Versed + hypotension

zzyzx

zzyzx

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I'd like to get some opinions on this: say you had a patient in VT with pulses who was 80 systolic but still fully alert and oriented, would you use Versed 1 - 2 mg prior to cardioversion? How much impact could that amount of Versed have on the BP, esp. considering a scenario where after you shock the patient he/she does not convert out of VT?
 
zzyzx said:
I'd like to get some opinions on this: say you had a patient in VT with pulses who was 80 systolic but still fully alert and oriented, would you use Versed 1 - 2 mg prior to cardioversion? How much impact could that amount of Versed have on the BP, esp. considering a scenario where after you shock the patient he/she does not convert out of VT?
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Is Versed the only choice? Because I'd go to the Etomidate.
 
n7lxi said:
Is Versed the only choice? Because I'd go to the Etomidate.
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Why etomidate? No analgesic effects and causes hypotension. Just curious.
 
zzyzx said:
I'd like to get some opinions on this: say you had a patient in VT with pulses who was 80 systolic but still fully alert and oriented, would you use Versed 1 - 2 mg prior to cardioversion? How much impact could that amount of Versed have on the BP, esp. considering a scenario where after you shock the patient he/she does not convert out of VT?
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Versed or Valium. The only problem is it still will not help for pain much and the PT is still going to feel it. If it is my PT and they are not symptomatic (chest pn, nausea, etc) I wouldn't cardiovert unless absolutely necessary.
 
crazycajun said:
Versed or Valium. The only problem is it still will not help for pain much and the PT is still going to feel it. If it is my PT and they are not symptomatic (chest pn, nausea, etc) I wouldn't cardiovert unless absolutely necessary.
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I saw a guy having a STEMI in my ER rotations with a bp of 54/30 fully A&O. A&O isn't the only indicator of stability or hemodynamic stability. If you have hemodynamically unstable V-Tach with a pulse it wont be with a pulse much longer unless you do something.
 
Frozennoodle said:
I saw a guy having a STEMI in my ER rotations with a bp of 54/30 fully A&O. A&O isn't the only indicator of stability or hemodynamic stability. If you have hemodynamically unstable V-Tach with a pulse it wont be with a pulse much longer unless you do something.
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54/30 with a STEMI is unstable and requires immediate intervention. 80 systolic may be PT norm and if there are not symptomatic why cause the PT unnecessary pain? Or risk sending them into Asystole? I am not saying don't put on the combi-pads and be ready but hospitals have options with anti-disrhythmics as where we do not.
 
This is going to sound cruel but who cares, shock him and keel the guy alive, sure it'll hurt but he's gonna be alive right?
 
Hunter said:
This is going to sound cruel but who cares, shock him and keel the guy alive, sure it'll hurt but he's gonna be alive right?
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Hunter you are missing the point. Not every PT needs electricity. You could very well cardiovert him and kill him at the same time. It happens all of the time. Sometimes it is out of your control but sometimes it could have been avoided.
 
crazycajun said:
54/30 with a STEMI is unstable and requires immediate intervention. 80 systolic may be PT norm and if there are not symptomatic why cause the PT unnecessary pain? Or risk sending them into Asystole? I am not saying don't put on the combi-pads and be ready but hospitals have options with anti-disrhythmics as where we do not.
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I'd be more worried about hypotension secondary to hanging an amiodorone drip more than I'd be worried about it from versed. Depending on where I am and my transport time is going to decide what I'd do.

What's their diastolic pressure? I want to know this person's MAP. 80 SBP is pretty low to be "normal" for a patient but weirder things have happened.

"stable" VT is a crap term, no one stays stable in VT. The last guy I saw in VT dropped 90 points SBP in <10 minutes, but I'm pretty sure the amio I hung had something to do with it as well.

With the pressure provided by the OP I'd be leaning towards cardioverting this guy sooner rather than defibrillating him later but my instructors have always stressed the point that we shouldn't be scared of electricity. I've seen more than a few patients get cardioverted in the hospital and had one man's AICD cardiovert him on my gurney as we were capturing a 12-lead.

Never seen someone cardioverted from VT with pulses into asystole. Not saying it can't happen though.

Hunter said:
This is going to sound cruel but who cares, shock him and keel the guy alive, sure it'll hurt but he's gonna be alive right?
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Retrograde amnestic effects from versed are a wonderful thing.
 
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Ketamine would be my choice. 0.5 mg/kg
I wouldn't delay shocking him for this though but the whole amnesia thing is nice too, we can titrate fentanyl for procedural sedation in a hypotensive patient if we are careful. But you don't have time for this if you feel the need to shock. Don't think any of this will really help the pain though.

But I may not zap this guy
 
So if you decide he is stable then amiodarone or if polymorphic would you give mag?
The mag question is for those of you saying he is stable at 80 mmhg. Doesn't seem too stable now
 
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blindsideflank said:
So if you decide he is stable then amiodarone or if polymorphic would you give mag?
The mag question is for those of you saying he is stable at 80 mmhg. Doesn't seem too stable now
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I've been on the "unstable" side of the table from the get go.

If it's polymorphic I'm not screwing around with mag and I'm cardioverting him. I don't want that degenerating into VF.
 
Give the midazolam. Even if it causes a bit more hypotension your about to fix it right?
 
usalsfyre said:
Give the midazolam. Even if it causes a bit more hypotension your about to fix it right?
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That's a very good point especially if you have a big line running WFO as you give it.

Unfortunately I would be hung out to dry by QA/QI for giving someone with a SBP <90 mmHg midazolam.
 
would you use Versed 1 - 2 mg prior to cardioversion"

No, it would probably make you too drowsy to complete the procedure.
:rofl:
(I couldn't resist, good answers and discussion above already).
 
crazycajun said:
Hunter you are missing the point. Not every PT needs electricity. You could very well cardiovert him and kill him at the same time. It happens all of the time. Sometimes it is out of your control but sometimes it could have been avoided.
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I know but that's not what the op asked, assuming he does need it, I'm not going to wait to save this guys life
 
NVRob said:
That's a very good point especially if you have a big line running WFO as you give it.

Unfortunately I would be hung out to dry by QA/QI for giving someone with a SBP <90 mmHg midazolam.
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Unfortunately this my problem as well. I hate to have such a thing factor into my decision making, but it's simply unavoidable.

That being said, I agree with usalsfyre. You're going to more than likely fix the current hypotension with the electricity, so why not make the procedure a little easier on them? Besides, a good fluid bolus should resolve any hypotension that the Versed caused, at least I believe so.
 
could I just ask?

What is your endgame?

If you have a guy who is A&O and having a STEMI, doesn't he need some kind of reperfusion therapy?

So long as he was mentating, both his heart and his brain are receiving blood.

Look at the potential outcomes of treating numbers.

A. You could cardiovert him and it would restore a normal rate/rhythm.
B. You could cardiovert him and kill all of the stunned cells reducing future cardiac output.
C. You could cardiovert him into asystole.
D. You could cardiovert him into a normal rate/rhythm which might last a few minutes, increase ischemia, and then watch him decompensate.
E. You could watch and if he starts to mentaly deteriorate take action then, and not have to worry about sedation/analgesia.

His BP might be that low and vtach his rhytm because he lost the intrinsic pacemakers from hypoxia.

Sometimes discretion is the better part of valor.
 
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