Versed + hypotension

[mycrofft]

Knowing "when not" is more valuable than just knowing "How".






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[Christopher]

C. You could cardiovert him into asystole.

That's the most common post cardioversion rhythm too. Last lady we cardioverted for flutter had a nice 8-9 second run of asystole...not a fun feeling for all parties involved :wacko:

 

[mycrofft]

I can just see the face of anyone in the compartment with the pt...

 

[blindsideflank]

Well if a stemi and you can recognize it then for us it would be olmc to decide if tnk was appropriate. Unfortunately I don't really understand the basis for this. It'll be nice when we are testing for troponin and bnp on car (in a few months I think!)

Converting him may reduce ischemia though. Sure his heart is doing it's job right now but are you just allowing more ischemia when you have an available treatment. I guess this comes down to your observations since hove been on scene. Has he deteriorated at all, in any way. If so I shock.

Sorry if the thread has veered from the op but its all a good discussion

 

[jwk]

I think a little versed is fine here. If he converts to a better perfusing rhythm, hypotension isn't going to be an issue, and if he crashes, the versed hasn't hurt you. Your object here is not to get rid of pain - it's to provide a short-term amnestic effect. They don't have to be unconscious. Good chance the next day that they won't remember it.

Etomidate is a garbage drug that is rapidly falling out of favor - I've stopped using it altogether. It's a poor choice for cardioversion. Assuming your patient converts, you'll still be able to talk with your patient and further assess them. Not so with etomidate.

 

[Smash]

Leaving aside Vene's point (which is a very good point) and going simply with the idea that the decision to cardiovert has been made, then yes, a little bit of midazolam is probably not going to do any harm and is the humane thing to do.

However, I have to agree with Vene about the need to sometimes sit on your hands and leave well enough alone. Not an easy thing to do sometimes!

 

[STXmedic]

Etomidate is a garbage drug that is rapidly falling out of favor - I've stopped using it altogether. It's a poor choice for cardioversion. Assuming your patient converts, you'll still be able to talk with your patient and further assess them. Not so with etomidate.

Jwk, what makes you say this? Not doubting you, merely curious. We're just now getting etomidate and would love to hear what cons you find with it.

 

[mycrofft]

Think about what may be need to be given later when giving a drug which is not directly saving a life. Especially anything that will get an anesthesiologist mad at you.

 

[DPM]

I'm still new to this... Would the versed still have the required effect if given after cardioverting? I.e. you light up the PT, then if the new rhythm is stable you give a little versed...?

 

[usalsfyre]

I'm still new to this... Would the versed still have the required effect if given after cardioverting? I.e. you light up the PT, then if the new rhythm is stable you give a little versed...?

Not nearly as well or reliably. What they need post cardioversion is analgesia. Why chance it?

 

[STXmedic]

There's supposedly a small amount of retrograde amnesia with Versed. However, I've been bedside with several family members who have received Versed. So far, they have all had full recollection up until about 30 seconds to a minute POST administration. So I have my doubts.

 

[NomadicMedic]

Etomidate is a garbage drug that is rapidly falling out of favor...

I was lead to believe that long term (>6 hours) adrenal insufficiency, the number one side effect of etomidate, was only a factor in patients receiving long term (>48 hours) infusions of the drug, such as continued sedation in the ICU, a practice which has stopped in most places. Patients receiving a single dose of 0.3mg/kg had normal adrenal function 12 hours after the drug was administered.

Are there new studies that show etomidate is a “garbage drug” that we should be avoiding? In systems that don’t use Ketamine or propofol, what is your suggestion for induction with RSI or rapid sedation for cardioversion?

 

[CANMAN]

I haven't heard of Etomidate falling out of favor, I think people just need to utilize it appropriately and consider other drugs when contraindicated. As far as cardioversion, if I felt so moved to give the pt. some juice then I would go Versed > Etomidate and hang a 500cc NS bolus while at it.

Induction agents at my service include:
Etomidate
Versed
Thiopental
Ketamine

 

[blindsideflank]

I'm newer and still dumb but how can you compare versed and etomidate? We are talking about analgesia here no? Amnesia, I don't know the comparison.
Am I the only one that like ketamine here?

 

[STXmedic]

I'm newer and still dumb but how can you compare versed and etomidate? We are talking about analgesia here no? Amnesia, I don't know the comparison.
Am I the only one that like ketamine here?

Not at all. Many love ketamine. Good luck getting on a service that carries it, though.

 

[ZootownMedic]

So some people have said that if they were in V-tach with pulses and stable then they wouldn't cardiovert...... What are your transport times? I am just curious because from everything I have been taught a patient is not going to be able to maintain that rhythm for very long. Are you saying that you just wouldn't cardiovert or are you saying that you wouldn't perform any intervention chemical or electrical.....

I would think that if they are stable then lidocaine or amiodarone would be the way to go but the second I thought they weren't it would be cardioversion time. Correct me if I am wrong or maybe I just misunderstood....

 

[usalsfyre]

I'm more ok with electricity than cardioversion.

Yes we're taught "lethal rhythm". I've also seen an elderly male sustain it for 6+ hours with no outwardly apparent ill effects other than "I'm a little light headed".

 

[NomadicMedic]

I'm newer and still dumb but how can you compare versed and etomidate? We are talking about analgesia here no? Amnesia, I don't know the comparison.
Am I the only one that like ketamine here?

We're not talking about analgesia at all. We're talking about sedation prior to cardioversion.

 

[Hunter]

This is veering a little off the original question but I just thought of something; in school I was taught that electrical therapy was for unstable and medications were for stable patients, only sign of being unstable I see here is the bp. However assuming the decision to shock has already been made I was told to not delay cardioversion to drafter a patient. Regardless of bp.

 

[Akulahawk]

Versed does have some retrograde amnesia effects, however, I suspect that effect greatly depends upon how it's administered. I don't have a whole lot of experience with giving Versed, however. I just haven't had a chance to really get to observe that effect myself. A few people I've worked with have observed the effect though.