Pre-Hospital Anti-Dysrhythmics

[trevor1189]

it also depends on ones definition os symptomatic.

I'm just a basic here, but symptomatic would include palipations/fluttering/pressure whatever your patient may call it.

This goes right back to the definition of signs and symptoms from EMT class.

Signs- Quantitative observations that can have a value placed on them.
Symptoms- Qualitative observations provided to you by your patient.

Some people in this thread seem to be confusing symptomatic with the qualitative measurements like the hypotension in the hemodynamically unstable person. Qualitative observations are inherently difficult to comprehend which is why we try to quantify them like the 1-10 pain scale. However, you have to remember symptomatic would include the SYMPTOMS. If your patient is in SVT with a rate of 180 and says my heart feels funny, then they are symptomatic and deserve to be treated. Am I wrong on that?

So I voted yes because the adenosine for SVT immediately popped into my head.

 

[Melbourne MICA]

I'm just a basic here, but symptomatic would include palipations/fluttering/pressure whatever your patient may call it.

This goes right back to the definition of signs and symptoms from EMT class.

Signs- Quantitative observations that can have a value placed on them.
Symptoms- Qualitative observations provided to you by your patient.

Some people in this thread seem to be confusing symptomatic with the qualitative measurements like the hypotension in the hemodynamically unstable person. Qualitative observations are inherently difficult to comprehend which is why we try to quantify them like the 1-10 pain scale. However, you have to remember symptomatic would include the SYMPTOMS. If your patient is in SVT with a rate of 180 and says my heart feels funny, then they are symptomatic and deserve to be treated. Am I wrong on that?

So I voted yes because the adenosine for SVT immediately popped into my head.

Yes and no. Remember treatment, especially in EMS may be definitive or symptomatic. There may also be a time frame attached - time critical eg. There may also be compelling evidence that pre-hospital intervention is not necessary even if symptomatic except where immediate life threat exists or perhaps a compelling history of rapid deterioration. And histories may be revealing or unhelpful as can be the pts themselves.

Tachyarrhythmias need to be reverted (or revert), no question... or is there? A pt may be in an SVT but have only mild symptoms and more importantly, no haemodynamic compromise. In terms of anecdotal stuff, I'm sure plenty of the guys can recount pts who have had extended acute or acute on chronic episodes of a tachyarrhythmia, like SVT or yes even VT, who have mild symptoms or no symptoms at all or alternately the dysrrhythmia has a protracted lifespan. I've personally seen a sixty something year old chap with full blooded VT which lasted all day and overnight and he looked happy as Larry. I visited him in his ward whilst he was sipping tea and eating dinner still in VT.

The doc treated him - ordinarily VT is of course considered a lethal arrhythmia. It didn't revert him but the salient point was when they sat back and looked at the situation - he was doing fine - not compromised in any way especially haemodynamically, the most important consideration with all cardiac events. Eventually the pts VT just...stopped...by itself.

You have to way up all the factors and the situation as a whole. The main thing is, don't fret about it but keep a keen eye on things. Monitor and observe. Intervene when the pt is compromised (or when you anticipate it). Symptoms can be managed judiciously and as needed often with just basics or simple pharmacotherapy.

None of this stuff is cut and dried - that's half the fun - flying by the seat of your pants out there on the raggedy edge but keeping up the facade of a cool exterior - "wow - the relative says - I was stressed to the max and you guys were just so calm about it all".

All good stuff. Enjoy.

MM

 

[Veneficus]

You have to way up all the factors and the situation as a whole. The main thing is, don't fret about it but keep a keen eye on things. Monitor and observe. Intervene when the pt is compromised (or when you anticipate it). Symptoms can be managed judiciously and as needed often with just basics or simple pharmacotherapy.

None of this stuff is cut and dried - that's half the fun - flying by the seat of your pants out there on the raggedy edge but keeping up the facade of a cool exterior - "wow - the relative says - I was stressed to the max and you guys were just so calm about it all".

This should be part of every prehopital textbook ever written. But the thread unfortunately demonstrates the "if....then" mentality of US EMS.(and some parts of medicine as a whole) The idea of a complex condition can be narrowed down to a simple treatment algorythm where yes/no questions show you which arrow you need to follow to "solve the problem." As if it was that simple.

But it is what keeps the academy style EMS mills in the US in business. It could be a bud light commercial... "We salute you Mr. saves lives by following instructions the janitor could carry out ambulance driver."

pardon my cynicism.

 

[MrBrown]

Case in point (kind of)

Went to a 20 year old this morning (on 0.5/27 sleep mind you) c/o palpations and burning feeling in chest.

Hx smoked a little bit of pot about 7hrs ago

3 lead showed ST at 150 w/o ectopy while 12 lead showed the same by my reasoning but also printed "Borderline ECG: Sinus Tachycardia, Right Atrial Enlargement" or something like that.

I was not with an Intensive Care Officer and we left her at home.

Now how many people out there would spin out and start loading her up on oxygen, aspirin and maybe some nitrates, be calling up for Intensive Care and taking her to the hospital?

 

[Melbourne MICA]

This should be part of every prehopital textbook ever written. But the thread unfortunately demonstrates the "if....then" mentality of US EMS.(and some parts of medicine as a whole) The idea of a complex condition can be narrowed down to a simple treatment algorythm where yes/no questions show you which arrow you need to follow to "solve the problem." As if it was that simple.

