Shocking an alert patient - V tach

[DFIB]

In the ER an elderly post op patient goes into V tach on several occasions about one hour apart. The rhythm is shocked and converted three times. The fourth time she presents v tach she is alert sitting up and conversing. The nurse says sit still honey this is gonna hurt and gives her 200 joules. The rhythm converts nicely. Is this common? Have any shocked v tach in an alert patient?

[paramedicmike]

It's not all that common. But it does happen. I've done it before. My patient was not particularly happy with me even after premedicating (recurrent VT, repeated conversions... similar to the case you presented above).

On a certain level it's kinda' neat to see.

[usmc_chris]

I don't believe I've ever shocked a fully "alert" patient. Most patients who need immediate cardioversion are going to show it - they probably won't be sitting up, chatting about the weather etc. - rather, they'll have unstable vitals, be short of breath diaphoretic, etc.

While it is true that this lady probably wouldn't have stayed up and cheerful for very long while in VT, I would imagine there would be time to premedicate. In an adult, average weight pt I will usually use 5mg Morphine and 2.5mg Versed IVP, assuming no allergies or other contraindications. The really neat thing about the Versed is it has some short-term amnesic properties, so if you give it and cardiovert within a couple of minutes, the pt will probably forget what you did to them, except for wonder why their chest hurts a little (and that's where the Morphine helps!).

Based on the condition you describe the pt, I see no valid reason to not to medicate the pt prior to cardioversion. Shocking a conscious patient [without meds on board], unless they REALLY, REALLY need it RIGHT NOW, is just plain mean, IMHO. Of course, I wasn't there, so probably shouldn't pass judgement without knowing more about the situation.

[JakeEMTP]

Based on the condition you describe the pt, I see no valid reason to not to medicate the pt prior to cardioversion. Shocking a conscious patient [without meds on board], unless they REALLY, REALLY need it RIGHT NOW, is just plain mean, IMHO. Of course, I wasn't there, so probably shouldn't pass judgement without knowing more about the situation.

I was just thinking, the nurse probably had to wait for orders to medicate the pt. from the puppet master (j/k Doc's and nurses) and decided to go ahead and cardiovert w/o it, which in and of itself would require orders I'm sure.

I've only seen the situation described by the OP once. Depending on the circumstances, the cardioversion w/o premedicating may very well have been warranted. I don't know, I wasn't there.

Edited August 31, 2011 by JakeEMTP

[usmc_chris]

Yes, understand, I forgot that that the OP specified it was a nurse in the ER. I agree, in some circumstances, it may have been warranted, but I wasn't there either

To the OP: do you know any more about the scenario? Any more details about the pt and her overall condition? Thanks!

[Kiwiology]

Yes, because you know people in VT has a high incidence of .... dying?

Our Paramedic Ambulance Officers can cardiovert and Intensive Care can sedate with midazolam prior

Edited August 31, 2011 by kiwimedic

[Just Plain Ruff]

Yes, because you know people in VT has a high incidence of .... dying?

Our Paramedic Ambulance Officers can cardiovert and Intensive Care can sedate with midazolam prior

At one of the last services I worked for our protocol for cardioverting a conscious patient was to give Morphine/fentanyl and Versed and then cardiovert. We did not need orders to do it. We just had to document what we did.

Seriously, if a patient needs it and can be medicated then why not standing protocol orders for it barring contraindications of course.

I've only cardioverted a couple of times, only once did the patient deteriorate so quickly that I didn't pre-medicate first and that patient ended up dying on us.

[ERDoc]

Being in the hospital is obviously a little different than being in the field. If they need to be cardioverted and are conscious, I'll sedate with etomidate or propofol. If they are that unstable then they won't be awake for very long. Probably by the time the equipment is ready to go they will no longer be conscious. VTach can be a very stable rhythm. We had a guy in the CCU who was in VTach for days. ER tried to cardiovert him both chemically and electrically. Ended up on drips and sitting in the ICU in VTach with a rate in the 130s for a couple of days while we tried to get him transferred to a facility that could do the ablation. I don't remember the details but there was some reason he couldn't be ablated in our hospital (funky anatomy maybe but I don't recall).

[systemet]

A couple of quick questions for ERDoc:-

(1) When you're using a drug like propofol that can cause hypotension, does it create problems if cardioversion fails? Or is the half-life so short that this is rarely a problem?

(2) How often do you see patients who have underlying electrolyte issues that need correction prior to successful cardioversion? At what point do you stop if cardioversion is failing to convert?

[ERDoc]

A couple of quick questions for ERDoc:-

(1) When you're using a drug like propofol that can cause hypotension, does it create problems if cardioversion fails? Or is the half-life so short that this is rarely a problem?

(2) How often do you see patients who have underlying electrolyte issues that need correction prior to successful cardioversion? At what point do you stop if cardioversion is failing to convert?

For VT, I have been fortunate enough to not have had a failure. You can get some hypotension with propofol but any problem I've had corrects pretty easily with a fluid bolus and waiting out the propofol. For cardioverion, I have a personal limit of 3 shocks of increasing joules. If I can't convert them after 3 shocks, I call one of the smart doctors (cardiology) to figure out what to do next.