TVP as prerequisite for Push-Dose Pressors (?)

[CWATT]

I was re-listening to EmCrit podcast #205 titled “Push-Dose Pressors Update” and around the 25min mark Dr. Weingart made the claim that ‘anyone using push-dose pressors should know how to initiate a Transvenous Pacer (TVP), otherwise they shouldn’t be using them’. My question is this — why does he consider TVP a prerequisite for push-dose pressors?

Obviouasly we aren’t about to do this intervention in the pre and inter-hospital environment (with possible exception to Kings County; they probably do craniotomies). Is the concern that clinicians might just keep repeat dosing in attempt to avoid bradycardia without treating the underlying problem (akin to thinking anticonvulsants like Midazolam are the treatment to seizures and overlook the underlying mechanism)? If so, this still doesn’t strike me as a contraindication.

Just curious what peoples’ thoughts are on the statement and possible rationale behind it.



Thanks,
- C


Link to EmCrit #205: https://emcrit.org/emcrit/push-dose-pressor-update/

 

[Peak]

I disagree. First off TV pacing is a bandaid and does not replace EC or implanted pacers. Also with the wide advent of TC pacing I'm not convinced that TV holds all the precedence it used to.

I think that, more importantly, you need to look at the risks and benefits of treatment. We sometimes still use PDPs on our CHD kids even if they have EC wires in place which is far more effective than TV pacing.

I think that you also have to look at the purpose of treatment. Is it a bridge or therapeutic? I have a low threshold for EMS/ED to give PDPs where I have a much higher expectation from intensive care or anesthesia. Are we keeping the patient alive to definitive care or using it in lieu of definitive care?

In your analogy would I fault EMS for repeated indicated doses of verses (instead of hypersonic saline), of course not. Would I fault an ED, it probably depends on their size and acuity. Would I fault an ICU, absolutely.

All therapies have a place, we just need to follow the evidence and ensure that we give patients the best care we can provide.

 

[VFlutter]

Only thing I can think of is paradoxical bradycardia sometime seen with Phenylephrine or potentially other PDPs. Abrupt increase in pressure creates a baro-receptor reflex. Not sure a TVP is necceary as it is usually short lived and should respond to Atropine or Iso.

 

[Carlos Danger]

I think sometimes Weingart says things like that just because he wants to make it appear as though he thinks on a much higher level than most. I also think he forgets that not everyone works in a place as well equipped and resource-rich as Janus General.

“Push dose” pressors may be relatively new to Weingart and the rest of the EM and EMS community, but they have been used routinely in anesthesia for decades.

I gave some bumps of neo an hour ago, and there isn’t a TVP available for 40 miles.

 

[RocketMedic]

Why in the Sam Hill would there be a TVP on an ambulance? Do they not know of TCP or that we’re not literally cardiologists in surgical suites?

 

[E tank]

Never heard of this person, but this seems a pretty dogmatic (and pretty naive statement to make) I guess he's talking about the occasional reflex bradycardia from phenylepherine? It's a compensatory mechanism in response to acute rises in BP in order to mitigate potential end organ harm. The bradycardia is supposed to cause the pressure to level off or fall, so why would anyone ever pace in that circumstance? I can't imagine that's what he's suggestion, but then the statement makes no sense from the get go .

 

[GMCmedic]

I dont listen to a ton of Emcrit, but I've never really heard much on there being specifically geared toward prehospital environments. I dont agree with the statement, but I doubt he had ambulances in mind when he said it.

 

[CWATT]

... I doubt he had ambulances in mind when he said it.

I agree, but since I have Ephedrine, Epi, and Phenylephrine push-dose protocols within my scope of practice and no ability to initiate a TVP, I figured it would be worth questioning his motivation for making such a statement and explore how that might apply to me in a pre and inter-hospital environment.

 

[Peak]

Even in referral centers TV pacing is not a common intervention.

Placing a TV pacer is pretty difficult. When you consider the anatomy the right IJ is your best shot, but floating into the RA and RV is no guarantee. It takes a skilled and experienced provider to place one, and I doubt most EM docs or even intensivists have placed one in the past 5 years.

We have a couple that sit in our trauma rooms in the ED. We have never placed one, rarely patients that go to cath lab may have one placed by cardiology if the patient is too tenuous to allow for a implanted pacer, but that is the only time I've ever seen one placed.

Our job in EM is to bridge to therapy be it a rural EMT basic or a tertiary referral center. Of the big cardiac hospitals in the city, adult or peds, I can't think any that are placing TV pacers in the ED.

 

[E tank]

Even in referral centers TV pacing is not a common intervention.

Placing a TV pacer is pretty difficult. When you consider the anatomy the right IJ is your best shot, but floating into the RA and RV is no guarantee. It takes a skilled and experienced provider to place one, and I doubt most EM docs or even intensivists have placed one in the past 5 years.

We do it all the time for TAVR. It really isn't any big deal. You do need to know how to use an external pacemaker. Way easier than passing a PA catheter. Still, I have no idea what that guy is talking about.

 

[Peak]

We do it all the time for TAVR. It really isn't any big deal. You do need to know how to use an external pacemaker. Way easier than passing a PA catheter. Still, I have no idea what that guy is talking about.

Correct, which is in the cath lab being placed by an interventional cardiologist.

I utilize epicardial pacing wires frequently so I'm plenty familiar with external pacing. I still don't think that it is very relevant for pre-hospital or ED care.

 

[VFlutter]

Correct, which is in the cath lab being placed by an interventional cardiologist.

It wasn't uncommon for our Intensivists to float TV wires in the ICU and occasionally down in the ER. Definitely happens outside the cath lab

 

[E tank]

Correct, which is in the cath lab being placed by an interventional cardiologist.

