Pre-Hospital Anti-Dysrhythmics

Are anti-dysrhythmics useful for ventricular dysrhythmias in pre-hospital medicine?

  • Yes, they are useful

    Votes: 26 83.9%

  • No, they are not useful

    Votes: 5 16.1%
  • Total voters
    31
U

usalsfyre

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To avoid hi-jacking another thread, what is ya'lls opinion of prehospital anti-dysrhythmics? Useful or not?
 
No, we've just been using them for fun all these years...


Is this a serious question?
 
Let me rephrase, poor question I appologize.

Is the termination of ventricular tachydysrthmias via medication in a non-hemodynamicly comprimised patient by the field providers useful? Why or why not? Is approprite in some settings and not others, and if so when and where?
 
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you mean converting a tachycardic rhythm in an otherwise stable patient? Not hypotensive, no AMS, no pulmonary edema?

If it were me, I'd give O2 and transport. If they're truly asymptomatic then why mess with it?
 
rmellish said:
No, we've just been using them for fun all these years...


Is this a serious question?
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I think he asks if they work during the time before we reach the ICU. I think no, lidocaine and procor are slow acting, but importent to the prognosis.
 
usalsfyre said:
Is the termination of ventricular tachydysrthmias via medication in a non-hemodynamicly comprimised patient by the field providers useful? Why or why not? Is approprite in some settings and not others, and if so when and where?
Click to expand...

No it is not and it is not something we do here, treat the patient and not the monitor.
 
If they are symptomatic from the arrhythmia and stable hemodynamically, not ALOC or anything, then yes, a pharmacological intervention is warranted.
 
Well sort of an answer, if you can include SVT/atrial fib.

H&^L yes.

One of the reasons I'm more active here again (I know, mixed blessing) is that I needed a different beta blocker*. Got new meds ten days ago. Now I have a tachy but pretty darn regular baseline, versus being down to only about two of every three beats being near regular. Palpitations, positional dyspnea, postural swings gone, for now. I can sneeze without pain down my left arm.

So, I say yes, at least if the ventricular issue is rooted in the atrium.


*Sotalol
 
rmellish said:
How else would they be symptomatic?
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Little old lady who fell and broke her hip, symptomatic from the fall but is in a-fib? Not gonna start pushing cardizem for her.
 
fma08 said:
If they are symptomatic from the arrhythmia and stable hemodynamically, not ALOC or anything, then yes, a pharmacological intervention is warranted.
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And I would argue intervention is only necessary when pt is unstable or altered. Your post is contradictory. Aside from LOC and hemodynamics how else can you be symptomatic from an arrhythmia to the extent that it warrants intervention?


fma08 said:
Little old lady who fell and broke her hip, symptomatic from the fall but is in a-fib? Not gonna start pushing cardizem for her.
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And I completely agree with you here. Must have misread the earlier post.
 
rmellish said:
And I would argue intervention is only necessary when pt is unstable or altered. Your post is contradictory. Aside from LOC and hemodynamics how else can you be symptomatic from an arrhythmia to the extent that it warrants intervention?
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Chest pain, shortness of breath, N/V, palpitations, weakness.

All clinical signs indicating that there could be something going on with the heart e.g. and MI, that would be causing the arrhythmia, in which case, the arrhythmia itself is an unneeded stress on the heart which I would want to treat immediately. Not only for the patient's comfort, or reducing the stress on the heart, but also to hopefully convert to a normal rhythm, or one where I can get a quality XII to check for underlying problems. Not to mention, just because they are stable now, doesn't mean they won't become unstable quickly. I'm not sure how I'd justify allowing a patient to remain in a potentially dangerous rhythm to the point of needing electrical therapy when I could have prevented it in the first place with the appropriate pharmacological therapy.
 
Compromise from a dysrhythmia should include severe chest pain, shortness of breath, pulmonary edema, ALOC, hypotension etc and should be in the setting of sustianed ectopy or abnormal rhythm.

Some guy with a bit of chest tightness from one or two PVCs is not a problem, somebody who is semi conscious from sustianed VT is.
 
MrBrown said:
Compromise from a dysrhythmia should include severe chest pain, shortness of breath, pulmonary edema, ALOC, hypotension etc and should be in the setting of sustianed ectopy or abnormal rhythm.

