Versed + hypotension

[Veneficus]

That's why I said I wanted more information in this case. All I have to go on is hypotension so right off the bat I'm leaning towards earlier treatment since that's all I have to go on. I was just playing a little devil's advocate since you had taken more of the opposite stance with the same limited information.

It's hypothetical anyway since we would have more information than just what was presented so its kind of a mute point.

I wasn't trying to take the opposite stance, I was attempting to point out that it is important to consider why and the potential outcomes of deciding on a specific course of action.

In a a patient not deteriorating, in a short transport, it may sometimes be a better choice to let the hospital handle it and just drive the pt in.

If the patient is unstable by multiple clinical signs, then I think the need for action is obvious.

I agree with you, it takes more than a number, If this is an elderly person, it is possible this person normaly has a systolic in the 90s. Which would make 80x not a considerable drop.

 

[FLdoc2011]

Does that mean you have nothing else to say?

It's moot point, doc.

Ha, thats what I get for typing on my phone.

 

[crazycajun]

Wow get slammed for a couple of busy shifts and it seems you miss everything. Thanks Vene for keeping some sanity in this discussion. For all of the newbies please remember.... Just because you have all of the gadgets, drugs and gizmo's available doesn't mean you have to use them on every PT. If you are treating your PT and not the monitor there will be instances that you don't need to do anything but monitor the PT. I have had people vagal on purpose because they knew it would drop their HR. If I were to pace this PT immediately then I would have performed an unneeded and possibly dangerous intervention.

 

[usalsfyre]

If you are treating your PT and not the monitor there will be instances that you don't need to do anything but monitor the PT.

As I've said again and again, why the heck even carry it if your going to ignore it?

I have had people vagal on purpose because they knew it would drop their HR. If I were to pace this PT immediately then I would have performed an unneeded and possibly dangerous intervention.

As was stated above, there's not really enough info to make a treatment decision here. The advice you give makes sense, but there's a bit more finesse to treatment decisions than "pt not monitor".

 

[mycrofft]

Question#1: what's wrong?
Question #2a and b: will it kill or disable the pt before we get to a hospital/can I treat enroute?
Question#3: What do I do first?

 

[coolidge]

why did someone write : Etomidate is a garbage drug

Why, curious?

 

[crazycajun]

As I've said again and again, why the heck even carry it if your going to ignore it?



As was stated above, there's not really enough info to make a treatment decision here. The advice you give makes sense, but there's a bit more finesse to treatment decisions than "pt not monitor".

I am not saying don't use the monitor however it is a diagnostic piece of equipment that can fail. That is the point I am making. With the way some medics and basics shove lead wires back in the bag, roll them tightly and just the general beating these pieces take it is very easy to look at the screen and see something that is not there. Many of today's medics are so caught up in the hype of drugs and electricity they also tend to forget to ask the basic questions and listen to their PT. I have seen medics bring PT's into an ER hooked up to a monitor with a rhythm and the ER physician ask how long the PT had been dead because someone forgot to check for a pulse. I have also seen cases where electricity was applied because the monitor showed a shockable rhythm only to hear them say the PT was A&O before and dead after.

 

[Dwindlin]

Why, curious?

The poster who said it was jwk, and if this is who I think it is, he/she is an AA. Etomidate has fallen out of favor with anesthesia because there are much, much better drugs to which they have access. Some of the reasons I see cited most are it causes myoclonus, adrenal suppression (often with just a single dose), and there may be a baseline increase in mortality with Etomidate use (granted the studies are mixed at this point, but if you have better options why risk it). Hopefully jwk will see this and post a much better explanation of why this drug has fallen out of favor, but this is my understanding currently.

 

[Handsome Robb]

For all of the newbies please remember....

Didn't you just finish medic school not too long ago? I might be mixed up...but I don't think so.

 

[Farmer2DO]

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.

Is Versed the only choice? Because I'd go to the Etomidate.

I wouldn't. Etomidate is OK for emergent airway situations, but when considered in the context of critical care medicine, it's a terrible drug.

http://www.biomedcentral.com/content/pdf/cc4979.pdf

"A single dose of etomidate is a major risk factor for the development of relative adrenal insufficiency for at least 24 hours after its administration" [Mohammad et al.]

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

Not according to this article.

a practice which has stopped in most places.

Thankfully.

Patients receiving a single dose of 0.3mg/kg had normal adrenal function 12 hours after the drug was administered.

Not according to everything I've read and been taught.

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.

I generally agree.

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.

I don't really agree with you, Rob. In my experience, if the drug does its job, then the dysrrhythmia resolves, and cardiac output improves.

Retrograde amnestic effects from versed are a wonderful thing.

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.

