Treatment of Narrow Complex Tachycardias

[chico.medic]

I was wondering if anyone had diltiazem(Cardizem) in their scope of practice. (I'm talking about EMS systems- Pre-Hospital.)

I realize that being a calcium channel blocker there are several considerations when administering the drug for tachycardias (Administration of diltiazem with digoxin can increase digoxin blood levels. Therefore, blood levels of digoxin are usually monitored to avoid toxicity. Similarly, concurrent administration of diltiazem with an anti-seizure medication carbamazepine (Tegretol) can increase blood levels of the seizure medication, and occasionally lead to toxicity. Concurrent administration of cimetidine (Tagamet) interferes with the liver breakdown of diltiazem, and significantly increases diltiazem blood levels. Therefore, cautious dosing is necessary when both medications are administered.) It can also cause a worsening of heart failure.

The reason I bring it up is I had a patient today in a Narrow Complex Tachycardia that resembled PSVT @ a rate of 180 BPM. His BP was 104/60, R-22 mildly labored, SAo2%-96 on room air. He had had a sudden onset of sub-sternal chest pressure radiating down his left arm about 20 minuets PTA. 10/10 on a pain scale. He was Alert & Oriented, GCS was 15. His skin was slightly pale, warm and moist. I administered Adenosine and that was enough to slow the rate to see that it was a Rapid Atrial Tachycardia. Seeing as Adenosine is not very effective on Atrial Tachycardias, the only other drugs we have in our protocols are Procainamide (Which is impractical to set up with short transport times,) and Verapimil.

Verapimil has fallen out of favor, and I see Physicians using Cardizem more frequently, at least in this area. So if it is proven to be so effective in the hospital setting, why then is it not favorable for use in the field?

 

[chico.medic]

Here's our protocol, to give you an idea of what I'm working with:

 

[Flight-LP]

Cardizem is widely used in EMS and is primarily a first line adjunct in new onset A-Fib. Was your pt. a COPD'r or have a Hx. of CHF? You are correct in your assertation that Adenocard is usually ineffective. However, if it did slow the supraventricular rate to say below 160 and ther is no other evidence of end organ failure, then I would just continue to monitor without further pharmacological intervention if my only options were Verapamil or Procainamide. I haven't used either in almost a decade!

Personally, I'd skip Cardizem and go with an Amiodorone and Lopressor ............

Both should convert the pt. to a stable sinus rhythm.

 

[fyrdog]

We carry cardizem in Hartford. I have used it 3 times in the last few months. I found it to work quickly and effectively. I administered a bolus followed with drip . The only think I don't like is the syringe system to mix it.


What ever happened to the monitors that you could print out a strip at 50mm/sec instead of 25mm/sec? That made reading a SVT or atrial rythm easier.

 

[chico.medic]

FlightLP, This was a 71 y/o male who had dealt with bladder CA off and on for 7 years, but is currently in remission. Aside from that he had no other history, lungs were clear, and he took no medications. The first dose of adenosine did not affect his rate, but a repeat dose of 12mg slowed it to 55 BPM (a-fib) only briefly, then he returned to a rate of 180.

 

[MedicPrincess]

We carry Cardizem.

 

[chico.medic]

It's quite thrilling every time I find out how "progressive" California is when compared to other states. :glare:

 

[Ridryder911]

We are carrying Caridizem as well, the choice of calcium channel blockers and other rate controlling medications has to carefully weighed out. I am used to Verapamil and personally have mixed feelings. I have yet seen very few times administration without vomiting and if they are on a Digoxin can produce brady-aystole patterns. One has to be sure as well that WPW is not an underlying cause due to administration of such blockers will have potential catastrophic events, thus antiarrhythmic medication such as Pronestyl should be considered.

Tachy rhythms may appear simplistic to treat, however; treating to the best of the cause and etiology is much harder than it appears.

R/r 911

 

[KEVD18]

my service carries cardizem. i guess there is some issue with the lyoject system and they are no longer issuing it. now, form what i understand, we can only get the kind that has te be refrigerated. big problem for us since, a) they never use it and b) it expires real quick if not refigerated. oh well. but too answer your question, my private service in ma carries it.

 

[Strike3]

Cardizem is carried here as well....Although not in my direct county for some reason..

 

[divinewind_007]

we have got cardizem here also...we no longer even have veraprimil on our trucks.

 

[Bongy]

We use mainly verapamil... But amiodarone also can be useful(in case of 1st onset less than 48 hours)....
But treatment also depend on clinical finding... if there is also some unstable findings like chest pain,low BP.. You can think about cardioversion also...