Some guy with a bit of chest tightness from one or two PVCs is not a problem, somebody who is semi conscious from sustianed VT is.
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That's the thing, pre-hospital pharmacological interventions for arrhythmia should remain a viable option because it depends on the patient. I remember a vivid encounter from a patient while I was in medic school who seemed to be in V-tac with a pulse. Ran through the ACLS algorithm and ended up needing cardioversion, but doesn't mean that pharmacological interventions were not warranted, (which were due to symptomatic yet hemodynamically stable).
 
We have amiodarone but audits have shown its being a little overused in patients who may have had a dysrhythmia but are not significantly compromised so it was resting somehwere sort of halfway between useful and prophylactic

I certianly would not withold amiodarone/cardioversion or atropine/pacing if it was indicated but in a stable patient who is not compromised I do not see the need.

From the memo

This procedure is to be used when the patient is either in VT or in another tachydysrhythmia that is causing significant cardiac compromise. Significant cardiac compromise ... requires more than ‘a bit of chest tightness’ and more than ‘a bit of shortness of breath’.

In general we are seeing amiodarone overused in this setting and the pendulum needs to ‘swing a little away’ from using amiodarone for fast AF unless there is significant cardiac compromise associated with it.
Note: amiodarone should only be very rarely used in the setting of a regular narrow complex SVT.

Whether or not to treat with cardioversion or amiodarone requires clinical judgement that weighs up the balance of risk. The more compromised the patient, the more important it is to cardiovert – particularly if the rhythm is thought to be VT.

Amiodarone is now to be given slowly over 15-30 minutes, rather than over 15 min, because the faster rate was causing too much hypotension.
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i think it dpends on many factors and we all know every case is different. it also depends on ones definition os symptomatic. some believe if there is a cardiac realted complaint ie:chest pain, pressure, palpitations, etc, this would be symptomatic. other only consider symptomatic to be related to vitals.

a-fib at 140-160 theres usually no reason to go crazy and get aggressive with antiarrythmics, a-fib 180+ plus theres no reason to wait til it is symptomtic or hemodynamically unstable. however with these you have to consider causes and treat those before throwin meds at it, as with any treatment.

v-tach is a fatal rythym when it is sustained and whether symptomatic or not. it will be symptomatic and unstable if untreated. now im not talking about patients with runs of v-tach, im refering to patients in a consistent v-tach. runs of v-tach treat the patient not the monitor and again for both consider underlying causes and treat first if possible.
 
fma08 said:
Little old lady who fell and broke her hip, symptomatic from the fall but is in a-fib? Not gonna start pushing cardizem for her.
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This is where a greater history and assessment will come into play. If I get the little old lady that fell and broke her hip, and is in an a-fib with RVR, im going to treat the obvious items first.. im going to give narcotics for pain and versed for muscle spasms and sedation... some fluids to see if her rate comes down, some oxygen of course, but if she sustains her rate... you'd better believe im going to be treating the underlying a-fib. You dont know unless you do some good homework if the patient fell secondary to being dizzy, maybe due to the decrease in her cardiac output from the combination of the a-fib and the rapid ventricular response. She also may have fell several days ago, and has not taken her medication.

Every situation is different. I've said it before and I'll say it again.. people here seem to want a cookbook answer for an outside the box problem. Many of the scenarios I see here people seem to want to get a definitive blanket answer... and that's just not a sound way of thinking when it comes to medicine.

I will absolutely treat any dysrhythmia if and when it is appropriate for the patient. If they present with cardiac chest pain and/or cardiac type symptoms, anything above a mild shortness of breath, dizziness, palor, nausea, diaphoresis, altered LOC, hypotension, etc and I believe strongly and can back up my belief with facts, then im going to treat with electricity.

If they present in a dysrythmia and they appear to be pretty stable, but the situation still calls for it then I will treat with cardizem, lopressor, amiodarone, lidocaine, or which ever medication is appropriate for the situation.

Now, stable in one situation might be unstable in another, once again, there is no blanket statement or blanket answer for all situations. Assess, re-assess and treat appropriately.. and ALWAYS be prepared to defend your actions with sound medical facts. If you cannot justify what or why you are doing whatever it is you are doing, then DONT DO IT.

If its a matter of lack of comfort, lack of knowledge or lack of skill and/or use of the skill.. then shame on you for not maintaining your minimum standards of competency for the job you are hired to do... and you are doing your patient a dis-service.

You folks might disagree with me, but my job is to begin treatment on these people when they call us and take them someplace for definitive follow up care. just giving people a fast ride to the ER is not acceptable to me.
 
ATR's

For the original poster - converting tachydysrhytmias before they lead to cardiac arrest has always seemed like a good idea to me. (Tongue in cheek sarcasm here only -).

MM
 
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