Not to be picky, but its not retrograde amnesia, its anterograde amnesia we're talking about. Retrograde means they forget what happened before you pushed the drug. Anterograde means they forget what happened after pushing the drug. (This is assuming you give the drug before the painful procedure.) People tend to speak of these terms incorrectly.

Give the midazolam. Even if it causes a bit more hypotension your about to fix it right?

I agree.

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

But doesn't he need to continue to perfuse in order to get to that point? In my opinion, anyone in sustained V tach is in danger of losing their perfusion to vital organs, which would make re-perfusing them a moot point.

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

But is his heart receiving ENOUGH blood? If he's in V tach, we know his ventricles likely aren't filling adequately, because by definition, his heart is depolarizing in a retrograde fashion, meaning he loses atrial kick. So if his coronary perfusion pressure is low, I would think his risk of going into V fib is significant.

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

Which is why I have the ability to pace.

Sometimes discretion is the better part of valor.

I have actually used that quote in treating patients (or not providing certain treatments). I just don't think it fits here. I think V tach needs to be treated. You can disagree, but that's my opinion.

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...?

Here's that difference between retrograde and anterograde. If the patient stabilized, I would consider giving it after if I hadn't first.

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

And amnesia.

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?

See study noted above.

I'm more ok with electricity than cardioversion.

Huh? Isn't cardioversion electricity?

When did Converting Vtach not become absolutely necessary whether it be chemically or electricity? I feel like I am missing something here.

I agree.

When the potential risk outweighs the potential benefits.

But what are the benefits to staying in V tach? It's not a rhythm that's generally considered compatible with life.

As was mentioned before, some people can remain in v-tach for hours.

But should they? Again, why wouldn't you want to get that to a better rhythm?

Can the average paramedic decide when the benefit outweighs the risk?

Sadly, I think this is one of the downfalls of our profession.

 

[Farmer2DO]

So, many good point brought up in this thread. Here are some thoughts:

The decision to shock vs. medicate with antiarrhythmics is based on stability. It's not just a BP issue; it goes to total perfusion, and you have to put it all together. BP, MAP, change in mental status, skin color, temperature and moisture, and the ability to palpate central and peripheral pulses all come into play. So does the relative health of the patient. The sicker the patient at baseline, the less likely they are to tolerate this rhythm. However, I still believe V tach needs to be terminated, no matter how you do it.

Amiodarone and lidocaine have been mentioned. Both have the ability to cause hypotension (certainly amiodarone more), but again, it's all relative. If the rhythm improves and cardiac output increases, isn't the patient better off? That being said, I think amiodarone is the better antiarrhythmic.

Anyone remember using bretylium tosylate?

The next question is about sedation prior to cardioversion. Again, depends on the situation. Did you come upon a patient found in V tach, who doesn't yet have IV access, who is in extremis? If so, light 'em up, and deal with the fallout. Or, do you have a patient that you were treating, who is on your monitor, who already has a line in place, and develops V tach in front of you? Here, it won't take long to give a little Versed if you decide to shock.

My $0.02.

 

[EMT John]

If you really feel the need to zap them "pain free", get that BP up anyway you can (Bilateral IV bolous, legs up, whatever you need to do) give them some MS and zap them. Done...

 

[Handsome Robb]

If you really feel the need to zap them "pain free", get that BP up anyway you can (Bilateral IV bolous, legs up, whatever you need to do) give them some MS and zap them. Done...

I feel like there are much better options in this situation than MS

Maybe I'm just a youngin' but we rarely use MS here. It's all fentanyl and versed. MS is only in ACS or abdominal pain from anecdotal experience and personal preference.

 

[EMT John]

Welcome to the wonderful state of California. All we get is MS, versed and Valium. I would love to have fentanyl. But no such luck.

No fun stuff for us.

 

[Handsome Robb]

Welcome to the wonderful state of California. All we get is MS, versed and Valium. I would love to have fentanyl. But no such luck.

No fun stuff for us.

Ah that sucks! Fent and versed is my favorite combination.

With those options I'd reach for the versed for the simple fact that I'm not that comfortable with valium (we don't carry it) and I don't see MS being a viable option.

Although you did say "pain free" and versed wont help with that.

 

[Handsome Robb]

So, many good point brought up in this thread. Here are some thoughts:

The decision to shock vs. medicate with antiarrhythmics is based on stability. It's not just a BP issue; it goes to total perfusion, and you have to put it all together. BP, MAP, change in mental status, skin color, temperature and moisture, and the ability to palpate central and peripheral pulses all come into play. So does the relative health of the patient. The sicker the patient at baseline, the less likely they are to tolerate this rhythm. However, I still believe V tach needs to be terminated, no matter how you do it.

Amiodarone and lidocaine have been mentioned. Both have the ability to cause hypotension (certainly amiodarone more), but again, it's all relative. If the rhythm improves and cardiac output increases, isn't the patient better off? That being said, I think amiodarone is the better antiarrhythmic.

