Unsedated Cardioversion

[Burritomedic1127]

I must have missed something...was that a rhetorical question?

I think part of the problem that comes up whenever this debate comes back is that people have very, VERY different definitions and understanding of what a "critical" or "unstable" patient really is.

Agree completely with different definitions of stable VS unstable. The question about the IO was in regards to "abandoning good care because of the pain" post earlier. Cardiac arrest/unresponsive sure IO with no lidocaine but a pt who is conscious and for whatever reason needed an IO, IMO, should get a local anesthetic. I'm required to give a min of 20mg and up to 40mg of lidocaine with a conscious IO. Wouldnt slam a flush home and watch them go through more pain for the garbage line of "this is saving your life."

 

[Burritomedic1127]

Cuz pushing fluid though the bone ****ing hurts...

Truth

 

[triemal04]

Agree completely with different definitions of stable VS unstable. The question about the IO was in regards to "abandoning good care because of the pain" post earlier. Cardiac arrest/unresponsive sure IO with no lidocaine but a pt who is conscious and for whatever reason needed an IO, IMO, should get a local anesthetic. I'm required to give a min of 20mg and up to 40mg of lidocaine with a conscious IO. Wouldnt slam a flush home and watch them go through more pain for the garbage line of "this is saving your life."

Ok, figured that was it, just making sure.

 

[TheLocalMedic]

Alright, so I'll throw this one out there for the crowd to chew on...

I had a guy the other day that we found laying on the ground, gasping with crushing chest pain, saying that he was having a heart attack. He was in rapid a-fib at a rate around 200, no radial and a pressure at 80 systolic. No history of a-fib, he was a little obtunded (not terrible, knew where he was and could follow commands, but thought the year was 1990-something, age was 60 something, no dementia). I tried for IV access twice, but no luck, and his presentation started to look even more dramatic.

So I lit him up. 200J sync cardioversion without sedation. I told him it would hurt and he basically gave me the thumbs up to just get it over with, and got the expected "MOTHER F*&#$!!!" response when I hit him. He converted, symptoms disappear, rate is a nice, stable 80 sinus rhythm and 12 lead looks pretty clean.

Was it the most fun experience of his life? No. Did it work? Yes. Afterwards he was feeling so relieved he tried to hug me.

To me that seemed like a pretty clear-cut case of an unstable patient, and I wasn't about to screw around with more IV attempts to try and get some Versed on board before zapping him. However, after reading this thread I'm willing to bet that there are some people out there who disagree, and I'm curious to hear what your thoughts are.

 

[Carlos Danger]

To me that seemed like a pretty clear-cut case of an unstable patient, and I wasn't about to screw around with more IV attempts to try and get some Versed on board before zapping him.

I agree, seems pretty clear cut to me. I don't know for sure that I would have even taken the time to attempt an IV. Even if I had an IV I don't think I would have given him anything.

 

[NomadicMedic]

I would have just lit him up. Maybe not with 200j, but certainly some electricity.

Cardiovert first, apologize later.

 

[Burritomedic1127]

Alright, so I'll throw this one out there for the crowd to chew on...

I had a guy the other day that we found laying on the ground, gasping with crushing chest pain, saying that he was having a heart attack. He was in rapid a-fib at a rate around 200, no radial and a pressure at 80 systolic. No history of a-fib, he was a little obtunded (not terrible, knew where he was and could follow commands, but thought the year was 1990-something, age was 60 something, no dementia). I tried for IV access twice, but no luck, and his presentation started to look even more dramatic.

So I lit him up. 200J sync cardioversion without sedation. I told him it would hurt and he basically gave me the thumbs up to just get it over with, and got the expected "MOTHER F*&#$!!!" response when I hit him. He converted, symptoms disappear, rate is a nice, stable 80 sinus rhythm and 12 lead looks pretty clean.

Was it the most fun experience of his life? No. Did it work? Yes. Afterwards he was feeling so relieved he tried to hug me.

To me that seemed like a pretty clear-cut case of an unstable patient, and I wasn't about to screw around with more IV attempts to try and get some Versed on board before zapping him. However, after reading this thread I'm willing to bet that there are some people out there who disagree, and I'm curious to hear what your thoughts are.

Would have done the same. Nothing wrong with that. From the picture you painted it sounded like he was decompensating pretty quick

 

[samiam]

This is quite interesting where this has all gone. From a personal experience, I am not exactly sure what I would rather have. I have had a nice 2 hour run of A-Fib with actual QRS's getting thru at about 203bpm and god knows how many P waves there were. I got the pleasure of adenosine x3 and then a nice cardioversion. I feel like I would still go for the adenosine first than the cardioversion assuming it was unsedated. Mine was with propofol and versed so I was fine but I feel like it would have not been pleasant had it not been. Then again adenosine is really not the most pleasant experience feeling like you are about to slip away and die x3.

