Fry vs. Drug

[CoyoteMedic]

First off, my applogies, I only have the very short baseline EKG, anyway onto the fun...

Your called out code 2 to a Doctors office in a town about 20 miles from the nearest receiving ER.

Upon arrivel, the MD meets you saying that she has a 30 yo male pt complaining of dizzyness. That they ran a 12-lead on him and that it came back in SVT. No vitals given, thats about all she had other then a printout of the 12-lead.

On assessment, pt laying prone on a exam table, A&O x4, C/O dizzyness, even while laying down. Denies any C/P, SOB, ABD pain, n/v, or any further C/C. onset was aprox 30-40 minutes ago while working on a farm. No chemicals were in use by the pt or in the area at the time.

Inital V/S: BP 80/p, P: 180, R: 20, skin Pale, warm, dry

Monitor shows:

Now, the protocols for the area I was working in at the time call for Cardioversion if a pt is unstable (one or more of: C/P, SOB, ALOC, Systolic BP less than 80, or pulmonary edema), or base contact for a adensoine order if the pt is boarderline.

I'm basicly just curious as to what those of you think. There are 50 differnt ways to attack each problem, and I'm curious as to some of the other approaches out there that others would take.

The info above is about all that I recall from the call, it happened about six months ago, but I'll try to answer what questions I can.

I'll post what happened in a few days.

[AZCEP]

You have to ask for Adenosine, but it is okay to cardiovert on a whim?

With those rules in place, and the patient you describe, I'd be cardioverting following some sedation/analgesic measures. Of course, if I'm in my own system the rules change significantly. I don't think you are asking what my system allows, so there is my answer.

[MrSpykes]

I am confused do you mean that if the pt is borderline then you have to call and see if the Doc wants cardioversion or Adenocard? This pt is not borderline so give them the adenosine. Cardioversion is gonna hurt even if you sedate because you probably won't have enough to completely sedate the px away, so you might as well use drugs first and see what happens, especially when the pt is stable.

[Ridryder 911]

Confusing protocols, first ask if they got a UDS (urine drug screen ) on him... have someone else take a blood pressure, palpation is only a guess and if he is warm and dry and alert with only a 80 palpated.. hmm something wrong. I would give him a some fluids and then some adenocard.. not working then consider it's time for Edison Medicine...if he was a middle age AMI candidate, I would approach differently.

R/r 911

[iMac]

I can see how he could be dizzy. Pulse is rapid enough which means the heart may not be perfusing enough oxygen to the brain which would cause the dizziness. (Having said that though I have a heart condition which puts at that rate and I'm ok, all depends on the individual)

The low BP is also most likely due to the inadequate perfusion. I had the exact same call last year, where are pt barely made it to the ER before he coded.

BLS care is all I would have available to me (ALS 45 mins away). My best option would have been keep him on the monitor, high flow O2, resting, start some lines TKVO, get a good Hx (Cocaine could also be a possibility, dehydration/trauma)and have your partner drive bloody fast to the nearest hospital. I would get everything out and ready for a possible code.

[Just Plain Ruff]

I fail to see where this patient is even close to being ready to code. I've had patients like this and one or two doses of adenocard or a jolt or two of current always did the trick. The ones I always worried about are the ones who don't respond to either of the above two treatments.

If you drive bloody fast to the hospital, wouldn't that increase the patients anxiety causing more distress and increase the possibility of a detrimental outcome.

I just don't understand why we have our partners driving to the hospital lights and sirens the patient has to be really really sick, near code before I'll drive hot to the hospital.

[Medic2588]

Per ACLS guidelines the patient is unstable. Regardless of underlying causes, his blood pressure sucks and therefore should be cardioverted. A stable BP I would go with Vagal Maneuvers and Adenosine, but the BP in this case is obviously low.

And I agree with Ruff. There's rarely a need to drive bloody fast to the hospital.

Devin

[canuckEMT]

This Pt in my book is still on the stable side even though he is mildly hypotensive. No SOB, CP, ALOC yet.

I would have my partner start an IV in an AC as I would like to try Adenosine first. While getting the IV Iwould be applying the pads to prepare for cardioversion if the first trial of Adenosine was unsucessful. If at any time his condition worsened, I would go straight to cardioversion and transport.

Maybe I see things a little different in this scenario and if anyone disagrees please let me know what I might be missing. We ahve been going over these scenarios for the past week in class so I thought I would try my hand at posting a little and see if I am on the right track or not.

[Thunderchild145]

Yea. This is not really a situation I'd give electric medicine first. I'd try adenosine. Failing to see results after 6/12/12 of adenosine or if the patient destableized (drop of BP, CP, syncope) then yea I'd cardiovert but I've always had better results in converting SVT with drugs than countershcoks.

[northernmedic]

I would start by trying a Valsalva maneuver then failing that go to 6 or 12 mg of adenosine. I have seen plenty of calls like this and usually they convery nicely with adenosine (providing there isn't another underlying cause such as drug use etc). I have had some success using the Valsalva, especially in younger otherwise healthy pts.