Unsedated Cardioversion

[samiam]

So excuse my ignorance but I am currently watching night watch on a and e and they had a elderly gentleman conscious with tachycardia 160 to 200. They tried adenosine twice then looked at the guy and said well gonna have to hit you with some energy. Shocked him with 50 then 100 joules perfectly alert no sedation no pain meds no nothing. Is this normal? The guy kinda freaks out and screams from the pain.

 

[jcroteau]

Was he unstable? If so, cardio version would be more important than the pain

 

[captaindepth]

Its kind of hard to answer without a more complete clinical picture but there are certainly times when synchronized cardioversion is indicated without sedation/pain management. If the pt is in a rhythm where electrical cardioversion is indicated and is hypotensive (deteriorating mentation) than immediate cardioversion is indicated without sedation. If the pt is not hypotensive then a benzodiazepine can be given prior to the shock. I've been told that giving Versed post cardioversion does have some amnestic effects and the pt wont remember what it feels like to be hit in the chest with 100J.

If the guy is perfectly alert and screaming from the pain, I'm guessing his pressure was ok enough to give Versed prior to the shock. Did they try any vagal maneuvers first before the Adenosine?

 

[gotbeerz001]

We had a guy at 220, alert and anxious but hypotensive so we cardioverted him without any sedation. He certainly felt pain but instantly converted to a rate of 80. He was very thankful. He wanted to AMA... We said no.

 

[chaz90]

I've had to cardiovert without sedation before...Hypotensive, declining mental status, and no IV access. Yup, time for some Edison Medicine.

For procedural sedation like this when IV access is already available we administer 0.1 mg/kg of Etomidate. I'd be more than happy to use some ketamine for it too if we carried it.

 

[Chewy20]

Watched that too, and yes people are cardioverted without pain meds. Turns out in the show the guy was septic, so that was an uh oh trying to cardiovert him. Fluid bolus would have been more appropriate.

 

[Chewy20]

Its kind of hard to answer without a more complete clinical picture but there are certainly times when synchronized cardioversion is indicated without sedation/pain management. If the pt is in a rhythm where electrical cardioversion is indicated and is hypotensive (deteriorating mentation) than immediate cardioversion is indicated without sedation. If the pt is not hypotensive then a benzodiazepine can be given prior to the shock. I've been told that giving Versed post cardioversion does have some amnestic effects and the pt wont remember what it feels like to be hit in the chest with 100J.

If the guy is perfectly alert and screaming from the pain, I'm guessing his pressure was ok enough to give Versed prior to the shock. Did they try any vagal maneuvers first before the Adenosine?

Forget what the BP was or if they even said, did not see anything besides them giving adenosine then the attempted cardioversion. It's a tv show, so who knows what was cut out.

 

[Nova1300]

I've had to cardiovert without sedation before...Hypotensive, declining mental status, and no IV access. Yup, time for some Edison Medicine.

For procedural sedation like this when IV access is already available we administer 0.1 mg/kg of Etomidate. I'd be more than happy to use some ketamine for it too if we carried it.

I'm stealing this gem!!

 

[chaz90]

I'm stealing this gem!!

Please do I certainly can't take creative credit for it anyway.

 

[Carlos Danger]

I did a handful of cardioversions when I was doing ground EMS and I never used any type of sedation, because it wasn't even an option in our protocols. Frankly, in an emergent setting I don't think it's a big deal at all; the shock is certainly uncomfortable but it is extremely brief. You can always give analgesia afterwards if they are in pain, though I don't think I've ever had to. I don't think amnesia is a big priority at all either.

In the hospital, elective cardioversions are done with any drug or combination of drugs. Propofol and versed seem most common, but etomidate, ketamine, and opioid are used by some anesthesia providers, as well.

 

[DrankTheKoolaid]

Same, have performed a dozen or so cardioversions and have only sedated 1. If they were stable enough for sedation then I would use Verepamil which worked in all but 1 patient. By that point he did become unstable and was to hypotensive to use sedation.

 

[Burritomedic1127]

Usually when cardioverting the pt is circling the drain, and the pressure is too low/unstable to sedate. I have sedated pts before but it doesnt happen everytime and its very pt/pressure dependent. For whatever reasons from the EMS gods, i constantly see hypotensive rapid afib pts that need to be cardioverted. Which brings me to this, would you ever not cardiovert a patient in rapid afib knowing that they have never been med complaint with their Coumadin/blood thinner? Only had one MD, who gave waves because I cardioverted the homeless non med complaint patient

 

[jcroteau]

Any chronic afib patient we need orders to cardio vert up here.

 

[NomadicMedic]

Cardioverted several people without sedation. Funny thing, it didn't bother me one bit. I didn't even feel it.

 

[NomadicMedic]

Good video to watch, if you've never actually seen a cardioversion.

 

[NomadicMedic]

And here's an unsedated cardioversion, looks like they just got a little bit of midaz on board…

 

[Burritomedic1127]

First rule of EMS, don't talk about EMS. Jinxed myself talking about cardioversions. Grandma had a SVT in the 200s

 

[NomadicMedic]

...And I just watched that episode of nightwatch where they juiced the dude in SVT.

"Turns out he was septic..."

Opps. Sorry about those shocks.

 

[Shishkabob]

So excuse my ignorance but I am currently watching night watch on a and e and they had a elderly gentleman conscious with tachycardia 160 to 200. They tried adenosine twice then looked at the guy and said well gonna have to hit you with some energy. Shocked him with 50 then 100 joules perfectly alert no sedation no pain meds no nothing. Is this normal? The guy kinda freaks out and screams from the pain.

First, who said he was unsedated? A crap-ton gets edited out to fit within the time slot, thus he very well may have gotten Ativan or Versed prior to the cardioversion.

Second, I don't have NOEMS protocols available, thus I don't know if they even have sedation, let alone what the blood pressure cut-off may or may not be for them. Maybe they have sedation but protocols prohibited its use in that period. Maybe when he spoke to the physician on the radio he wanted to hold back the sedation. Etc etc etc.

...And I just watched that episode of nightwatch where they juiced the dude in SVT.

"Turns out he was septic..."

Opps. Sorry about those shocks.

I've given Adenosine to, and the hospital cardioverted several times, a lady who was tachy solely from dehydration from NV and diarrhea for a few days. She was altered, hypotensive, 190s-200s, no fever, and minimal hx from family. Our bad. Live and learn. As my medical director said during the QA process, "It's called practicing medicine for a reason."

 

[NYBLS]

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.