Unsedated Cardioversion

[chaz90]

I was able to get a somewhat decent view of the BP on the show and it was in the upper 80s systolic. We could have missed some sedation in the editing as other have pointed out. He also tried pushing the adenosine through a 20 in the dudes hand and was mystified when it wasn't effective.

Agreed with the pressure. 88 over something if I remember correctly.

I've had success with Adenosine through 20G in less than central locations. It's not ideal, but you have to work with what you have. I think the bigger reason it didn't work at all was that the patient was in fact tachycardic secondary to sepsis rather than any sort of AVNRT or PSVT.

 

[Christopher]

Cardioversion of septic patients is a no-no. Far too often we forget compensatory tachycardia itself isn't what you treat.

That being said:
1. Sedate. If they can answer your questions they have time for and deserve sedation (unless they refuse).
2. Adenosine can/does work through distal peripheral IV's. Given this patient had a variable heart rate it is highly unlikely his rhythm was reentrant, thus adenosine did not work because it does not fix non-reentrant rhythms.

 

[TheLocalMedic]

Cardioversion of septic patients is a no-no. Far too often we forget compensatory tachycardia itself isn't what you treat.

Agreed. It can be easy to get hooked into the "Holy cow, look at that heart rate! We gotta do something about that!" mentality and then forget to look for other non-cardiac causes.

 

[COmedic17]

Sedation is for.....kittens.

In all honesty, if someone is unstable enough that cardio version is immediately necessary- I'm not going to waste valuable time sedating. If they are somewhat stable, I'm going to go the medication route first. If it's still an issue ( hospital is close to my "area" of response, so I'm doubtful) then I could sedate and cardiovert.
If I cardiovert a stable person without first trying a medication based treatment, The hospital will be less then pleased. If I waste time sedating a critical patient to cardiovert, the hospital will be less then pleased.

However make sure you SHOULD be cardioverting if your going to do it.
Also make sure you SHOULD be using medication (adenosine , etc) if your going to.

Cardioverting isn't beneficial to sepsis or hypovolemia.
Adenosine isn't beneficial... At all... To afib RVR. Also don't give it to people with heart transplants. Also, it might behoove you to ask a patient if they have a history of WPW.

Also, I like to toss on fast patches prior to adenosine. Especially for those patients who "never go to the doctor, so there for a have no medical history". Keep in mind if a patient has WPW there's a chance adenosine will put them into VTACH. Recent studies have shown its not as common as once believed, but it's a risk. In addition, if they have WPW with afib- adenosine is lethal. Don't be that person.

Think about the patho-physc before any treatment. You can't be "robotic" as a medic. It's not " if A, then do B". You have to really think about the whole picture.

I have met people who want to slam adenosine in peoples as soon as they see SVT on the monitor. Then you point out its An irregular rhythm. That changes everything. Or they see an SVT and ignore the fact the patients skin is on fire and skin is tenting. That also changes everything.

 

[Burritomedic1127]

Sedation is for.....kittens.

In all honesty, if someone is unstable enough that cardio version is immediately necessary- I'm not going to waste valuable time sedating. If they are somewhat stable, I'm going to go the medication route first. If it's still an issue ( hospital is close to my "area" of response, so I'm doubtful) then I could sedate and cardiovert.
If I cardiovert a stable person without first trying a medication based treatment, The hospital will be less then pleased. If I waste time sedating a critical patient to cardiovert, the hospital will be less then pleased.

However make sure you SHOULD be cardioverting if your going to do it.
Also make sure you SHOULD be using medication (adenosine , etc) if your going to.

Cardioverting isn't beneficial to sepsis or hypovolemia.
Adenosine isn't beneficial... At all... To afib RVR. Also don't give it to people with heart transplants. Also, it might behoove you to ask a patient if they have a history of WPW.

Also, I like to toss on fast patches prior to adenosine. Especially for those patients who "never go to the doctor, so there for a have no medical history". Keep in mind if a patient has WPW there's a chance adenosine will put them into VTACH. Recent studies have shown its not as common as once believed, but it's a risk. In addition, if they have WPW with afib- adenosine is lethal. Don't be that person.

Think about the patho-physc before any treatment. You can't be "robotic" as a medic. It's not " if A, then do B". You have to really think about the whole picture.

