Treatment Question for Vtach with pulses

Moto017

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Definitely unprepared for this call. Curious to see what you would have done differently treatment wise and for more clarification of unstable and stable v-tach.

Work for IFT company and called to nursing home for ER transfer with unknown complaint. Arrive to find elderly pt appearing hemodynamically stable with c/c of SOB with accessory muscle use. Pt AOx4, rhonchi in upper lobes, clear lower lobes, tachy radial pulse, and 34/min resp rate labored, -fever/chills/night sweats, and -pain.

Nurse states pt has been SOB since this morning, no O2 treatment due to SpO2 96%, Denies any resp or cardiac Hx, only Hx of CA mylenoma, and NKDA.

Pt placed on O2 15LPM NR, loaded into ambulance where ECG showed V-Tach, BP was unable to obtain but pt AOx4 and with radial pulse, and hospital 1/2 mile away. Defib pads placed.

Would you consider this pt unstable and shock him, treat with lidocaine, or transport as stable vtach knowing worst case scenario pt codes with only paramedic and emt and only enough time to let receiving hospital know we are pulling in.
 

Handsome Robb

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Lido is old school. In the scenario you presented 150 mg of amio in 100cc/10 minutes. If their mentation decreases synchronized cardioversion otherwise transport routine to the hospital and let them deal with it.

Despite popular belief people can maintain VT for a long time.

May I ask why the NRB with an SpO2 of 96?

You could definitely make an argument that this patient is symptomatic and you need to go straight to cardioversion.
 

Aidey

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I would want to see the EKG first. While I know that seemingly stable V-tach pts exist, SVT with aberrancy is MUCH more common. For the most part, the treatment is the same, but still. In a half mile transport I doubt I would do much treatment.
 
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ccrook

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While the hospital is only 1/2 mile away, you are a paramedic and should deal with the situation if you have the ability and not pawn it off to the ER. Just because the patient has a pulse now doesn't mean she will still have in 15 sec. Since the patient is alert and appropriate we know that she is perfusing her melon and is therefore relatively stable. Since she is not unstable we can treat her with medication as opposed to electricity. As my brother stated amiodarone is a great drug and would be appropriate. Lido however, is a great drug and I have had very good results with it. A 12 lead would be prudent, but I probably would have bolused her if it was truely V-Tach and I had a protocol that allowed pre-radio contact Lido for V-Tach.
 

Aidey

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Unless there is a traffic jam, it is going to take me longer to do a 12 lead, IV, fluid bolus and draw up and prep the amiodarone than it will to drive to the hospital. It isn't "pawning off" if the patient is going to receive more appropriate care by being at the hospital sooner.
 

JPINFV

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Unless there is a traffic jam, it is going to take me longer to do a 12 lead, IV, fluid bolus and draw up and prep the amiodarone than it will to drive to the hospital. It isn't "pawning off" if the patient is going to receive more appropriate care by being at the hospital sooner.


Is your 12 lead, IV, fluid, amiodarone going to be done faster than transport to ED, move patient inside, move patient to bed, give report, then for the ED to do 12 lead, IV bolus, draw up amiodarone, give amiodarone?
 

exodus

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I am slightly concerned with the fact you weren't sure what to do though...

SOB and UTO a bp, I would sure consider that unstable!
 

Aidey

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Is your 12 lead, IV, fluid, amiodarone going to be done faster than transport to ED, move patient inside, move patient to bed, give report, then for the ED to do 12 lead, IV bolus, draw up amiodarone, give amiodarone?

Depends on whether or not the RN receiving the patch actually lets the ED doc know we are coming. We rarely get boarded in the halls waiting for beds, and if the ED doc meets us in the room there are not usually any delays in treatment. If the RN receiving the patch doesn't believe us and I have to go hunt down a doc it can take considerably longer.

However, I do know that the arse chewing I would get for giving amiodarone to someone with that BP would last WAY longer than transport to ED, move patent inside, move patient to bed, give report, wait for ED to do 12 lead, IV bolus, draw up amiodarone and give amiodarone. The only time we can give a hypotensive pt amiodarone is if they also happen to have CPR in progress.
 

nocoderob

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VT with SOB, no BP, and diaphoresis is not stable my friend. Why was the patient not put on the monitor until getting in the bus?
 
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Moto017

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Thanks for the input! Had this discussion with a few co-workers and came up the same, with all different opinions. I understood unstable as inadequate perfusion. In this case, adequate perfusion, and symptomatic. However, in the ER he was cardioverted into sinus tach and placed on lidocaine drip.

May I ask why the NRB with an SpO2 of 96?
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Regardless of SpO2 if the pt is fighting for O's, give it to them

Why was the patient not put on the monitor until getting in the bus?

Thats where I was not prepared for this call. I transferred the pt directly to the ER. May have changed my treatment to treating onscene if I had brought my equipment in. It was the first time I actually needed equipment with IFT. Live and learn.
 
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DrankTheKoolaid

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And a patient is never stable, thats for horses. They are either compensated or uncompensated
 
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Jon

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VT with SOB, no BP, and diaphoresis is not stable my friend. Why was the patient not put on the monitor until getting in the bus?


Thats where I was not prepared for this call. I transferred the pt directly to the ER. May have changed my treatment to treating onscene if I had brought my equipment in. It was the first time I actually needed equipment with IFT. Live and learn.

You know, I've been there and done that. Anytime I'm taking an ER call on a transport truck, I bring my gear (monitor and ALS bag) in. I don't like getting burned, and I've learned the hard way.

In the end, you're a freaking paramedic... so be prepared to act like one. It's not whacker-ism, it's being able to do your job.
 
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Moto017

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"So, let's answer our question, is this patient stable or unstable? Because he has a normal mental status and good perfusion, we would classify him as stable. "

"If the patient has stable monomorphic V. Tach, without signs of poor ejection fraction, as our patient here does, the drug of choice is Pronestyl (procainamide)."

Per article on EMS World
 

Bullets

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Regardless of SpO2 if the pt is fighting for O's, give it to them

But if her Sp02 is 96% isnt she not fighting for oxygen? She may have increased work of breathing, but her blood is sufficiently oxygenated. Maybe a NC at 2-3L would have been more appropriate, and as a BLS provider its about all i could do
 
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Frogil

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I think the discussions done above is really precious for me because I came to know more from this.
 

akflightmedic

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I think the discussions done above is really precious for me because I came to know more from this.

Post count filled...success.
 

sirengirl

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VT with SOB, no BP, and diaphoresis is not stable my friend. Why was the patient not put on the monitor until getting in the bus?

This.
When I get into the box if I hear anything that I vaguely think might be cadiac or respiratory, I load up the stretcher. I ran a call at 1am for the local torture home for a UTI and I still loaded the stretcher in case it was cardiac. Ya never know... The minute you described the patient, I thought IV, etomidate, sync.


Regardless of SpO2 if the pt is fighting for O's, give it to them

Also, this. A very salty, incredibly intelligent street medic once told me that it doesn't matter if they're compensating; if they're fighting to compensate and hold that 96, they won't be compensating for long.
 

the_negro_puppy

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Pt is obviously unstable?

Within my scope I would call for ICP backup, consider aspirin, perform 12 lead and get IV access, also prepare defib pads.

Can't cardiovert or give lignocaine at my level, would transfer L&S with possible rendezvous with ICP

I have had one such patient and did pretty much the above. Pt was overweight type 2 diabetic c/p syncope with vomiting. BP 60/40 ish, nil radial pulse. Did the aspirin, 12 lead, IV. ICP sedated with midazolam and attempted cardioversion no dice. Pt made it to hospital without arresting GCS15.
 

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