Complex cardioversion?

[Laura Anne]

LOL..... 8) Everyone has those days of not being hukid....including myself! :wink:

[Just Plain Ruff]

now if we could only get a spell check on those run reports Ive had to review.

[brock8024]

I recently read an article in JEMS by James F. Goss about cardioversion of atrial fibrillation with a rapid ventricular response rate being contraindicated for a severe underlying pulmonary disorder. I'm not sure if I agree. What do you guys think? Check out the article below (all spelling mistakes are mine, not the author's, as I had to retype it since I could not find a link!)

Complex Cardioversion

By James F. Goss

You’re dispatched to the residence of an elderly male with difficulty breathing. On arrival, you find a 74-y/o male in severe respiratory distress. He has altered mental status and appears to need to sit up to breath. His wife reports he has a two-day history of progressive dyspnea much worse than his baseline, as well as a history of emphysema, atrial fibrillation (AF), CHF, and continued smoking.

The patient is cachectic, appears wasted, and has dry, flaky skin except around his lips, which are blue. Your assessment reveals significant suprasternal and intercostal retractions, absent breath sounds bilaterally, and use of accessory muscles. Vitals: BP 92/48; pulse thready and unable to count at fast rate; RR 44. Also observed is 4+ pitting pedal edema, extending to mid-calf, and mild abdominal distention.

A cardiac monitor reveals an unusually high tachyarrhythmia with an irregular rate of around 220. (Note: rates are usually significantly lower.) Due to the increased heart rate, it’s difficult to discern the underlying rhythm.

Your partner, also a paramedic, insists on attempting synchronized cardioversion per local protocol for symptomatic tachyarrhythmia with rates greater than 150. You think the respiratory compromise should be treated first, and you contact your base station. The base station agrees that cardioversion isn’t the best approach in this case and directs code 3 transport with respiratory care, including high-flow 02 and albuterol.

Although the monitor reveals a tachyarrhythmia with a ventricular rate of 220, this isn’t the primary problem. The tachyarrhythmia is secondary to the severe exacerbation of the patient’s emphysema and the attendant hypoxemia and myocardial ischemia.

This patient has a history of COPD and chronic AF, as well as CHF....[i’m leaving out some of the authors explanations of these diseases.]……and increased symptomatic tone usually worsens that condition, as do the hypoxia and increased anxiety and stress of respiratory decompensation. Exacerbation of your patient’s respiratory condition, along with hypoxemia and hypercapnia, contribute to increased sympathetic tone and subsequent increase in heart rate.

AF can be accompanied by ventricular response rates up to 300. Most cases of AF are chronic and shouldn’t be cardioverted due to the high risk of post-conversion embolic stroke along with the fact that chronic AF will reoccur within a very short time.

So would cardioversion by the best choice for a patient with poor air movement and hypoxemia? After all, when we hit the “reset button” on the heart through cardioversion, the cardiac cells require oxygen to restart. Thus, cardioversion of AF with a rapid ventricular response rate is contraindicated for a severe underlying pulmonary disorder.

Treatment to improve oxygenation should be initiated immediately. Improving ventilation and oxygenation will likely result in a decrease in sympathetic tone and heart rate. Although CPAP would be a better choice, IV diltiazem or verapamil may be indicated to slow the heart rate, improve ventricular filling, and decrease myocardial oxygen demand.

During transport, the patient’s respiratory status improved mildly as reflected by an increase in audible air movement on auscultation of the lungs, improved saturation, and a mildly decreased heart rate. Despite these changes, the patient remains in severe distress on ED arrival. In the Ed, his heart rate is slowly reduced and his status improves, and that patient is later transferred to the ICU.

Ok I have read this again and I personally think that the respiratiory problem is causing the tachy heart rate. I can not prove it but if you think about it if you are full of fluid and having to use a lot of energy to breath your heart rate is going to increase. This patient's heart is already irritable and I am sure it would not take much for it to get the job done. the problem with this is that the filling time is going to be low which will cause low Cardiac out put.

I would ask the patient and his wife about meds and when he last took them. He has had a increasing SHOB over the last 2 days and now has 4+ edema in his legs. Lungs are full of fluid and his is using all muscles to breath. I would give him the lasix and MONA if possible. It takes lasix a few mins to work and with all the edema and fluid it should help. The Morphine will help with moving fluid also as well as Nitro. I am looking at getting the fluid out and fixing the breathing problem before cardiac since I personally believe this is the true problem. This guy also should be cpap or intubated.

I always go back to basic and follow ABC way of doing things. This guy has a Airway, His breathing is well not the best to say the least. So we need to fix that before going on to Circulation.

It has been drilled into my head but my instructors to TREAT THE PATIENT NOT THE MONITOR!!!!!! I am also taught to think about what is going on. I believe and RID tell me if I am wrong, but my school also teaches us to think out side the box and not cook book medicine.

I think if cardioversion is the top thing to do for this person then they have either forgot the ABC's of assessment or are treating the MONITOR not the PATIENT.

In the end of all this if it is hard to read

1) treat the SHOB that has been going on for 2 days.

2) Meds to help with one

3) advanced airways if needed

4) Treat the Cardiac issues

Lets face it we can fix the rate but if we do not fix what is causing the problem the Heart rate will go right back up and take more oxygen.