It definitely seems like the stability of the patient is key here. If they are walking and talking then please give them some propofol!

 

[NomadicMedic]

...of course the stability of patient is what you take into consideration. That's what what this whole discussion has been about.

unstable patients get electricity.

stable patients get sedation... Than electricity

 

[MonkeyArrow]

Had a case today in the ED of a man with previous cardiac Hx and an ICD with Vtach in the 120s. CC was chest pain and palpitations. He was talking and perfusing well on 2 L 02 home oxygen, but still in Vtach. EMS crews who brought him in couldn't find a IV after sticking him multiple times. In essence, he didn't get any treatment en route. At our facility, he received 2 PIVs upon arrival. Shortly thereafter, he decompensated and his SpO2 stats dropped. Even though he suddenly went from being "stable" to "unstable", we still took the time to give him 100 of Fent and 20 of etomidate before cardioversion. He also was given successive 100 and 75 mg boluses of lidocaine by the EDP and cardiology, because the patient stated that it had worked for him before. The lido didn't work, and we moved onto cardioversion, successfully converting with 120 J. He went into a ventricular rhythm in the 55-65 bpm range, with a pressure somewhere over 70/50. Somewhere in there, we also pressure infused a liter of saline into him. Pt. survived to CCU admission, talking and breathing on his own. His pressure remained in the 70/50 range, and his SpO2 at 100% on nasal cannula.

Point of the story: I don't really know. Maybe it's that what really seems unstable to us really isn't all that abnormal. This guy states he had baseline vitals of 80/60, so his presenting BP wasn't that abnormally low. Sure, we delayed cardioversion by 3-4 minutes in an "unstable" patient, so what? Most of us out there in the field would have immediately though this patient is sure to die, this is not a perfusing rhythm. By the looks of it, it wasn't. But this pt. probably had this rhythm for the better part of two hours.

On a side note, I would also like to point out that this is another example of what a hospital can do for a patient that EMS cannot do out in the field. Push lidocaine for Vtach as a first line drug? Interrogate the ICD? (His ICD did not fire because the threshold was set higher than 120)

*Note, while I have been calling it Vtach, it is more technically wide-complex tachycardia. However, there were no p-waves or discernible QRS complexes. However, it was determined between the EDP and the cardiology doctors that this was ventricular in origin.

 

[NomadicMedic]

If a patient was able to articulate that Lidocaine had successfully converted his ventricular rhythm in the past, you could be damn sure I'd be on the phone with medical control requesting orders.

He would also have pads on his chest and the life pak would be in SYNC.

**That's one thing that paramedics can do pre hospital. I'd bet that the doc in the ED wasn't looking at lido as his first line drug either. But that expert consult from cardiology was a smart thing.

And would you still be grinning about how you waited those 3 or 4 minutes to give the PT etomidate and fent and then you couldn't convert him back to a sustainable rhythm?

Tl;dr? Cool story bro. Cardiovert unstable patients. Period.

**ps: O2 sats, not stats.

 

[Tigger]

Had a case today in the ED of a man with previous cardiac Hx and an ICD with Vtach in the 120s. CC was chest pain and palpitations. He was talking and perfusing well on 2 L 02 home oxygen, but still in Vtach. EMS crews who brought him in couldn't find a IV after sticking him multiple times. In essence, he didn't get any treatment en route. At our facility, he received 2 PIVs upon arrival. Shortly thereafter, he decompensated and his SpO2 stats dropped. Even though he suddenly went from being "stable" to "unstable", we still took the time to give him 100 of Fent and 20 of etomidate before cardioversion. He also was given successive 100 and 75 mg boluses of lidocaine by the EDP and cardiology, because the patient stated that it had worked for him before. The lido didn't work, and we moved onto cardioversion, successfully converting with 120 J. He went into a ventricular rhythm in the 55-65 bpm range, with a pressure somewhere over 70/50. Somewhere in there, we also pressure infused a liter of saline into him. Pt. survived to CCU admission, talking and breathing on his own. His pressure remained in the 70/50 range, and his SpO2 at 100% on nasal cannula.

Point of the story: I don't really know. Maybe it's that what really seems unstable to us really isn't all that abnormal. This guy states he had baseline vitals of 80/60, so his presenting BP wasn't that abnormally low. Sure, we delayed cardioversion by 3-4 minutes in an "unstable" patient, so what? Most of us out there in the field would have immediately though this patient is sure to die, this is not a perfusing rhythm. By the looks of it, it wasn't. But this pt. probably had this rhythm for the better part of two hours.

