First call for a paramedic student

[captaindepth]

That's a reasonable assumption given the distribution of ST-elevation and likely infarct related artery. I'm not concerned about shortening the delay in the 1AVB, but instead increasing the rate.

Yes the rate is what needs to be increased, I guess i was just wondering if atropine would have worked in this case.

Do you think an increased rate would cause more infarction to the heart distal to the occlusion? Is that something we should be concerned about? I have not seen someone deteriorate from this type of rhythm and Im struggling with finding what the threshold should be for more aggressive treatments.

 

[Brandon O]

Do you think an increased rate would cause more infarction to the heart distal to the occlusion? Is that something we should be concerned about? I have not seen someone deteriorate from this type of rhythm and Im struggling with finding what the threshold should be for more aggressive treatments.

Yes and yes. It's always something to think about. You have to weigh the risk versus potential benefit.

As you can see from this thread, people have gone both ways. It would be a judgment call and I think both choices could be reasonable. (Well, depending on your area it also might be decided by protocol, but...)

 

[Christopher]

Yes the rate is what needs to be increased, I guess i was just wondering if atropine would have worked in this case.

I have no evidence from the ECG or clinical history that would suggest atropine would not be effective. The rhythm is supraventricular, with evidence of intact AVN conduction.

Do you think an increased rate would cause more infarction to the heart distal to the occlusion? Is that something we should be concerned about? I have not seen someone deteriorate from this type of rhythm and Im struggling with finding what the threshold should be for more aggressive treatments.

Myocardial oxygen demand is an interesting topic. If we leave the low rate, with low cardiac output and low blood pressure, we're probably not supporting good coronary blood flow to an already compromised heart. If we speed the rate up, we can increase cardiac output and blood pressure, possibly improving myocardial perfusion.

You'll certainly hear about pacing being preferred over atropine, or epi/dopamine being "equivalent" to pacing...but all of these have different goals and all of these are non-trivial treatments.

My threshold for Rx in these patients is largely driven by the clinical situation. I'm comfortable with fluids, atropine, and pacing given this clinical situation. Or, depending on the distance to the PCI facility and the patient's status, perhaps just fluids and pad placement. Not a lot of absolutes in this specific case.

 

[Handsome Robb]

Can anyone use "chemical pacing" on standing orders in a 911 setting?

Definitely agree it's a good option, maybe not for this patient but there's definitely a population who would benefit from it.

 

[Christopher]

Can anyone use "chemical pacing" on standing orders in a 911 setting?

Definitely agree it's a good option, maybe not for this patient but there's definitely a population who would benefit from it.

We're Atropine/Fluids (given situation), then Pacing or Dopamine (given situation or lack of clinical response to pacing), then Epi infusion.

 

[chaz90]

Can anyone use "chemical pacing" on standing orders in a 911 setting?

Definitely agree it's a good option, maybe not for this patient but there's definitely a population who would benefit from it.

Standing orders for us in regards to hemodynamically compromising bradycardia include atropine, fluids, TCP, dopamine, and epinephrine drip, roughly in order and situationally dependent of course.

 

[DesertMedic66]

Standing orders for us in regards to hemodynamically compromising bradycardia include atropine, fluids, TCP, dopamine, and epinephrine drip, roughly in order and situationally dependent of course.

Same with us, however the Epi drip is not usual and we would have to call for orders.

 

[Handsome Robb]

Standing orders for us in regards to hemodynamically compromising bradycardia include atropine, fluids, TCP, dopamine, and epinephrine drip, roughly in order and situationally dependent of course.

That's how we have it as well but epi is with OLMC only.