Effect of CA++ or just inconvenient timing?

DrankTheKoolaid

DrankTheKoolaid

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Had a call the other day that i haven't quite figured out.

Called to local clinic for a 76 YO/Female with chest pain. Get to clinic to find female patient lying low fowler's on exam table pink warm dry, RR16 non labored Lungs CTA without complaint. While partner was getting her hooked up get report from FNP who states patient at home had 4/10 chest pain not relieved by single 0.4ntg. FNP upon patient arrival assessed and put her on "7" literes O2 via NC and administered a second NTG at which point patient states pain down to a zero which patient relates was from the O2 and not the NTG. FNP doesnt keep CM in the clinic as she cant read em. FNP states patient prior MI 1 year ago with no meds or allergies. While im receiving report I hear the familiar alarm on the monitor as my partner hooked her up look over and she's in a rapid atrial tach 170's 180's with a bp of 128/70. Initially appeared to be SVT but after getting her to vagal down pretty clear was a A-fib W/RVR.


Anyways i get the order for Verapamil and CA++ as it's one of the few we have to mother may I for. So i get everything drawn up and after giving the CA++ over 5 minutes patient HR increased to 220 with a complaint of 4/10 CP. Since i already had it drawn up and the patient remained PWD with no shortness of breath with no drop in BP i gave the Verapamil 2.5mg. First dose no change other then complete relief of the CP and bringing her rate back to a uncontrolled Afib w/RVR at 160's 180's.. Second 2.5mg dose coverted her to a ST at 120 without ectopy.

Now my question is was the CA++ the cause of the increasing atrial rate? I fully understand the slow and fast CA channels and expected the rate to increase. But after the call i dbl checked in the field guide and it shows a SE of the CA++ as a decrease in heartrate which doesnt make sense to me. Any of you guru's that can step up and set me straight it would be much appreceited.


Corky
 
edit

couldnt find the edit button anywhere. Last line should have read was it the CA++ causing the increased ventricular rate not the atrial rate.

Corky
 
I am shocked that your protocols are as such. I have not seen Verapamil used in the field for nearly a decade and unless you know they are hypocalcemic why the Ca+? As well, what type of calcium do you use... Calcium Gluconate?

R/r 911
 
re

Calcium Chloride, given to prevent the possible hypotension caused by the CA++ channel blocking at the level of the vessels themselves preventing constriction. Yeah were behind the times in the way of rate controllers here. Our medical director is a bit funny about them for sure.

Corky
 
He must be an old doc,

this is done not only for verapamil

The calcium channel blocking effects that many cardiac drugs have are medited by adding increased substrate. (aka calcium)

depending on the type of tissue or the effects desired, some medications will better select specific tissue receptors over others. Adding the calcium amplifies this action with the idea it will better localize the effects.

As it was stated, there are more modern methods. Like a lower dose or more specific medication. The Ca blocker + CA maybe his comfort zone. It may be cheaper than an alternative. It may make the provider feel they are saving lives and doing something.

It would probably be a good idea to ask your medical director why he/she likes this. It may even work best on the subset of population you see.
 
Veneficus said:
He must be an old doc,

It would probably be a good idea to ask your medical director why he/she likes this. It may even work best on the subset of population you see.
Click to expand...

Better yet, inform them this is 2009. I have not heard or even seen Calcium Chloride and Verapamil used since the early 80's. Really there is a reason we no longer use them. Research had demonstrated administering calcium chloride was a dangerous event not knowing the base line. Also Verapamil is a great medication but not usually in the prehospital setting, do you carry Adenocard? I have witnessed Brady-Aystole patterns in patients that was on Digoxin. Majority of the time I administered Verapamil they vomited, no matter what.

Calcium Chloride was a routine medication in EMD/PEA and it worked ..... only problem was it induced post seizure and cerebral swelling so bad most never regained afterwards.

R/r 911
 
re

We do carry adenosine but that is not effective in converting Afib. I considered using it to confirm A-fib but was able to do that using vagal maneuvers. Hopefully i will run into our medical director soon and ill try to get a conversation going on maybe using diltiazem.

Corky
 
The first service I worked for carried Verapamil until about eight months ago, but it was a backup, behind adenosine and diltiazem. Never once saw the verapamil used.

911 service carries CaCl, but no diltiazem. go figure.
 
re

Trinity County in far Northern California, west of Redding in the mountains.

Corky
 
The medication you should be carrying is called Cardizem .25 mg/kg and ofcourse you may experience some dilation and decrease in blood pressure however most patient respond favorably to fluid bolus.
 
I do beleive that he already stated that he wanted Diltiazem on the truck. He stated that he would talk with his MD about aquiring it?
 
Congrats. You have now participated in one of medicine's longest traditions of stupidity. Almost as bad as IV quinidine. The idea, back in the days of moses, was that giving Calcium (of either flavor...chloride or gluconate...doesn't matter) blunts the hypotensive effects of CCBs (here, namely, Verapakill). We stopped doing this because it didn't work. Here it sounds like it didn't kill your patient which is nice. But dilt would have been better. And giving the calcium always makes you tachycardic. I'm surprised they wanted you to give this. Think of Ca as the opposite of K (you treat hyperkalemia and hypocalcemia the same way, for example). What also is a little confusing: the patient converted? CCBs slow down the rate of AFlubber, not convert them (good thing, too) - so if it was an automatic tachycardia-then I'll buy into the whole conversion thing...if not, the final rhythm may not have been ST. Call your medical director. Make sure they know we've landed on the moon, Bretylium is off of the protocols, and the revolution will not be televised...
 
We carry Metoprolol here. The one time I have had to use it, it got the job done. The pt did not experience any of the side effects associated with the drug, except a little dizziness. I believe this service use to carry Cardizem, but found that it was easier to store Metoprolol on the trucks.

tydek
 
Diltiazem would be nice, but I don't think any counties in California carry it. I know for sure that no one in So Cal has it and instead uses verapamil.
 
+1 for beta blockers prehospital
 
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