling the electricity. IM ketamine works far better than other IM pain medicine. I do this prior to IO'ing a semi-conscious patient that needs vascular access. works better than the lidocain flush.

 

[StCEMT]

IM ketamine works far better than other IM pain medicine. I do this prior to IO'ing a semi-conscious patient that needs vascular access. works better than the lidocain flush.

I like this idea, haven't thought of that. Tucking this idea away.

OP. I agree with how you did it. If you dont have those bad tingly feelings and have easy access, then rock on.

 

[NPO]

if you're concerned about pre-medication prior to cardioverting someone. if they dont have an IV just hit them with IM ketamine and hope it kicks in prior to them feeling the electricity. IM ketamine works far better than other IM pain medicine. I do this prior to IO'ing a semi-conscious patient that needs vascular access. works better than the lidocain flush.

I wish I had ketamime..

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[VentMonkey]

I wish I had ketamime..

You read his memo, trust me I tried even though it was an answer I already knew.

 

[NPO]

You read his memo, trust me I tried even though it was an answer I already knew.

Your efforts are appreciated.

It needs to start at the state level. So I did some poking around...

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[VentMonkey]

It needs to start at the state level. So I did some poking around...

Yes, this I already knew, but he said "suggestions". I had a few other items on their PM me if you'd like, he emailed me back that same day, and a day before his memo.

 

[E tank]

if you're concerned about pre-medication prior to cardioverting someone. if they dont have an IV just hit them with IM ketamine and hope it kicks in prior to them feeling the electricity. IM ketamine works far better than other IM pain medicine. I do this prior to IO'ing a semi-conscious patient that needs vascular access. works better than the lidocain flush.

I've never had to sedate with IM ketamine before cardioverting someone, and I wouldn't necessarily say don't do that. But I wonder if someone could criticize it because the required IM dose for effect might possibly induce some cardiac excitation which is sort of what is being treated with a shock in the first place. Curiosity only, but has anyone ever wagged a finger over that?

 

[Carlos Danger]

The problem that I see with IM ketamine for cardioversion is that if you are giving a large enough dose of ketamine to have both a rapid onset and significant sedating effect, you are giving a pretty whopping dose, which not only may not be the best thing in someone with an irritable heart, but also means you have to deal with the side effects of a large dose of ketamine.

If someone needs to be cardioverted emergently, frankly I don't worry much about sedation.

 

[VentMonkey]

Randomly brief derail-

If anyone ever gets a chance to sit in on a TEE, it's well worth it. Just remembered seen one during CCP clinical and watched the cardiologists digging around while the CRNA pushed Propofol every so often to keep the patient sedated.

...sorry, back to the regularly scheduled thread.

 

[hometownmedic5]

The problem that I see with IM ketamine for cardioversion is that if you are giving a large enough dose of ketamine to have both a rapid onset and significant sedating effect, you are giving a pretty whopping dose, which not only may not be the best thing in someone with an irritable heart, but also means you have to deal with the side effects of a large dose of ketamine.

If someone needs to be cardioverted emergently, frankly I don't worry much about sedation.

This is pretty much where I'm at. I don't electively cardiovert. If I'm going with Edison, you're wantonly unstable and need to be zapped right now. If you're stable enough for sedation, you're stable enough for medicine and I'm going to start there. If its not going well, you'll get your sedation in between adenosine doses, but if my evaluation says cardiovert now, i dont have time for meds. You can have some fentanyl later, once you're not quite so dying-ish.

Ketamine is now an optional med in Massachusetts(and my service has elected not to carry it), but they put it in the wrong protocol(behavioral sedation/chemical restraint), at the wrong dose; so to use it for anything else(if I had it) would need a mother may I call, and I really dont have time for that in this setting. It is my hope that, in a few years, it will become a mandatory medication, they will change the dosing to be less insane, and it will apply across multiple protocols.

 

[StCEMT]

Just my $0.02, I don't really care about full sedation. If it dulls the pain, that's good enough for me. I've cardioverted without sedation and it looked like it sucked. If I can't, sorry bout ya, but if I can then I'd like to try. Like hometown said though, that's assuming they don't need me to start with cardioversion to begin with.