Input please

[emtjack02]

Last night I had a call that I keep playing in my head.
Dispatched for possible diabetic problem.
Uoa alert to verbal orient to person place (not to much off baseline per fam). BS 264. BS 90/62. radial pulse 100. Denies sob/cp, appears to be slightly labored but sounds like she's a chronic chf'r.
Assessment and line in the house, moved to rig, applied monitor showing afib/svt 180-200s. I wanted to slower her down but all we have is adenosine. transport time is 7min. She has a hx of afib and it appeared to be strongly afib with burst of svt. I guess my question is would you give the adenosine or what for the hospital? Comments?

 

[Sail195]

I do not have much knowledge on it but i was on a similar call with a medic a few weeks ago, we toned for a second medic also and they opted to give the adonizine, similar history and signs and symptoms you explained except the pulse was north of 175.... worked like a charm although watching the monitor and seeing the heart stop was pretty unnerving... from what they were explaining to me as they did it our protocols are 6 - 12 - 12 if needed... well she stopped and restarted 3 times off the first dose so obviously we didn't do the other two....



Once again I am only a basic that has seen the drug been used in a similar situation so take it for what it is lol

 

[Shishkabob]

Sail, one of the precautions of adenosine is that it can cause transient asystole when administered.


Jack-- Do you have an EKG strip? What do you mean by "burst of SVT"?

I would say no, since it's only a "burst" and not consistent, but we'll wait till some of the more experienced come in.

 

[DrankTheKoolaid]

re

with the patients history and lack of other assessment finding IE skin signs, i would go ahead and wait for the ED to deal with it. With your 7 minute ETA even though the patient BP is beginning to get questionable she seems to be without complaint by what you posted so no real need for heroics. Fluid bolus and consider vagals to try to slow the rate so you could better differentiate. Or you could also speed the rate the paper is fed out from your monitor and check for regularity/irregularity that way. Patient would really need to be fully evaluated with labs to determine therapeutic levels of what ever anti clotting agent she is on before reconverting that unless she was unstable. If she was truly unstable adenosine is not known to convert A/Fib so cardioversion would have been your choice of treatments.

 

[emtjack02]

Sail, one of the precautions of adenosine is that it can cause transient asystole when administered.


Jack-- Do you have an EKG strip? What do you mean by "burst of SVT"?

I would say no, since it's only a "burst" and not consistent, but we'll wait till some of the more experienced come in.

Sorry dont have the strip. She would be a nice fib and then for like 2-3sec it would be completely regular in that same rate range. I completely forgot about vagal (damn). I marched the Rs out thats why I said it was both fib and svt.

 

[DrankTheKoolaid]

re

You know something else people forget about is using the QRS tone in your monitor. Your brain is going to hear the irregularity from your ears much faster then seeing it on the monitor.

 

[fma08]

XII lead, vagals, and fluids are what I would have added. If it was truly afib, I would not have administered the Adenosine. You don't carry a beta blocker or calcium channel blocker? That would have been something to consider if you do. Obviously like was said before, if they were really unstable (ALOC, cool pale diaphoretic, low BP, etc) light em up B) But fluids would have been my first drug along with trying the vagals.

 

[emtjack02]

XII lead, vagals, and fluids are what I would have added. If it was truly afib, I would not have administered the Adenosine. You don't carry a beta blocker or calcium channel blocker? That would have been something to consider if you do. Obviously like was said before, if they were really unstable (ALOC, cool pale diaphoretic, low BP, etc) light em up B) But fluids would have been my first drug along with trying the vagals.

I did give her 150-200ml NS. Attempted a 12lead but the data was noisey(freakin LP12). No CCB or BB.

 

[wyoskibum]

applied monitor showing afib/svt 180-200s.

It has to be one or the other. You need to follow the rules for interpreting your ECG's. Was it regular or irregular? Was there a P-wave? Was the QRS wide or narrow?

Irregular without P-wave would point towards a-fib:

I would be careful trying to convert a chronic afib rhythm. Especially since the pt seemed to be stable and your close to the ER. Was the pt on cumadin? As stated above, consider a BB or CCB.

Regular would point towards SVT:

With stable pt you would go least invasive to most invasive. Vagal, adenosine. Unstable consider electricity.

 

[emtjack02]

It has to be one or the other. You need to follow the rules for interpreting your ECG's. Was it regular or irregular? Was there a P-wave? Was the QRS wide or narrow?

Irregular without P-wave would point towards a-fib:

I would be careful trying to convert a chronic afib rhythm. Especially since the pt seemed to be stable and your close to the ER. Was the pt on cumadin? As stated above, consider a BB or CCB.

Regular would point towards SVT:

With stable pt you would go least invasive to most invasive. Vagal, adenosine. Unstable consider electricity.

Thank you for the refresher...that is how I determined that there was afib also the places that were regular w/ a p wave. Crazy I know, that's why I am asking people.