I have met people who want to slam adenosine in peoples as soon as they see SVT on the monitor. Then you point out its An irregular rhythm. That changes everything. Or they see an SVT and ignore the fact the patients skin is on fire and skin is tenting. That also changes everything.

For the most part, you should have time to give some sort of sedation before cardioverting. Yes, if the pt is circling the drain, minimally responsive, with a pressure in the 50-60s refractory to fluid, then hell yeah light em up. But I'd be pretty pissed if I have some symptomatic arrhythmia going on with a pressure in the 80s and you didn't give me any sedation. I've heard many medics (not directed at you), say how " sedation or pain management is earned, it's not a right blah blah blah", which is garbage. We all want to "do no harm" and "less invasive/best for patient options". Sedation is truly caring for the pt. Just something to think about before you give grandma/grandpa their breakfast of a nice non sedated 100J

 

[COmedic17]

For the most part, you should have time to give some sort of sedation before cardioverting. Yes, if the pt is circling the drain, minimally responsive, with a pressure in the 50-60s refractory to fluid, then hell yeah light em up. But I'd be pretty pissed if I have some symptomatic arrhythmia going on with a pressure in the 80s and you didn't give me any sedation. I've heard many medics (not directed at you), say how " sedation or pain management is earned, it's not a right blah blah blah", which is garbage. We all want to "do no harm" and "less invasive/best for patient options". Sedation is truly caring for the pt. Just something to think about before you give grandma/grandpa their breakfast of a nice non sedated 100J

I think you may of overlooked this part of what I said

If someone is unstable enough that cardio version is immediately necessary- I'm not going to waste valuable time sedating. If they are somewhat stable, I'm going to go the medication route first. If it's still an issue ( hospital is close to my "area" of response, so I'm doubtful) then I could sedate and cardiovert.


I'm not an unreasonable person. If the patient is reasonably "stable" and other treatments are not providing a favorable outcome, of course I'll sedate. But I'm not going to to cardiovert a completly stable person-ever. There's no reason. They are stable. If they are crashing, I'm not wasting time on sedation. If they are symptomatic but not circling the drain ( so if they are "reasonably stable"), medication has been unresponsive, then I will sedate. However transport is typically never over 10ish minutes (max, typically less) so I have never had to sedate/cardiovert a "reasonably stable" patient.

 

[NYBLS]

I think we need to keep in mind that cardioverting a patient is sometimes significantly less dangerous then going the medication route. Am I saying we should just shock people? No. But I hate the distinct fear that we are nervous to do something that can save a life because it will hurt. No kidding it will hurt, but so does an IV, IO and EJ. Am I going to abandon those items and good care because of the pain? No.

 

[Carlos Danger]

I think we need to keep in mind that cardioverting a patient is sometimes significantly less dangerous then going the medication route. Am I saying we should just shock people? No. But I hate the distinct fear that we are nervous to do something that can save a life because it will hurt. No kidding it will hurt, but so does an IV, IO and EJ. Am I going to abandon those items and good care because of the pain? No.

In what way? Do you have a reference for that?

 

[Burritomedic1127]

I think you may of overlooked this part of what I said

If someone is unstable enough that cardio version is immediately necessary- I'm not going to waste valuable time sedating. If they are somewhat stable, I'm going to go the medication route first. If it's still an issue ( hospital is close to my "area" of response, so I'm doubtful) then I could sedate and cardiovert.


I'm not an unreasonable person. If the patient is reasonably "stable" and other treatments are not providing a favorable outcome, of course I'll sedate. But I'm not going to to cardiovert a completly stable person-ever. There's no reason. They are stable. If they are crashing, I'm not wasting time on sedation. If they are symptomatic but not circling the drain ( so if they are "reasonably stable"), medication has been unresponsive, then I will sedate. However transport is typically never over 10ish minutes (max, typically less) so I have never had to sedate/cardiovert a "reasonably stable" patient.

