Pacing question

[Sharktooth]

i had a call the other last night with my partner. 78 year old male who complained of weakness and dizziness. I took a BP and he was very hypotensive, a little diaphoretic and had a weak radial. My partner told me to apply O2 and put him on the monitor asap.

I did so and the pt had a slow heart rate in the 30's and BP was 68/42. My partner was working on an iv and told me to do a 12 lead.

I showed my partner the strip and his eyes were big as saucers. He said pt was having an MI and to do a 15 lead. I did the 15 lead and that didn't look good either. I rarely see that look of urgency in my partners face. We loaded up quick and got enroute due to being in a rural area.

En route pt was given aspirin and pacer pads were put on. My partner started giving him a lot of fluid to raise his BP. After about 25 min the pt coded. We had another rescue intercept and continued transport. Pt was pronounced at hospital.

Later after discussing the call I asked my partner if he paced the pt. he said no and didn't want to elaborate , I didn't poke for more as to why not but now I am curious if this would have helped. Any thoughts? I know acls says to pace but wasn't sure about the MI part.

 

[Burritomedic1127]

Can't speak to the why/why nots of your partners actions, but can only assume certain things. Sounds like the pt was having an inferior MI with right sided involvement. These MIs have more parasympathetic tone and are usually hypotensive (preload dependent). I've or the cath lab has had no problem when I've had to pace or push atropine on these pt's having a right sided MI

 

[BecomingaBetterEMT]

Does your partner have more knowledge then you. Is he/she a paramedic and your an EMT?

 

[gotbeerz001]

Does your partner have more knowledge then you. Is he/she a paramedic and your an EMT?

To inquire why a bradycardic and hypotensive pt wasn't paced is an appropriate question at any level. If there is a good reason, the conversation is over.

 

[NomadicMedic]

It seems as though there's a lot of paramedics who are very shy to use electricity. They don't like to pace, they're scared to cardiovert… The only time the pads come out is when it's a shockable rhythm during an arrest.

I'm not sure where this mindset came from, but I've noticed it a lot.

 

[BecomingaBetterEMT]

I was just curious because the post was written as if their partner was making all the major decision instead of working together as a team.

 

[NomadicMedic]

I was just curious because the post was written as if their partner was making all the major decision instead of working together as a team.

It reads as though the OP is an EMT and was curios why his paramedic partner didn't pace the PT. If this is indeed the case, the paramedic partner IS responsible for ALL of the patient care decisions.

As in most cases of EMTs asking "why didn't my paramedic partner do so and so?" We don't have anywhere near enough detail to even hazard a guess as to why certain interventions happened or didn't happen.

 

[LACoGurneyjockey]

i had a call the other last night with my partner. 78 year old male who complained of weakness and dizziness. I took a BP and he was very hypotensive, a little diaphoretic and had a weak radial. My partner told me to apply O2 and put him on the monitor asap.

I did so and the pt had a slow heart rate in the 30's and BP was 68/42. My partner was working on an iv and told me to do a 12 lead.

I showed my partner the strip and his eyes were big as saucers. He said pt was having an MI and to do a 15 lead. I did the 15 lead and that didn't look good either. I rarely see that look of urgency in my partners face. We loaded up quick and got enroute due to being in a rural area.

En route pt was given aspirin and pacer pads were put on. My partner started giving him a lot of fluid to raise his BP. After about 25 min the pt coded. We had another rescue intercept and continued transport. Pt was pronounced at hospital.

Later after discussing the call I asked my partner if he paced the pt. he said no and didn't want to elaborate , I didn't poke for more as to why not but now I am curious if this would have helped. Any thoughts? I know acls says to pace but wasn't sure about the MI part.

HR in the 30s and a pressure in the 60s not improved with a fluid bolus. Sounds like a perfect indication to pace. I can't really say what if anything was done wrong, I wasn't there and there's always more to a story, but I can't see any reason not to pace based on the info you've provided.

