Chest Pain

[AEMTstudent]

I'm gonna go out on a limb and say you didn't read the whole thread...

Everyone has already covered it pretty well. With a patient like this you bet I'm sitting on scene and getting things done before we go anywhere.

If we can't get a line we can't get a line. I'd look for an EJ. I would not drill this guy unless I had to. While VT is a lethal arrhythmia people can sustain it for long periods of time (read: hours if not days). If his MAP stays solid and he stays "stable" I've got no problem waiting for the ER to try and get access with some of their tools before popping this guy with an IO.

Also be transporting non-emergent as well unless he decided that he wanted to dance on the way to the hospital.

What would it change if you suspected A-flutter with a conduction delay or SVT with aberrancy?

Agreed. I read the first post and discarded the rest.

Wouldn't you be cardioverting for this? I could be way off here, enlighten me.

 

[Handsome Robb]

Agreed. I read the first post and discarded the rest.

Wouldn't you be cardioverting for this? I could be way off here, enlighten me.

I've got no way to sedate him unless I go IM or IN and the former wouldn't kick in until we were giving our handoff report in my system and the latter isn't all that effective. It's a painful procedure and is malpractice to cardiovert an awake and oriented patient who's hemodynamically stable.

He's not sick enough to warrant me drilling into his bone. Some will argue he has potential to deteriorate but my argument is if he does an IO takes literally 10 seconds so I'm not worried about that. Plus if this guy goes to hell in a handbasket on me the first placing I'm reaching is to the monitor to zap him not for drugs.

The hospital has tools (ie ultrasound) they can use as well as a controlled environment. I'd rather transport him the way he is and let them find access and provide the appropriate therapy than cause him a lot of discomfort and administer a therapy that isn't indicated.

EMS education teaches that everyone in VT is going to die right her right now. Yea it's a lethal dysrhythmia but it is one that many can maintain for hours if not >24 hours.

Also, if I don't fix the underlying problem the dysrhythmia is just going to come back. Why not let the ERP and cardiology mull it over and get it right the first time?

 

[AEMTstudent]

I've heard of adenosine use being very painful and shocks i'm guessing would be equally sucky. Would you consider metoprolol for the aflutter?
Thanks for the clarification.

 

[Handsome Robb]

I've heard of adenosine use being very painful and shocks i'm guessing would be equally sucky. Would you consider metoprolol for the aflutter?
Thanks for the clarification.

If this is VT I'd use amiodarone over adenosine personally. Lidocaine would be an option to as well as procainamide. Amiodarone doesn't have the nasty "I'm going to die" feeling side effects that adenosine does.

FWIW my protocol is either transport or cardiovert for A-flutter.

If it were A-flutter I'd prefer to use a CCB like diltiazem to slow the rate in a prehospital setting. You could use amiodarone too but then you have the potential to actually convert to a sinus rhythm and have potential for clots being kicked from the atria as a result of blood pooling from ineffective atrial emptying.

If you gave adenosine to an a flutter patient it won't hurt them, it's not uncommon for it to happen, have a transient slowing of the ventricular response to allow flutter waves to be identified and then change treatment pathways.

 

[Akulahawk]

I've heard of adenosine use being very painful and shocks i'm guessing would be equally sucky. Would you consider metoprolol for the aflutter?
Thanks for the clarification.

Like Robb, I would prefer diltiazem for rate control over metoprolol in A-flutter. Adenosine doesn't hurt, it causes the patient's heart to slow or even stop, which is what makes the patients really not like the stuff... but it might slow the heart enough to be able to see the underlying rhythm.

 

[AEMTstudent]

Like Robb, I would prefer diltiazem for rate control over metoprolol in A-flutter. Adenosine doesn't hurt, it causes the patient's heart to slow or even stop, which is what makes the patients really not like the stuff... but it might slow the heart enough to be able to see the underlying rhythm.

This is good information to know. I just checked our drug file and we don't carry dilitazem.