 

[medic3416]

I would be careful trying to convert a chronic afib rhythm. Especially since the pt seemed to be stable and your close to the ER. Was the pt on cumadin?

Defiantly need to be careful when cardioverting someone with chronic A-fib. The chance of CVA or PE is very real due to coagulated blood from the atria traveling to the brain or to the lung causing a PE. In fact the risk of CVA or PE continues for up to 72 hours after. You absolutely need to try to find out if the patient is on cumadin and how long they may have been in A-fib before cardioversion if possible. Of course if the patient is unstable then you need to weigh the risk verses benefit and do it if necessary.

 

[triemal04]

Thank you for the refresher...that is how I determined that there was afib also the places that were regular w/ a p wave. Crazy I know, that's why I am asking people.

Are you sure you were seeing a p-wave when the rate increased? If she was in a rapid afib the "regular" period may have been a brief increase in the heartrate that appears regular due to how fast it was going; at 200+ it's not always that easy to see irregularity. What did you mean by "sounds like a chronic chf'r?" Did she have fluid in the lungs? Was she dx'd with CHF? Be kind of important to know that...

 

[Ditchmedic]

If you are not sure if its afib or svt. I wouldn't push adenosine. It won't work on afib and could cause a period of aystole that might just make you mess yourself. Good responses from those above. Be prepared for many more runs that you will play back. Talking with others is a good way to straighten things out in your head.

 

[akflightmedic]

Assessment and line in the house, moved to rig, applied monitor showing afib/svt 180-200s.

As usual, I will target a different aspect of your question since others already addressed the obvious stuff.

1. Do you not take a monitor in the house with you? If not, why?
2. Applying a monitor is part of my assessment and is usually done long before an IV is in place. It only takes a few seconds while you are gathering history and doing vitals.

How long were you in the house doing an assessment and getting an IV (on a patient who you thought to had a 100 radial pulse), plus the time of moving the patient to the truck, then placing the monitor on them after more chatter (explaining procedure, etc)?

Honestly think of all that time wasted without the knowledge of their true cardiac status.

Now ask yourself, is the 7 minute hospital time relevant or are the timeliness of your assessments/procedures MORE relevant to the time factor?

Let us do a "what if". What if you had connected the monitor right off the bat and knew what you were dealing with. Are you still 7 minutes from the hospital or is that time window actually much longer? Are you going to try more definitive treatment prior to moving the patient? Do you really want to move the patient to the unit at this time?

(Just asking all the above and it may or may not be relevant to this particular condition but it can certainly be applied to many other EMS calls)

A MAJOR pet peeve of mine is when people justify NOT giving a warranted treatment by stating that the hospital is "only" x minutes away. If the patient needs something, you better have it done or trying to do it, not sitting back and saying no bother cause we are only this close. (Again rhetorical, not directed at OP)

 

[emtjack02]

As usual, I will target a different aspect of your question since others already addressed the obvious stuff.

1. Do you not take a monitor in the house with you? If not, why?
2. Applying a monitor is part of my assessment and is usually done long before an IV is in place. It only takes a few seconds while you are gathering history and doing vitals.

How long were you in the house doing an assessment and getting an IV (on a patient who you thought to had a 100 radial pulse), plus the time of moving the patient to the truck, then placing the monitor on them after more chatter (explaining procedure, etc)?

Honestly think of all that time wasted without the knowledge of their true cardiac status.

Now ask yourself, is the 7 minute hospital time relevant or are the timeliness of your assessments/procedures MORE relevant to the time factor?

Let us do a "what if". What if you had connected the monitor right off the bat and knew what you were dealing with. Are you still 7 minutes from the hospital or is that time window actually much longer? Are you going to try more definitive treatment prior to moving the patient? Do you really want to move the patient to the unit at this time?

(Just asking all the above and it may or may not be relevant to this particular condition but it can certainly be applied to many other EMS calls)

A MAJOR pet peeve of mine is when people justify NOT giving a warranted treatment by stating that the hospital is "only" x minutes away. If the patient needs something, you better have it done or trying to do it, not sitting back and saying no bother cause we are only this close. (Again rhetorical, not directed at OP)

I usually do take the monitor in with me...I didn't this time around. Not sure why. All good points you made. Thanks for the thoughts.

 

[piranah]

she could have been in a-fib the whole time and the rate (when a rhythm is indicernable due to rate and it has narrow ORS or from an origin of the atria it is SVT you can give the adenosine in SVT to slow it for a second to see if it is a-fib then break it with a CCB or BB..but thats all contraindicated...pt pressure to low, give a 250cc bolus and see where u are....you give a CCB or BB and they're pressure is that...you have now possibly cut that pressure in half..and possibly killed ur pt...give a bolus, try a vagul give the adensosine if the vagul fails...(that is of coarse if ur still not sure its a-fib....) but if you have confirmed it a-fib adenosine prolly will not work....fluid Os and t/p...do no harm. i dont think im missing anything..