 

[samiam]

You dont have a rhythm strip do you?

 

[cruiseforever]

Can't speak to the why/why nots of your partners actions, but can only assume certain things. Sounds like the pt was having an inferior MI with right sided involvement. These MIs have more parasympathetic tone and are usually hypotensive (preload dependent). I've or the cath lab has had no problem when I've had to pace or push atropine on these pt's having a right sided MI

Is not Atropine contraindicated with some one having a MI? Or is just service dependent?

 

[DesertMedic66]

Is not Atropine contraindicated with some one having a MI? Or is just service dependent?

AHA still lists it as "use with caution" in patients having an MI.

 

[hogwiley]

So basically the issue is whether or not your partner saw something on the 12 lead that made him reluctant to pace? The patient was an unstable bradycardic patient, so he probably should have been paced. I cant think of any contraindications to pacing youd see on a 12 lead in that situation. Being paced can be an unpleasant feeling bordering on painful ive been told, so maybe your partner was worried about putting an AMI patient in more pain or having to sedate someone who is seriously hypotensive, BUT if you successfully pace them, the hypotension should improve. So maybe have something ready to give for sedation, see how they tolerate the pacing and if it improves their BP and go from there. Anyway were acting like Monday morning QBs though.

 

[triemal04]

There is going to be very little if anything on a 12-lead that would be a contraindication for pacing this patient. Even with someone having a MI, they are profoundly bradycardic and hypotensive, either due to the rate or ineffective contractions of the heart; the problem needs to be fixed.

If you increase the rate with pacing or with meds (epi drip), yes the myocardial oxygen demand goes up, though less with pacing. Is that bad with someone having an MI? Yes. But which is worse? Extra damage, or a high potential for being...dead?

This guy should have had his rate increased by one method or another. Hopefully the fact that your partner wouldn't talk to you afterwards means that he is very aware that he screwed up and is not happy about that.

It'll depend on your departments QA/QI process, but don't be shocked if this get's reviewed.

 

[zzyzx]

I wonder if he tried to pace but failed to get it to work. This is very common. Do you guys have dopamine or epi drips? Atropine would also have been an option if the bradycardia was a sinus rhythm.

 

[Burritomedic1127]

Is not Atropine contraindicated with some one having a MI? Or is just service dependent?

Not really. You need to help this patient have some pressure and some heart rate to work with. This is a damned if you do, damned if you don't type of deal we see in EMS. And if you're not sure, call med control real quick.

I wonder if he tried to pace but failed to get it to work. This is very common. Do you guys have dopamine or epi drips? Atropine would also have been an option if the bradycardia was a sinus rhythm.

We have both drips mentioned. If atropine/pacing don't work, we'll go straight to an Epi or Dopamine drip. In this scenario, we would go Dopamine as first choice to choose and adjust the effects of the medicine VS the sledgehammer that is epi. Real bad allergic reactions and septic shock refractory to fluid boluses get the Epi infusion.

 

[Nova1300]

Given the sparse information, it's tough to make an informed judgement about your partner's actions.

In this scenario, assuming the patient is in severe cardiogenic shock, I personally would have made an attempt at pacing. It may increase blood flow to the coronary arteries by increasing the cardiac output and give you a shot at better perfusion.

If it was a 3rd degree heart block from knocking out the AV node, the left ventricle may remain well perfused and have adequate function to sustain cardiac output if paced at a higher rate.

However, this was likely a rhythm I like to call the ventricular "death march." When you completely occlude a major left-sided coronary, a large chunk of the left heart gets poor perfusion, the ventricle fails, and cardiogenic chock ensues. As you would expect, that devastating ischemia plays out dynamically on the ekg, progressing to big, wide, polymorphic yuck. Its morose, but absolutely fascinating to watch the ekg as the heart acutely fails. I'm wondering if that was what you were seeing.

in my own experience, these patients may briefly respond to pacing or inotropes. They are difficult to capture transcutaneously because they are a acidotic from malperfusion, their electrolytes quickly become abnormal, and the electrochemical gradient of the heart is altered. If you get capture, it usually doesn't last long and was unlikely to change the inevitable cardiac arrest

As a general rule, patients this old and this sick do not leave the hospital intact despite any and all prehospital or ED efforts, including hemodynamic stabilization.

