47 y/o female syncopal episode

[Dwindlin]

If I had access (and good rate control drug) I would go that route. As in this scenario I have neither with a roughly 20min transport (for me) I would go ahead with a couple mg of IN versed and light her up.

 

[Handsome Robb]

In regards to her BP I would have also been checking skin temp. If her hands and feet are cold I would most certainly believe that bp. I don't care how good you are a 12 lead takes longer then 30 seconds. And I am still a firm believer and preacher to my paramedic students that time = muscle.

Is 30 seconds to a minute going to make that big of a difference? I doubt it. As a medic student, not even a full medic I can still place and acquire a 12 lead in about 1 minute.

 

[DrankTheKoolaid]

re

Normal ground transport times for me are usually greater then 45 minutes to the local podunk ED and can be up to 2.5h to the closest cardiac/trauma center. And for the next 7 months air support is spotty at best with winter setting in here. I would rather cardiovert and stabilize then transfer. Instead of being on a mountain peak with no help when she decides to really become unstable aka dead........

 

[usalsfyre]

Not trying to state the obvious but I think a fairly good indication cardioversion wasn't indicated is that she didn't code enroute and the ED didn't elect to perform one...

 

[Dwindlin]

And electricity destroys muscle as well....

It takes my partner consitently less than a minute to apply a 12 lead, but we run a lot of them.

The B/P is something your uncomfortable with. The fact is she sounds as though she's perfusing somewhat decently.

http://heart.bmj.com/content/80/3/226.abstract

Decent article about the effects of cardioversion on cardiac muscle.

 

[usalsfyre]

http://heart.bmj.com/content/80/3/226.abstract

Decent article about the effects of cardioversion on cardiac muscle.

Interesting, very small sample size but I had been misinformed it always damaged the myocardium. Thanks for the article.

 

[DrankTheKoolaid]

re

True, thankfully she did well. This is the best part about the scenerio forum.. all the differant view points. For the record we still carry Verapamil and the thought of giving CA and Verapamil again scares the hell out of me. Verapamil I don't mind and have used it often with great results, but pretreating the hypotensive patients with Ca again scares the hell out of me.


Yay for cardizem finally up for consideration in California!

 

[Handsome Robb]

I still don't see how cardioversion is indicated here. She is relatively symptomatic with the shoulder/scapular pain as well as hypotension however her mentation still remained intact and showed no trend towards losing her mentation. like usals said BP is just a number. The other point that was overlooked, was the BP automated or manual? I'm not going to trust an automated BP with that SBP.

Someone said check her skin, are her extremities warm? If so the pressure is more than likely higher than the number shows, especially with her mental status.

Maybe I'm influenced by my short transport times <15 minutes to a Level II or cardiac capable hospital.

 

[rhan101277]

I forgot to mention that the rate varied from 110 up to 160. When the rate would drop to 110 the pressure would come up some. I hesitated cardioverting her due to her history, I could have called med control for some second opinion. Our protocols state that rates below 150 rarely need cardioverting and the rate would be constantly changing which is understandable for RVR.

The ER did not cardiovert either

 

[rhan101277]

Even without a rate control drug I'd be hesitant to cardiovert. As far as B/P goes, it's just a number . If she's alert and talking, she's perfusing.

So who here would have provided this lady sedation prior to therapeutic electrocution?

This is exactly why I didn't cardiovert, everything isn't always textbook and I would continue to talk to her and she would be completely alert. If at any point she became unresponsive or had altered mental status, I would have converted.

 

[DrankTheKoolaid]

I forgot to mention that the rate varied from 110 up to 160. When the rate would drop to 110 the pressure would come up some. I hesitated cardioverting her due to her history, I could have called med control for some second opinion. Our protocols state that rates below 150 rarely need cardioverting and the rate would be constantly changing which is understandable for RVR.

The ER did not cardiovert either

That is a totally different story. variable Afib rate VS sustained RVR

 

[rhan101277]

We do have cardizem on board, if I could have gotten a line established I would have called but I really doubt they would order it without looking at the patient since she was so hypotensive. Cardizem is contraindicated in severely hypotensive patients and in the absence of all the ER services I don't have in the back of my truck it would be concerning.

Something else to think about is this woman may run with pressures around 100 systolic and her body is used to operating this way.

 

[Dwindlin]

That is a totally different story. variable Afib rate VS sustained RVR

Aye. That little tidbit changes things quite a bit

 

[boingo]

I doubt I would cardiovert, a judicious fluid bolus, a little Fentanyl IN for pain management and and EJ or IO for access. An AF at that rate isn't that much of a concern and seems an unlikely cause for her hypotension in and of itself. Rate control with Cardizem after some fluid might be appropriate.