On a side note, I would also like to point out that this is another example of what a hospital can do for a patient that EMS cannot do out in the field. Push lidocaine for Vtach as a first line drug? Interrogate the ICD? (His ICD did not fire because the threshold was set higher than 120)

.

Shocking. The hospital is able to do things that EMS cannot do. Possibly because it is a hospital.

We get it.

 

[MonkeyArrow]

Shocking. The hospital is able to do things that EMS cannot do. Possibly because it is a hospital.

We get it.

Just waiting for the next transport-or-work-on-scene-arrest debate (well, it's only me against everyone else) that comes up, when everyone says, "The hospital can't do anything that I can do in the field."

 

[Nova1300]

Had a case today in the ED of a man with previous cardiac Hx and an ICD with Vtach in the 120s. CC was chest pain and palpitations. He was talking and perfusing well on 2 L 02 home oxygen, but still in Vtach. EMS crews who brought him in couldn't find a IV after sticking him multiple times. In essence, he didn't get any treatment en route. At our facility, he received 2 PIVs upon arrival. Shortly thereafter, he decompensated and his SpO2 stats dropped. Even though he suddenly went from being "stable" to "unstable", we still took the time to give him 100 of Fent and 20 of etomidate before cardioversion. He also was given successive 100 and 75 mg boluses of lidocaine by the EDP and cardiology, because the patient stated that it had worked for him before. The lido didn't work, and we moved onto cardioversion, successfully converting with 120 J. He went into a ventricular rhythm in the 55-65 bpm range, with a pressure somewhere over 70/50. Somewhere in there, we also pressure infused a liter of saline into him. Pt. survived to CCU admission, talking and breathing on his own. His pressure remained in the 70/50 range, and his SpO2 at 100% on nasal cannula.

Point of the story: I don't really know. Maybe it's that what really seems unstable to us really isn't all that abnormal. This guy states he had baseline vitals of 80/60, so his presenting BP wasn't that abnormally low. Sure, we delayed cardioversion by 3-4 minutes in an "unstable" patient, so what? Most of us out there in the field would have immediately though this patient is sure to die, this is not a perfusing rhythm. By the looks of it, it wasn't. But this pt. probably had this rhythm for the better part of two hours.

On a side note, I would also like to point out that this is another example of what a hospital can do for a patient that EMS cannot do out in the field. Push lidocaine for Vtach as a first line drug? Interrogate the ICD? (His ICD did not fire because the threshold was set higher than 120)

*Note, while I have been calling it Vtach, it is more technically wide-complex tachycardia. However, there were no p-waves or discernible QRS complexes. However, it was determined between the EDP and the cardiology doctors that this was ventricular in origin.

Holy lord that's a lot of drug for a cardioversion.

 

[PotatoMedic]

Not really. Kinda on the high end for fentynal but not that bad.

 

[Nova1300]

Not really. Kinda on the high end for fentynal but not that bad.

We may have to agree to disagree on this one. But it brings up a good point.

Do you guys really feel an opiate is appropriate for cardioversion? I will tell you, my answer is no.

 

[PotatoMedic]

At most I would give 25-50mcg's, usually I would only sedate but I could see pain medication being given since it does hurt.

And all I was thinking was dosage of medications. I can give up to 200mcg in trauma and 100mcg for medical. So again giving 100 for cardio version seems much but giving fentynal does not (to me) seem unreasonable.

 

[Carlos Danger]

Holy lord that's a lot of drug for a cardioversion.

My thoughts exactly.

 

[Nova1300]

I think it's reasonable to give them. The thought process and motivation for giving opiate is sound. But let me tell you why I think it is not terribly useful, though this is anecdotal :
First is the brevity of the stimulus. Although cardiversion is incredibly uncomfortable, it lasts a fraction of a second. There is no residual pain. But there is residual opiate now floating around. Which is fine in stable patients. But patients in extremis from their rhythm frequently have hypoxia and hypercarbia. And an opiate with no painful stimulus to treat becomes nothing more than a respiratory depressant, not something you want in a patient already hypoxic or hypercarbic.

Secondly, and this is the part that is completely anecdotal, I think opiates are far more effective in some types of pain than others. In general I have found that opiates are useful in pain caused by a constant stimulus, usually achy and dull. I do not find opiates treat a sharp or sudden painful stimulus well. And though I can't think of a word to describe the discomfort of cardiversion, I would relate it closely with sharp.

I think effective sedation for cardioversion comes in two flavors: make them briefly unconscious or make them forget it happened. And that involves small doses of an induction agent or an amnestic. Fentanyl is neither of those things. That, combined with the potential respiratory effects of residual opiate in a patient with no pain to treat and the very real potential for deterioration is enough to keep opiates out of my arsenal for cardioversion.

 

[Brandon O]

You're worried about duration of effect even for fent?