I'm curious what others would do. Assuming this was straight-forward cardiogenic shock from a huge MI. Would you try to pace? Would you jump straight to inotropes? Or atropine (which I personally would avoid altogether)? Would a rhythm diagnosis change your management (3rd degree hb vs. big, ugly Brady idioventricular kind of rhythm)?

 

[CANMAN]

Given the sparse information, it's tough to make an informed judgement about your partner's actions.

In this scenario, assuming the patient is in severe cardiogenic shock, I personally would have made an attempt at pacing. It may increase blood flow to the coronary arteries by increasing the cardiac output and give you a shot at better perfusion.

If it was a 3rd degree heart block from knocking out the AV node, the left ventricle may remain well perfused and have adequate function to sustain cardiac output if paced at a higher rate.

However, this was likely a rhythm I like to call the ventricular "death march." When you completely occlude a major left-sided coronary, a large chunk of the left heart gets poor perfusion, the ventricle fails, and cardiogenic chock ensues. As you would expect, that devastating ischemia plays out dynamically on the ekg, progressing to big, wide, polymorphic yuck. Its morose, but absolutely fascinating to watch the ekg as the heart acutely fails. I'm wondering if that was what you were seeing.

in my own experience, these patients may briefly respond to pacing or inotropes. They are difficult to capture transcutaneously because they are a acidotic from malperfusion, their electrolytes quickly become abnormal, and the electrochemical gradient of the heart is altered. If you get capture, it usually doesn't last long and was unlikely to change the inevitable cardiac arrest

As a general rule, patients this old and this sick do not leave the hospital intact despite any and all prehospital or ED efforts, including hemodynamic stabilization.

I'm curious what others would do. Assuming this was straight-forward cardiogenic shock from a huge MI. Would you try to pace? Would you jump straight to inotropes? Or atropine (which I personally would avoid altogether)? Would a rhythm diagnosis change your management (3rd degree hb vs. big, ugly Brady idioventricular kind of rhythm)?

Like you said pre-hospital this guy is kinda screwed with the massive evolving MI that is on-going.... The OP said they were in a rural area, I would have considered air-medical transfer to a STEMI center as soon as possible if that was an option.

As far as treatment I agree Nova given the likely acidosis and cardiac failure this patient could be extremely challenging to manage and is likely to have a poor outcome. With that being said though I would have attempted pacing immediately, small 250ml fluid bolus and obtain a venous lactate level, and be prepared for rapid/aggressive management with Levophed, Dobutamine, and Epi infusions in that order, and consider Vasopressin as an adjunct due to the acidosis. I would not give Atropine personally in this setting. Also a hefty amount of diesel fuel is in order for this soul....

 

[zzyzx]

Why no atropine? Its the easiest thing you can do.

 

[CANMAN]

Why no atropine? Its the easiest thing you can do.

We know that anything we do for this patient is going to increase myocardial oxygen demand as already stated. In my opinion, given this scenario, there is no guarantee that Atropine is going to fix your hypotension by increasing the rate, but we do know it's absolutely going to increase the rate. With that being said I don't have any control once the dosage of Atropine is given. I would rather start something I know is going to fix the hypotension, and is something I can titrate, therefore I can dial in just enough to fix the hypotension, and likely keep the heart rate relatively under control, especially over a longer transport time. Slamming home 0.5 of Atropine might be the easiest thing to do, however attempting to pace the patient, or if that fails mixing a quick drip will not take much more time.

 

[cprted]

Why no atropine? Its the easiest thing you can do.

It's difficult to titrate or D/C atropine if the patient reacts poorly.