AZCEP

Yes, a 12 lead would be of benefit in this case but only after the rate is controlled to be able to see what type of atrial activity is present. A wide complex tachycardia with a rate greater than 300 needs to be considered to be due to an accessory pathway. You will notice that no strip was produced of any lead, and I would still consider this to be due to an accessory pathway. If learning is the intent, and not to deliver a war story that will detract from the original discussion, then by all means. EMS49393's case would be a good one for it's own thread. Placing it in amongst the discussion of a wide complex tachycardia of unknown origin would detract from the clarity needed for both cases.

I said that introducing a second scenario into this discussion would be counterproductive because it would confuse the issue of managing this particular situation. It does make for a good topic, but should be placed in a thread dedicated to it rather than added on to one that is unique to itself. As for the case at hand, because of the AV node's function of slowing conduction between the atria and the ventricles an accessory pathway would almost have to be in effect to get a rate this fast. More importantly than specifically identifying the accessory pathway would be considering that it might be in action when you see this type of rhythm. If we consider that the atria can fibrillate up to 700 times per minute, or flutter at 300+ per minute it becomes very apparent that there is something amiss with the physiologic brakes that the AV node provide.

In the very first post, zzyzx noted that the rhythm was a "wide complex tachycardia". There are a good number of wide complex tachycardias that do not originate from the ventricles. No where did I say anything about this being ventricular tachycardia. I was not being "snotty". I was calling your attention to the fact that this scenario had already had bypassed the direction you thought it was going. If you want to post your scenario and ECGs then feel free to start another thread. Adding them to this discussion may well be counterproductive.

What exactly does this have to do with the scenario presented? Nowhere is this situation discussing a narrow-complex tachycardia.

Where did you get that bit of information? You shouldn't go back to that source ever again. http://medical-dictionary.thefreedictionary.com/sublingual Sublingual is below/beneath the tongue. Buccal is between the gums and the cheek. Oral is the space on the superior side of the tongue up to the hard palate. Oral administration does not imply the substance is swallowed. That would be PO, or para-oral.

Ahhhhh, now I see the confusion. The manufacturer is suggesting that for a re-entrant pathway tachycardia, adenosine is acceptable to use. Because WPW can be a reentrant mechanism, it would be reasonable to use. Without speaking for them directly, I would guess that they are referencing the possibility of other accessory pathway dependent rhythms that may not have a wide QRS complex associated. WPW does not always widen the QRS complex, nor does LGL for example. In the event you decided to use adenosine the rhythm could convert to VF, which you would promptly defibrillate. This may not be the worst course of action, but if given the opportunity would you want to do this to a patient that isn't showing specific tachycardia related signs? My thought is if treatment is needed for this situation use some sedation/analgesia, and cardiovert. Because the information provided presents a relatively stable patient, I'd be inclined to wait for more controlled circumstances. ...or at least let someone else screw it up :wink:

Hopefully, you've had a chance to go back and reread the scenario that zzyxx presented to see where the misinterpretation came from. Epinephrine has been the vasopressor of choice for the last 30+ years. It's clinical effectiveness has been under investigation for at least the last ten. Other agents are poised to take it's place. Epinephrine has never been used with the sole intent of "stimulating the heart". It's role in ECC has always been to provide peripheral vasoconstriction, and central vasodilation to allow for the "shunting" effect that we want. If you are teaching paramedic students, then you should already know that amiodarone is an antidysrhythmic. Your statement is akin to saying that because you use lidocaine after epinephrine, it too will stimulate the heart. Clearly, this is a misrepresentation of the drugs mechanism of action. http://www.rxlist.com/cgi/generic/cordarone_iv.htm There is a drug profile from Rx List.com. It should help you to fill in the gaps to better understand how amiodarone (Cordarone) is used.

When it was first introduced, it was quite pricey but the cost has come down significantly. Especially when you consider that it can replace several medications cost should not be the determining factor in having it or not. Please tell me that your instructor did not tell you this. This is a complete fabrication. Patients need to be on the anti-dysrhythmic that is effective for the situation they find themselves in. Amiodarone, due to it's wide range of indications, is extremely useful to have available. Patients will remain on it until something better becomes available. Typically this means admission for ICD placement. You really need to look this information up as there is valuable insight to be gained from knowing it. If your instructor hasn't already guided you in this direction, it would be a good idea for you to show some initiative on your own to find out.