Anyone remember using bretylium tosylate?

The next question is about sedation prior to cardioversion. Again, depends on the situation. Did you come upon a patient found in V tach, who doesn't yet have IV access, who is in extremis? If so, light 'em up, and deal with the fallout. Or, do you have a patient that you were treating, who is on your monitor, who already has a line in place, and develops V tach in front of you? Here, it won't take long to give a little Versed if you decide to shock.

My $0.02.

You bring up a good point with the cardiac output improving and I agree with it. Like I said my all my experience is anecdotal.

I love it when people point out things that I didn't really consider, it gets me thinking.

Last time I checked bretylium was used mostly around the time I was still in middle school so I unfortunately can't comment on that one

 

[systemet]

is the point I am making. With the way some medics and basics shove lead wires back in the bag, roll them tightly and just the general beating these pieces take it is very easy to look at the screen and see something that is not there.

I don't think this is that likely, especially if you're doing 12-leads. Certainly the cables can become damaged --- he early LP12s were notorious for this -- but this isn't going to make VT appear where there was no VT before.

I have seen medics bring PT's into an ER hooked up to a monitor with a rhythm and the ER physician ask how long the PT had been dead because someone forgot to check for a pulse.

This is just terrible, but speaks more to a basic lack of competence and an inability to perform a physical assessment. If someone doesn't understand what PEA is, and doesn't check vital signs on a patient, there are much bigger issues going on. Hopefully the crew in question has got chewed out and remediated.

I have also seen cases where electricity was applied because the monitor showed a shockable rhythm only to hear them say the PT was A&O before and dead after.

Not sure I understand --- are you talking about cardioverting a perfusing tachyarrhythmia into a pulseless rhythm? Because this is simply a risk of cardioversion, that's got to be considered when you're balancing the relative merits of drug therapy versus cardioversion versus doing nothing.

 

[Akulahawk]

Not to be picky, but its not retrograde amnesia, its anterograde amnesia we're talking about. Retrograde means they forget what happened before you pushed the drug. Anterograde means they forget what happened after pushing the drug. (This is assuming you give the drug before the painful procedure.) People tend to speak of these terms incorrectly.

Not to be picky, but I actually was speaking of retrograde amnesia. That's why I used the term. I'm fully aware of the fact that Versed produces anterograde amnesia. The retrograde amnesia effect is, at best, limited to moments immediately prior to administration. Beyond that the immediate period prior to administration, there will not be any amnesia effect. The amount of time that encompasses "immediately prior" is not well known. Is it two minutes? Five minutes? Thirty seconds? Knowing this, I would much rather premedicate someone about to undergo a painful procedure than depend on a much less reliable ability for Versed to produce retrograde amnesia. Of course, I'd also want to premedicate someone with a good pain med as well...

 

[NomadicMedic]

I wouldn't. Etomidate is OK for emergent airway situations, but when considered in the context of critical care medicine, it's a terrible drug.

http://www.biomedcentral.com/content/pdf/cc4979.pdf

"A single dose of etomidate is a major risk factor for the development of relative adrenal insufficiency for at least 24 hours after its administration" [Mohammad et al.]

Interesting that you base your argument against etomidate on a study done on compromised, septic patients, when all of the other material which studied etomidate vs Versed as a rapid one dose sedative for painful, one time events (such as cardioversion) showed no significant issues with that one time dose. Most studies showed etomidate as 'a safe, effective drug." The study you quoted showed that half of the PTs had adrenal insufficiency PRIOR to etomidate! And the conclusions of the study state, "Relative adrenal insufficiency is present in most patients with septic shock after the administration of etomidate. Caution is recommended when using etomidate in these patients."

I don't think that the small study you cited is enough to class etomidate as "a terrible drug".

Try these on.

http://www.sciencedirect.com/science/article/pii/S0196064403005109

http://www.theannals.com/content/38/7/1272.short

http://onlinelibrary.wiley.com/doi/10.1111/j.1553-2712.2001.tb00539.x/abstract

If I had to cardiovert a PT, who had a line up, was hemodynamicly unstable ... yet I felt required sedation prior to cardioversion, I would most likely chose etomidate over midazolam.

 

[crazycajun]

Didn't you just finish medic school not too long ago? I might be mixed up...but I don't think so.

I have been in EMS since 1985. I was a licensed medic from 1986 to 1998. I left EMS for 2 years to go into Health and Safety and came back in 2000. I stepped down to an I level cert in 1998 because it was easier to get the required IST hours. Because of my experience I remained an I for 11 years as I made the same amount of money with less headaches. I only decided to go back and renew my medic certs for reasons that would allow me to continue in the field until I decide to retire. I have trained EMT's and Medics for over 15 years.