Like I said it wasn't directed at you. And I'm not going to go full ACLS refresher, but I would hope you would never cardiovert a stable Pt ever. My point is not the algorithms we choose, medicine before Edison and all that. My point is, if it came to the point where your findings deemed an electrical therapy appropriate than it's not you could sedate, it's you should sedate. So would not want to sedate the grandma in rapid Afib with crushing chest pain, low BP, looks like crap, but PERFECT mental status? Doesn't matter if I'm on a call one block from the hospital, short transport times shouldn't be a deciding factor if some gets sedated. Personally, I wouldn't leave the house till everything was taken care of. With the stable, unstable, reasonably unstable Pt terms thrown out the window, if a pt can hear you and understand what your saying, regardless if transport time, and need to be cardioverted, give some sedations. It's like the old be kind rewind sayings of VHS tapes, you don't have to but you should.

 

[Burritomedic1127]

I think we need to keep in mind that cardioverting a patient is sometimes significantly less dangerous then going the medication route. Am I saying we should just shock people? No. But I hate the distinct fear that we are nervous to do something that can save a life because it will hurt. No kidding it will hurt, but so does an IV, IO and EJ. Am I going to abandon those items and good care because of the pain? No.

Giving pain management is good Pt care. End of story. I'm not saying sedate someone for every IV but electrical therapies are big painful procedures where sedation will help the pt. Next time you see someone get cardioverted in the ER, not pre hospital, tell me if the MD/PA/RN doesn't have some sedation medication running. Explain to me then why you give lidocaine for a conscious IO

 

[Burritomedic1127]

Man I need to proof read my posts for spelling. "Give some sedations" is my new term haha

 

[COmedic17]

Like I said it wasn't directed at you. And I'm not going to go full ACLS refresher, but I would hope you would never cardiovert a stable Pt ever. My point is not the algorithms we choose, medicine before Edison and all that. My point is, if it came to the point where your findings deemed an electrical therapy appropriate than it's not you could sedate, it's you should sedate. So would not want to sedate the grandma in rapid Afib with crushing chest pain, low BP, looks like crap, but PERFECT mental status? Doesn't matter if I'm on a call one block from the hospital, short transport times shouldn't be a deciding factor if some gets sedated. Personally, I wouldn't leave the house till everything was taken care of. With the stable, unstable, reasonably unstable Pt terms thrown out the window, if a pt can hear you and understand what your saying, regardless if transport time, and need to be cardioverted, give some sedations. It's like the old be kind rewind sayings of VHS tapes, you don't have to but you should.

Your essentially repeating everything I just said, so I'm going to assume your more concerned about arguing then reading what I actually said.

I stated I would never cardiovert a stable patient. Verbatim. In those exact words.

I also stated I would sedate a "reasonably stable" patient if need be/I was able to, however transport times are so short by the time I tried the medication interventions, I would more then likely already be at the hospital. I'm not going to go park in a Walmart parking lot to elongate transport times to So I can have ample time to try all medicinal approaches, then sedate and Cardiovert.

In response to your " So would not want to sedate the grandma in rapid Afib with crushing chest pain, low BP, looks like crap, but PERFECT mental status?" Statement , my answer is no. If her blood pressure is so low, and she looks like crap, she's not stable. You speak of algorithms. I ask you to please review the algorithm for unstable tachycardia. I believe it says "consider sedation" and cardiovert. I'm not going to let her go into VTACH becauseI was prepping for sedation why she was clearly very unstable.

In addition, Please find me literature that states anybody with an intact mental status is automatically "stable". There's people who have been shot five times, have low BP, and are mentally alert. If they have a tension pneumo are you going to withhold that treatment due to them feeling pain? Are you going to waste time sedating them when they could crash any minute? I would sure hope you wouldn't.

Sometimes what's in the best intrest of the patient isn't the most comfortable.


But as I stated, a lot of the "points" you are trying to make are repetitive of things I have already said. So I don't believe you are reading what I am saying as much as you are looking for a reason to argue.

I will have a DISCUSSION with you but I'm not going to continue on with a redundant argument.

 

[Burritomedic1127]

Where do i start

First off, ill repeat it was never originally directed at you.

Yes i was repeating your verbatim of saying i hope you never would, Because you were explaining, you never would cardiovert a stable person. This is us agreeing

Just my style of medicine, i would never move a pt that needed to be cardioverted to the rig, so i wouldnt have to stop at at walmart parking lot. You have "ample time to try medicinal approaches, on scene. But hey i think they have really badass emt shirts for cheap. Dont know why we do anything prehospital anyways, we should drive fast.