That is a common misconception that people like to throw around when they want to do something other than think the situation through. We are not judging this patient by the possibility/probability of deterioration of this rhythm. A good many patients will remain in an otherwise significant tachycardia for days/weeks with no issues. Based on the information given in the scenario, he is not unstable. Being diaphoretic following a jog does not absolutely correlate with sympathetic discharge due to his heart rate. Either direction you decide to look at this from, you can be justified in thinking it. devildoc0908, This dysrhythmia is one that you should not do anything that will affect the AV nodal conduction. Even without seeing the rhythm, you should be able to determine what is happening based solely on the rate. This is the one time that it tells you enough to base a decision on. A vagal maneuver, or adenosine will slow conduction through the AV node and precipitate VF in this patient. Beside the fact that neither are indicated for a "wide-complex tachycardia", why would you want to use either of them? Amiodarone does not cause the heart rate to increase as Scaramedic noted. I hope you got your wires crossed and were thinking of something else. Amiodarone may take a while to show the effect you are after, but it will not speed the heart rate up. Even if it was possible to do so, this heart is going as fast as it is able to. Short of overdrive pacing, if you could get it that fast, you are not going to make it go any faster.

What other education do you have already? If you've taken an EMT class, and think that the paramedic will be anything like it you are sorely mistaken. Unfortunately, an EMT class is often the only program that many paramedic candidates have to compare things to. If I follow the timeline you propose here, it looks like this is a college based program, right? This is a good thing, if it is, not so much if it's not. It will be more intense than any EMT class you've ever taken. It will be slightly less so than most other college level classes. Since you already have A&P I/II in hand, you should be well ahead of the curve. That all depends on the scheduling of the program. If you have Mon/Wed classes, you will probably get a few of the Mondays off for observed holidays and such. There is probably a Christmas break/spring break built into the schedule as well. You may not be sitting in class, but you will probably need to be doing clinical rotations during these "breaks". See above. The DOT requires 1000 clock hours for a reason. You can't get the education you need by cutting corners. You will have to work at this, and your patients deserve no less. It is not uncommon to have 18-20 out of 24 maximum pass the class. This number doesn't tell you anything about how many are actually good paramedics when they get done however. I'd say that of the 72 students I've had, roughly 50 completed the program and 40 passed NREMT testing. Of the 40, I'd allow 15 of them to work on my family. This is not to say the others aren't capable, just that some of the character issues that I noticed during class would receive a swift boot out my front door if they ever appeared in my house. You have to have the full support of whomever is in your life prior to starting the program. Unlike some things in life, once you begin class the amount of work will quickly multiply to the point you will have little time/energy for anything else. DO NOT get married prior to class. DO NOT find a new girlfriend/boyfriend either. They will not understand why you can't spend time with them. Easily, 40% of my students have had some kind of life crisis during their time in my program. Several divorces, breakups, and even a few suicide attempts. Some just aren't cut out to do this type of work. Since you've completed the prerequisites, take the time to back over your anatomy and physiology. Know this information frontwards/backwards/inside out/upside down. When others in your class are having trouble understanding a concept, you will be able to fall back to this foundation. Good luck to you.

You've answered your question in a round about sort of way, and it is encouraging that you are thinking the situation through. If you can determine with certainty that the rhythm is caused by a re-entrant mechanism, Adenosine will work just fine. With the rate discussed, there is no possible way that re-entry alone is causing it. The physiologic slowing the AV node renders won't allow it. In this case there has to be an accessory pathway involved. Jumping to treatment in the face of a stable patient can be tempered with some time. Cardioversion would be the treatment of choice, if you can accurately determine how long this patient has experienced this dysrythmia.

No we should not suspect WPW. We should KNOW that this is WPW with a rapid ventricular response, and it cannot be anything else. The rate tells us this. Adenosine works by blocking the AV node. Doing this to an accessory pathway tachycardia is a good way to cause cardiovascular collapse. The benefit is the short duration of the drug. The down side is, well, you might not be able to get them back.

This patient is "symptomatic", they are not unstable to this point anyway. Stable/unstable vs. symptomatic/asymptomatic is of importance when deciding how aggressively to treat the patient in front of you. With this patient's symptoms, I'd elect to place the hands free pads, and monitor closely for changes.

I did not say "sinus tach". I said stable tachycardia, of which this is. This patient is asymptomatic, save for the diaphoresis. You have time to evaluate the rhythm to find the best treatment for it. Due to the rate, there is only one possibility. This patient does not need cardioversion, nor any of the commonly available prehospital medications. Ca++ channel or beta blockade will make this rhythm worse. Amiodarone is the best choice, but it too will cause a deterioration in the patient's hemodynamics with it's administration. DO NOT take this patient to the standard cath lab. They need radio frequency ablation.

