Stable Sinus Bradycardia and tachycardia

[EmergencyMedicalSike]

So in unstable, symptomatic bradycardia you would give atropine or dopamine and consider transcutaneous pacing and in unstable symptomatic tachycardia, adenosine if regular QRS and consider synchronized cardioversion. But what would you do if the patients are bradycardic or tachycardic but are not symptomatic and stable?

 

[TXmed]

Generally Fluid bolus and transport

 

[GMCmedic]

Id ask what was normal for them and go from there.

Sent from my SAMSUNG-SM-G920A using Tapatalk

 

[hometownmedic5]

First off, you didn't specify to what level this hypothetical patient is outside of norms. A HR of 30 is a different conversation than 50.

Assuming you're talking about a borderline case:

Rule #1: Don't poke the bear unless you have to.

If they are stable(no CP, normotensive, mentating, etc) then I wouldn't be intervening significantly. Establish access, monitor, 12ld, judicious administration of iv fluids and watch.

I might remove the appropriate medications from the drug box and have them easily at hand. I might have a set of therapy pads at hand also. What I'm certainly not going to do is start screwing with a patient who is dealing with whatever may be wrong with them well without intervention. That's how you get into trouble.

This is a call I'm not writing my chart during. I'm focused on my patient and any changes to their status. I'm ready to intervene at a moments notice; but I'm not throwing drugs at a patient just because the book says it's necessary.

 

[VentMonkey]

But what would you do if the patients are bradycardic or tachycardic but are not symptomatic and stable?

A lock, monitor, followed by some witty banter, and/ or basic comfort measures. Leave well enough alone. They may not even get a line depending on the circumstances leading up to their HR.

 

[StCEMT]

Basically what's already been said. Keep that necessary stuff within arm's reach, but otherwise it's about time for baseball season to pick back up so there is a 9/10 chance we can talk about the Cardinals and have an easy ride.

 

[Summit]

OP said "unstable symptomatic" but we need more specific. Circumstance, hx, acuity and the patient determine the treatment, if any.

 

[EmergencyMedicalSike]

OP said "unstable symptomatic" but we need more specific. Circumstance, hx, acuity and the patient determine the treatment, if any.

Anything with the CHAPS acronym (Chest pain, hypotension, ALOC, perfusion, shortness of breath)

 

[hometownmedic5]

Read it again. The OP opened with unstable/symptomatic and then breezed through the usual treatments. The last line is what to do if they are diagnostically tachy/brady but stable/non symptomatic.

 

[VentMonkey]

Anything with the CHAPS acronym (Chest pain, hypotension, ALOC, perfusion, shortness of breath)

I've never heard of this silly acronym, but most well seasoned paramedics know when to treat symptomatic arrhythmias vs. when not to and have given you their answers, what more do you want, OP?*

*I skimmed through most of this post.

 

[EmergencyMedicalSike]

I've never heard of this silly acronym, but most well seasoned paramedics know when to treat symptomatic arrhythmias vs. when not to and have given you their answers, what more do you want, OP?*

*I skimmed through most of this post.

Nothing. I've received the answers I was looking for. I was more or less answering to what summit asked for which was specifics and I answered with CHAPS which was the symptoms I was taught to be wary of.

 

[VentMonkey]

Nothing. I've received the answers I was looking for. I was more or less answering to what summit asked for which was specifics and I answered with CHAPS which was the symptoms I was taught to be wary of.

Fair enough, most paramedics don't work off of the acronyms (or at least shouldn't use them that heavily as a crutch, IMO).

All those things are fine and dandy, to an extent, but they can also open up endless avenues for providers that struggle thinking outside of the proverbial "box". If the patient looks sick and it's coupled with an arrhythmia then (at least for me) I'd be more inclined to treat/ be ready to treat.

 

[DesertMedic66]

VOMIT

Vitals, O2 (if needed), Monitor, IV (if needed), Transport.

Finish ePCR, grab a snack, clear for next call.

 

[VentMonkey]

VOMIT.

 

[truetiger]

Don't forget push dose epi...I would definitely choose that before dopamine. Epi is going to act on the entire myocardium as well as give us a boost in blood pressure that we're seeking vs atropine that is only going to affect rate in 28% of cases and give us no pressure support. Push dose epi can be deployed faster than dopamine....1cc of cardiac epi into 9cc of saline flush. Directions are even on the box.

 

[CALEMT]

But what would you do if the patients are bradycardic or tachycardic but are not symptomatic and stable?

Vitals and reassess.

 

[Akulahawk]

But what would you do if the patients are bradycardic or tachycardic but are not symptomatic and stable?

If the patient is asymptomatic and is otherwise stable... little to nothing and watch them very, very closely. Assuming the patient goes along with everything: monitor, saline lock, flooded line at the ready, and transport while chatting the whole way there to continually assess level of consciousness.

Never forget to take your patient's physical conditioning into account. When I'm resting and physically very quiet, my heart rate will slow into the upper 40's. When I'm in decent shape and resting, my heart rate will drop to around 46/min. Certain types of athletes will have resting heart rates in the 30's, perhaps even high 20's without issue because their hearts have adapted sufficiently to maintain a decent cardiac output even at those low heart rates.

Oh, and yes you should always ask the patient what's a normal heart rate for them. Once people start being seen more frequently, they'll likely know.

Truly, sometimes your best bet is to think much, worry much more, do a bunch more of nothing, all while being ready to go full-tilt-boogie.

From above (great quotes):

Rule #1: Don't poke the bear unless you have to.

This is a call I'm not writing my chart during. I'm focused on my patient and any changes to their status. I'm ready to intervene at a moments notice; but I'm not throwing drugs at a patient just because the book says it's necessary.

 

[medichopeful]

Directions are even on the box.

Wait, really? I've never noticed that. What does it say?

 

[Summit]

Read it again. The OP opened with unstable/symptomatic and then breezed through the usual treatments. The last line is what to do if they are diagnostically tachy/brady but stable/non symptomatic.

Yea I often stop reading posts part of the way through depending how interesting I find them

 

[hometownmedic5]

It happens.

Bottom line here is we don't treat equipment, we treat patients. Once you start messing with patients and their compensatory mechanisms, you start something you may find you are under qualified/equipped to handle. If they need intervention, intervene appropriately. If they don't, observe and wait. "Well, the book says we treat xxxxx problem with xxxxxx treatment" is a hacky excuse that will not play in court, M&M rounds, or QA/QI review.