For the example pt, i would be BS if you didnt sedate my grandma. Yeah her pressure is low (lets say 80), low pressure, chest pain = unstable (i just read my ACLS for the first time). Would 0.5 mg Versed tank her pressure? Prob not. Would it make her feel somewhat more comfortable when we cardiovert her absolutely.

I consider sedation constantly, thats while all my pts that need to be sedated, get sedated.

 

[Carlos Danger]

For the example pt, i would be BS if you didnt sedate my grandma. Yeah her pressure is low (lets say 80), low pressure, chest pain = unstable (i just read my ACLS for the first time). Would 0.5 mg Versed tank her pressure? Prob not. Would it make her feel somewhat more comfortable when we cardiovert her absolutely.

I would say that if someone is sick enough that you doubt their ability to safely tolerate more than 0.5 mg of midazolam, then they probably don't need anything at all. Would that much Versed "tank her pressure"? I would expect not, but it could have some negative effects, and the BP is already low, and you might not have a clear picture of all the comorbidities. Plus, I would question how effective such a small dose would be at meeting your goals, especially if you aren't going to wait 5 minutes or so for the effects to peak.

 

[COmedic17]

Would 0.5 mg Versed tank her pressure? Prob not. Would it make her feel somewhat more comfortable when we cardiovert her absolutely.

I consider sedation constantly, thats while all my pts that need to be sedated, get sedated.

Unless is a cardiac arrest, it's typically load and go. Fire has them ready by the time We get there to go straight on my cot with baseline vitals taken


Secondly, for sedation it is "recommended" slow push of over 1-2 minutes. Versed also has an onset of 2-3 minutes of given IV. 15 minutes if given IM ( should you not be able to obtain a line). 3-5 minutes is a pretty significant portion of a ten minute transport. Even if your on scene, that's a significant amount of time to spend sedating a patient with a falling blood pressure and inadequate skin vitals.

A side effect is also hypotension..right along with a decreased respiratory drive, arrhythmias, and bronchospasm. Which is why a lower dose if recommended if BP is under 100. It is also recommended to " use with caution" in patients over 70 years old for these reasons. Will .5mg aid in some of the pain assisted with cardio version? Maybe. But is it worth prolonging cardio version in an unstable patient? I don't believe so. I have dumped 10mg of versed (max dose) in intubated patients and they have still kept fighting.


Do what you do, but I am not going to waste time sedating an unstable patient with crappy skin vitals and a falling BP.

 

[NYBLS]

Giving pain management is good Pt care. End of story. I'm not saying sedate someone for every IV but electrical therapies are big painful procedures where sedation will help the pt. Next time you see someone get cardioverted in the ER, not pre hospital, tell me if the MD/PA/RN doesn't have some sedation medication running. Explain to me then why you give lidocaine for a conscious IO

Where did I say I would not provide analgesics?

 

[COmedic17]

And to add to the lidocaine/conscious IO- there's even exceptions to that too.

It's not recommended, for use in 2nd&3rd degree heart blocks, WPW, people allergic to corn, or if they have recieved Amio.

If lidocaine was contraindicated I would still drill without it. If they are in bad enough shape to need an IO I think the pain is the least of their problems.

Is pain management preferable? Yes. But it's not always possible or the best option for the patient.

 

[Carlos Danger]

And to add to the lidocaine/conscious IO- there's even exceptions to that too.

It's not recommended, for use in 2nd&3rd degree heart blocks, WPW, people allergic to corn, or if they have recieved Amio.

That's a new one to me. Do you have a reference for that?

 

[NomadicMedic]

0.5mg of versed won't be worth a fart in a windstorm when you cardiovert someone. Even after 5mg, they still howl like a banshee. They usually don't remember it though.

 

[COmedic17]

That's a new one to me. Do you have a reference for that?

Sure. Ill look some up real quick



Here's an easy to read reference

http://www.drugs.com/mtm/lidocaine-injection.html




Here's some references that are a little longer, but more reputable sources.

http://www.fda.gov/Safety/MedWatch/SafetyInformation/ucm342035.htm

http://dailymed.nlm.nih.gov/dailymed/archives/fdaDrugInfo.cfm?archiveid=11189




And here's some pdf files

www.medsafe.govt.nz/profs/datasheet/l/lidocainesol.pdf

www.accessdata.fda.gov/drugsatfda_docs/label/2012/018461s056lbl.pdf