New issuing of the appropriate signage for these individuals, but this is not an isolated situation. DXM is popular because of the narcotic type effects it causes, but is becoming more difficult to obtain. Standard overdose treatment with a trial of Narcan works just fine.

Stable tachycardia grants the luxury of time. At that rate, there is only one possibility for what the rhythm can be and it is not ventricular. Avoid all AV nodal blocking agents while moving quickly to the hospital of choice that has the capacity for radio frequency ablation.

I will only go into great detail if the patient is presenting in such a way that the standard treatment will make things worse. Mostly due to my dread of repeating the same story so many times.

Stage and let law enforcement find the patient. I'm not a bloodhound.

IO access is not the panacea that everyone is making it out to be. Yes, it is quite useful when you need vascular access, but there are several key problems with it's widespread use. The most glaring is the inability to fluid resuscitate without a pressure infuser. An EZ-IO properly placed will not flow greater than 100 ml/hr with gravity. This does nothing to reverse the effects of hypovolemia that made IO access necessary in the first place. Because of that problem, you have to be very careful using the site for fluid pushes. I've been witness to several syringe initiated fluid boluses following drug administration that have actually forced the IO out of the site. This was done by highly educated emergency physicians, so I don't want to hear about the lack of prehospital education on this one. As I said, IO is a good option, but it needs to be tempered with some reality. A central vein is much better for the critical patient than an IO. The prehospital providers that are allowed to do them, and are successful should not be stripped of the privilege just to make things easier for a few that want a new skill.

Look for the retail price of the two drugs. Amiodarone was significantly more expensive than lidocaine, but I believe that now the two are closer in price. The need for PVC is only if amiodarone is being used for a continuous infusion over 24 hours. In the prehospital environment, the "leeching" effect is much less of a problem. Amiodarone has much more clinical indications than lidocaine due to it's broader mechanism of action. A standard drug profile of both will give you this information.

If you don't let your skirt get in the way they aren't so bad:D Isn't that what the gurney is for anyway?

If you want to keep this to yourselves, then don't provide the information to a media outlet. This type of system reeks of the city government thinking they know what is best for the public without having the first clue. This type of system is a band-aid, and nothing more. The area wanting paramedics, but not being willing to pay for it is the whole reason that the intermediate level was developed in the first place. There are plenty of paramedics to provide the service level the public wants/needs without making up something "new". Like anything, it will take money and dedicated individuals to make it happen. Making things easier for 9 people will not solve the problem. If you would like for us to take you seriously, you might consider learning some grammar as well. Your post looks like it was written by a 3rd grader. The population listed was for one of the outlying counties, not Louisville, KY specifically.

Apparently KY is still in the stone age. :roll:

The major differences will depend on the type of transplant the patient has received. Some will have only ventricular tissue grafted into the existing heart. Others will have the entire heart replaced. Single SA node with dual ventricular activation is pretty common. With a full replacement, the heart is no longer innervated so they typically won't respond to the vagal stimulation that comes with inferior wall events. They will still respond to the release of adrenergic hormones, but anti-cholinergic drugs won't have much of an effect.

You can provide the treatment without the test as well. The ER techs are not operating in a vacuum, and likely have more support for doing so than you do in your limited service. Then why do you continue to use it as the example for why you should be allowed to do something? The ALS providers do not "need" you to do anything. Save for perhaps becoming an ALS provider yourself. A finger stick blood sugar will not relieve them of their responsibility to provide care to the patients they are assigned to. Likewise, it will not alter your ability to provide oral glucose. How does this change with a finger stick blood sugar being done? The procedure takes all of 60 seconds from the time you decide to do one. Because you can't provide the treatment that the patient needs, your scene times should not be altered at all. Allowing you to perform a diagnostic test does nothing to alter the system problem you are describing. Your area is understaffed with ALS, and needs more of them. It is folly to consider that allowing more add-on skills to the BLS providers will fix this problem. This is not a matter that falls under the standard risk-benefit assessment. You will not receive any information you can do anything with. Therefore, you do not need to be allowed to perform the test. If your patient is altered, and can protect their own airway, go ahead and use your oral glucose. The damage comes when the patient is altered and cannot manage their own airway, and you use the oral glucose anyway. The test is irrelevant based on the clinical context you find yourself in.