But it is what keeps the academy style EMS mills in the US in business. It could be a bud light commercial... "We salute you Mr. saves lives by following instructions the janitor could carry out ambulance driver."

pardon my cynicism.

The way things often are you have every right to some cynicism - but not too much. At the end of the day we must all teach the "gentle" art of ambulance care - that's' the bits about dealing with people the right way and using knowledge and technologies as tools but not as the sum total of our services.

Managing a tachyarrhythmia is in most respects no different from managing a minor problem. It still requires a plan of action based on common sense, a sound grasp of the situation based on information (not speculation or assumptions) and a logical and empathic thought process.

And it must ALWAYS revolve around a patient advocacy focus.

The only difference between a stubbed toe and a VT is what tools you employ to give the person (that be the pt) the best chance at recovering to normal health and well-being. And it doesn't have to be the EMS suit who tuns the final key for the "this way to your recovery" door. Sometimes we just point them in the right direction and make sure they go to the right door in the first place.

MM

PS Thanks for the kind remarks Veneficus.

 

[MrBrown]

90% of ambulance practice is people management, 9% is basic, fundamentals of care and 1% is drugs and complex intensive care.

What the patient needs often does not come in bullet point format in a little spiral bound book.

 

[usalsfyre]

Melbourne,

You made my point more perfectly than I could. It wasn't a "should we be treating lethal unstable dysrhythmias" thread, obviously, we should. This was more of a "should we be treating hemodynamaicly stable relatively non-symptomatic dysrhthmias or waitinging and letting the guys in white coats who make big money playing with calipers evaluate it?"

If ER docs often defer treatment to cadiologist in this type of patient then why are we rushing to push drugs? If they're unstable, electricity followed by the pharmocological treatment of your choice. Otherwise, ask yourself, are you playing over your head?

 

[Melbourne MICA]

SVT's

Melbourne,

You made my point more perfectly than I could. It wasn't a "should we be treating lethal unstable dysrhythmias" thread, obviously, we should. This was more of a "should we be treating hemodynamaicly stable relatively non-symptomatic dysrhthmias or waitinging and letting the guys in white coats who make big money playing with calipers evaluate it?"

If ER docs often defer treatment to cadiologist in this type of patient then why are we rushing to push drugs? If they're unstable, electricity followed by the pharmocological treatment of your choice. Otherwise, ask yourself, are you playing over your head?

I think analysis of such situations has to go even further than the stable or unstable pt or even the pt who has a history of SVT's or is a first offender if I can put it that way.

When we are making decisions, that is, making a committent to a course of action, the analysis that guides it must be thorough, precise, logical and intuitive.

So what are we really saying here?

1. Your anaylsis contains information derived from an examination of all the readily available facts (such as past/present med history, circumstances of the event, drugs, physiological/psychological mitigators) which is pertinent and relevent - hence thorough;

2. Precise in so far as the technical details are well established and isolated - a good 12lead, yep its SVT, obs reveal whatever, S&S's - the pt fits in one of your protocol boxes pretty well, there is a well established and reasonable treatment plan which goes with such cases - you've crunched the numbers, joined the dots and crossed the technical T's.

3. Your analysis is not random, an alternative therapy secondary neuronal pathway outcome, its fits the matrix of prevailing and well established medical practice - its a sound, well rounded and reasonable piece of medical logic - based on common sense and the fact that most grownups can be expected to think stright when needed and would come to a similar conclusion if in your situation.

4. Use your sense of intuition - another way of saying drawing on experiences.Never overlook the value or input of your past experiences or those of the pt/family/rellies etc. Past experiences are memory patterns burned onto your brains hard drive. They are a by-product of analyses already done by your brain and there to be utilised and exploited. Thats' why, after exposure, practice and time (how your memories are created) many of your actions are automatic - the right Iv, O2, monitor, the right drug etc etc. You can carry out these fucntions without thought.And don't forget, (because your brain never does) the old grey matter hard drive is also re-writeable.

Your memorised thought patterns are an overlay you can apply to any event. And when you put the tracing paper of the past memories over todays event you will notice subtle or not so subtle differences which will alter that established thought matrix for the next time a similar situation arises. But the original is still there. Not only that but the grey bits up there are so good they can marry up seemingly unrelated memory patterns from other experiences with todays and compute a new and perhaps radically different brains eye view of what is happening and what you should do about it.

The changes you note with each new event are another memory pattern in and of themselves and there to remind you that each event is unique and individual - a warning not to stereotype your practice or rely soley on your autopilot. Always be sure to take the controls of the plane no matter how much you trust the ground controller or the autopilot.

To be on-topic for the discussion here's a little example.

A elderly pt is in SVT with mild symptoms and no haemodynamic compromise, obs are good and she has been in her normal health recently. You have a bit of travel time to the ED but not too far away. Treat or not?

No replies asked for just food for thought.

MM

PS.Seems like going around in a circle but are we?
AMI, CCF, Cardiomyopathy, new HT and cardiac meds.
PPS. Not trying to be Doctor MM here - just saying how I look at things if it helps all/any of us.