I utilize epicardial pacing wires frequently so I'm plenty familiar with external pacing. I still don't think that it is very relevant for pre-hospital or ED care.

Nor is it relevant for PDP's. And I've floated transvenous pacers. We do it if the access is via ij. Not the cardiologists. With the advent of reliable TC pacing, it has become a thing of the past in the ED.

 

[rescue1]

From listening to EmCrit, I get the feeling that Scott Weingart has very strong feelings about what the capabilities of an emergency department should be, including things like having ultrasound in the department, being able to treat cardiac arrests beyond the scope of ACLS (with things like esmolol or ECPR or whatever is cool this month), or apparently TVP. Every so often in an episode he'll throw out a statement like "if you can't do X, you probably shouldn't be an ED". It's obviously impossible for every ED, especially rural EDs, to meet the standards of his Level 1 tertiary care hospital, and so it can seem a little silly for him to keep harping on it. On the other hand, having seen resuscitations done in certain lower volume ERs (I'm sure anyone who does ALS IFT or flight IFT has seen this too), maybe he's got a point.

But I don't think TVP and push dose pressors have any specific relation other than being things that Weingart thinks every emergency doctor should be able to do.

 

[Peak]

It wasn't uncommon for our Intensivists to float TV wires in the ICU and occasionally down in the ER. Definitely happens outside the cath lab

TV pacing just isn't that common in modern practice. I've had more bilateral thoracotomies than TV pacers, I've had more bedside EVDs in the ED than TVPs, I've had more open hearts opened back up and operated on in the unit than TVPs. We have CHD cases that come to us from around the world and age related disease cases sent to us from across the region, and our practice is not dissimilar from other heart programs in the state.

Those with a high degree block not related to transient factors like medication overdose or acute electrolyte abnormality really should have a permanent pacemaker placed. There is a fair bit of literature about transduction abnormalities around TAVR placment, but the prudent cardiologist would place pacemakers in high risk patients while in the lab or plan on immediately returning to the lab and placing one should a high degree block or symptomatic bradycardia develop. To make the medical team responsible for poor cardiac management is not appropriate. There will of course be some instances where TCP is indicated and I'm not arguing there isn't, but it is becoming increasingly less relevant in current practice.

I'm steadfast against turning the ED into the Unit. As someone who does both ED and inpatient critical care the ED will never be the unit. I don't believe in things like cannulating to ECMO in the ED, placing impellas, active cooling, and so on in the ED. If a hospital cannot rapidly disposition (like under 30 minutes) intensive care patients into the age and condition appropriate intensive care unit they should be on advisory and if that patient still arrives should be transferred to a facility that can appropriately manage that level of care. Of course there will be many community and critical access hospitals that cannot do this, but of course they are not the ones who are arguing for starting this type of critical care in the ED.

I also don't necessarily think that week need to hold EMS (not including interfacility critical care transport who accepts these patients) or EDs to the knowledge level of (non-TC) external pacers. There is so much more relevant care that needs to be developed before that becomes the issue we prioritize. The work of EMS and EDs are to triage, provide basic stabilization, and appropriately disposition patients of every age and countless maladies. EMS and the ED do not get to sub-specialize in a specific disease state management, and in fact I would wager that if I handed an external pacer to the majority of non-cardiac ICU nurses they would have no idea how to use it, why would we introduce this to the ED?

 

[StCEMT]

I dont listen to a ton of Emcrit, but I've never really heard much on there being specifically geared toward prehospital environments. I dont agree with the statement, but I doubt he had ambulances in mind when he said it.

Gonna side track a bit here, but I think the DSI, LAMW, and the dominating the vent podcasts he did are all worth the time to listen to for prehospital folks. Beyond that? Eh...

 

[DesertMedic66]

We had a local non-cardiac center place a TVP in their 7 bed ED about a month ago.

Patient was being paced TC for a 3rd degree block. The receiving hospital/physician would not accept the patient until the TVP was placed. Once it was placed the receiving facility said they were full and could no longer take the patient. Longest 2 hour bedside delay I have had in a long time.

 

[E tank]

We had a local non-cardiac center place a TVP in their 7 bed ED about a month ago.

Patient was being paced TC for a 3rd degree block. The receiving hospital/physician would not accept the patient until the TVP was placed. Once it was placed the receiving facility said they were full and could no longer take the patient. Longest 2 hour bedside delay I have had in a long time.

That would have really s***ked to pace that patient with external pads...good for them. Probably happens a lot.

 

[Carlos Danger]

I listened to EmCrit a lot when it was new. Dr.

Gonna side track a bit here, but I think the DSI, LAMW, and the dominating the vent podcasts he did are all worth the time to listen to for prehospital folks. Beyond that? Eh...

Yeah, I listed to EmCrit a lot when it first came out, but haven't in a long time, with the exception of when someone links to one somewhere that sounds interesting.

Dr. Weingart is obviously a really smart guy who likes to challenge the status quo and comes up with some good ideas. I totally agree that a minority of what he talks about is really usable in the EMS environment. Personally, I'm not a big fan of his style and the way he seems to take credit for "inventing" so many things that are really just adaptations to the ED environment of techniques that are old hat in the OR and ICU.

But his podcast is high quality and he was a pioneer of the FOAMed movement. People say he's a great teacher and speaker in person. Gotta give credit where it is due.

 

[VFlutter]

he seems to take credit for "inventing" so many things that are really just adaptations to the ED environment of techniques that are old hat in the OR and ICU.

Next podcast...Percussion pacing for scrubs who can't place TVPs