Strip Tease 7

[Tom B.]

I've had good luck with Adenocard and Cardizem, too. If "good luck" is defined as terminating AVNRT or slowing the ventricular rate with AF. But what was the point? Looking back on my career (at a time when I had a much different outlook than I do today) I did these things because I could, and because it was fun, and because it meant that I was a "good" or "aggressive" paramedic. It wasn't about the patient. It was about me.

In one of the few (if not the only) studies of prehospital Adenocard, it was given inappropriately 20% of the time, including regular wide complex tachycardia (5%) and irregular wide complex tachycardia (2%).

I myself have seen Adenocard given for patients in acute pumonary edema with sinus tachycardia or AF with RVR. When asked why the paramedic gave Adenocard, they both said, "heart rates > 150 can't be sinus tachycardia".

How many EMS systems educate and train their paramedics to the point where, 100% of the time, a 12 lead ECG is captured with excellent data quality documenting the arrhythmia, the print button is pressed prior to the administration of Adenocard to document the pause, and a 12 lead ECG is captured of the post-conversion rhythm?

In my experience, not many.

As for Cardizem, we recently pulled it off the truck. Why? Because how often do you have a patient with new onset AF with symptom onset < 48 hours who is stable? Not often. And how do you really know for sure that the symptom onset was < 48 hours? Usually when we see AF/RVR it's a heart failure patient with shortness of breath who needs oxygen, NTG, and CPAP. Not Cardizem. Why not allow the physicians at the hospital to risk stratify the patient, do a bedside echo to rule out a clot in the left atrial appendage, and heparinize the patient if necessary? I know some argue that Cardizem won't convert AF. Well, I've seen it many times as a cardiac monitoring tech on a stepdown unit.

So no, I'm not a huge fan of prehospital antiarrhythmics. If the patient is unstable, then cardiovert. If the patient is stable, capture a 12 lead ECG with excellent data quality, start an IV, place the patient on oxygen, place the compo-pads as a precaution, and take the patient to the hospital. Documenting the arrhythmia in 12 leads is the most important thing you can do for the electrophysiologist who follows up on the case.

If you must give an antiarrhythmic, you should do so cautiously, in accordance with your protocols, and with the understanding that any antiarrhythmic can be proarrhythmic, or even fatal if given in the wrong circumstances.

That's why I wouldn't monkey around with AF/WPW in the field, except with electricity, and even then only if the patient was clearly unstable.

Tom

Any antiarrhythmics? I've had some really good luck with both Adenosine and Cardizem.

Edited May 26, 2009 by Tom B.