Parkinson/benign tremors prevent ECG

[mobey]

From a recent call.

66 y/o with a "benign tremor" of the upper limbs he has had since childhood.

Pt was c/o chest pain, pale, cool, dry.

You can barely identify a rhythm with the leads placed on the chest.... Now they must be moved to limbs for a 12 lead.

Do you sedate? or an Antiparkinson such as Cogentin?

Benzo's?

Forgo the ECG and treat symptoms?

The purpose of this question is to get a feel for standard of care.... I do not have one for these patients.

[DartmouthDave]

Hello,

I wouldn't sedate the patient or use Cogentin for the trmors. Also, it is my understanding that Cogentin is mainly used for EPS effects (parkinsonian symptoms, dystonia, akathisia and tardive dyskinesia) of medications. I am not sure if it would help with this patient's tremors. However, I am far from an expert on Cogentin.

I degress.....

Will the 12-lead/3-lead change the care you provide? In most cases...no.

If you can offer pre-hospital thrombolytics and you have a long transport time their could be some use to giving Ativan (ect...) to get a 12-lead to see if their are ST-elevations. If you have a short run to the hospital I wouldn't sedate.

If you only have the standard M.O.N.A. treatment options sedation for a 12-lead won't change what you are going to do too much. IMHO.

Cheers

[Just Plain Ruff]

I agree with Dave, if the 12 lead won't add to your treatment then forego it and wait till the ED.

I have a history of BET's (benign essential tremors) since I was about 24. They are no longer noticeable. The medicine I took (propranolol) took care of them. At times they were bad enough that I couldn't even hold a pencil or pen. It made starting IV's a hoot.

What I did notice though is once I started concentrating on the task at hand, like starting an IV, the tremors stopped. Wierd but my neurologist said that is what would happen.

I think when my tremors were at their worst, an EKG could have been done but it would be pretty wavy.

Again, I think that if you can hold off on the EKG and wait till he gets to the hospital then wait, but if not, you should be ocntacting medical control and discussing this. Giving ativan or some sedation without discussing it with the doctor in this instance is not a good idea.

[fiznat]

Your limb lead (II, III, aVF) electrodes should start at the limbs and then work in towards the chest only if necessary.

Barring some unseen circumstance, I can't see a real justification for giving a sedative for the purpose of cleaning up ECG artifact -- especially in the ambulance. I suppose there is a time and a place for such a procedure, but it seems like a very rare and narrow window to me.

Edited July 15, 2010 by fiznat

[Just Plain Ruff]

So a question I have is this, would stopping the tremor abruptly with using a sedative be detrimental to the patient?

[speedygodzilla]

I would go ahead and treat the patient.

I would try for a 12-Lead and even leave it attach to retry enroute. Who knows, maybe you'll get lucky. However I would not focus too much effort on it. Of course be sure to document.

[croaker260]

hey all, long time poster, first time listener

Anyway...

Consider this...while "limb placement" of the 12 lead is optimal, it is by no means mandatory. There have been times when that has been the only way for me to get a readible 12 lead for a number of reasons, for example: Amputees, patients with burn dressings on arms and legs, agitation and tremors.

So, considering that there is indeed an alternative to the "limb lead 12 lead", giving a sedative, especially one of the limited number of sedatives typicaly carried on EMS rigs which cary a number of inherrant risks, simply to get a limb lead 12 lead in an otherwise stable, calm, and compliant patient is not something that meets the risk:benifit equation in my book.

Just my thoughts.....

Steve