Brock

[Just Plain Ruff]

Outstanding post Brock and I'm sure the cardiac experts will weigh in on what you have had to say.

I agree, you treat the patient and not the monitor. You treat the underlying problem and the external findings will often fix themselves.

It sounds like the treatment of the respiratory issues began to fix the patients problem. So was cardioversion wrong on this patient? Probably not but if you follow your protocol religiously and allow for no deviation or thinking outside the box then you run the risk of missing something, and that something may be a critical or fatal error

I too would probably have treated the respiratory issue rather than immediately considered cardioversion.

The question I think on this would be the following. Could the cardiac monitor have cardioverted this patient at all? The rhythm was undetermined, could the monitor have even caught the places it requires to cardiovert? I am not so sure.

This was a very critical patient and would have taxed even the best medic out there but we have to learn to think around the protocols and around the monitors and treat the patient.

That's my 2 cents for what it's worth.

[firefighter523]

If all of you cackling hens would stop crying about how I hurt your feelings we can get to the point on this "AGAIN". I am trying to tell brock that if you find a pt in a tachy rhythm as well as all of the above manifestations, YOU NEED TO FIX THE RHYTHM FIRST!!!! Unless this thing has been going on for quite sometime and the pt was unaware due to his/her compensation, and taking in fluids, this pt is probably not in fluid overload, it is just in the wrong places. When someone goes into a tachy rhythm, it causes back pressure in the pulmonary vasculature, due to the poor filling of the left ventrical, causing a "screen door effect, releasing the plasma into the aveolar spaces. If you allow the heart to pump properly, the fluid will return from the innerstitial space back to where it belongs.

This is why I am saying you need to take care of the underlying problem. You are right when you say "treat the pt and not the monitor", but you need to use the monitor as a tool, and take the pt's status in concideration with that. If you see a narrow or wide tachy arrhythmia, you NEED to assume that that is the pts problem! For one, you can't rule out that is not, therefore you need to treat it, and two, the pathology of a dysrhythmia makes all the sense in the world!!

[Just Plain Ruff]

wow another condescending post from our favorite poster.

Again you did not answer my question as to how long have you been a medic?

But I'm not expecting a reply from you. After all I'm just a cackling hen.

credibility shot.

by the way, did you even read the last paragraph, the patient responded with the albuterol and increased oxygenation or are you too wrapped up in your all mightiness that you choose to read only what supports your cockamamie theories?

I will ask you another question, do you think that the monitor could have even had the ability to cardiovert this rhythm? I've been on many scenes where the patients rhythm was so fast that the monitor was unable to capture where it was supposed to cardiovert at.

Again I ask you, how long have you been a medic?

[brock8024]

If all of you cackling hens would stop crying about how I hurt your feelings we can get to the point on this "AGAIN". I am trying to tell brock that if you find a pt in a tachy rhythm as well as all of the above manifestations, YOU NEED TO FIX THE RHYTHM FIRST!!!! Unless this thing has been going on for quite sometime and the pt was unaware due to his/her compensation, and taking in fluids, this pt is probably not in fluid overload, it is just in the wrong places. When someone goes into a tachy rhythm, it causes back pressure in the pulmonary vasculature, due to the poor filling of the left ventrical, causing a "screen door effect, releasing the plasma into the aveolar spaces. If you allow the heart to pump properly, the fluid will return from the innerstitial space back to where it belongs.

This is why I am saying you need to take care of the underlying problem. You are right when you say "treat the pt and not the monitor", but you need to use the monitor as a tool, and take the pt's status in concideration with that. If you see a narrow or wide tachy arrhythmia, you NEED to assume that that is the pts problem! For one, you can't rule out that is not, therefore you need to treat it, and two, the pathology of a dysrhythmia makes all the sense in the world!!

This is my whole thing right here, IT COULD BE A PUMP PROBLEM OR A LUNG PROBLEM!!!

If it was a heart problem I will agree that is can cause the Fluid in the lungs and such.

If it is a Lung problem it can cause the fluid and Rapid Heart Rate.

How do you or can you tell which can first. It is like the chicken or the egg question. For this reason I will go back to

A- Airway

B- Breathing

C- Circulation

Airway before Breathing and Breathing before Circulation.

So you cardiovert this guy and throw him inot respiratiory aresst, which you can fix but why not go in order.

I do not understand, from this no one can tell which caused the problems. The heart causing the breathing problems or the breathign problems causing the heart problems. So I say fix the breathing then the circulation.

[firefighter523]

Ruff, Do you make it a habit giving a beta-agonist to a person with a tachy arrhythmia? Let's make a sick heart work harder, why don't we!!

Broke, YOU ALWAYS FIX DYSRHYTHMIAS BEFORE YOU DO ANYTHING ELSE!!!!! They will compensate for only so long.

[Just Plain Ruff]

well as far as I'm concerned, this patients airway is not stable nor is his breathing stable. Fire, If you follow your mnemonics that you are so fond of touting then you seem to have missed the first two of the three mnemonics A-airway B-breathing and you jumped right to C - circulation

But then again, you sound like someone with this cool toy and you are gonna shock the patient no matter what. No matter what a differing viewpoint is of yours you come back with negative insults and will not take anyone's opinion into consideration.

Oh well, some never learn until they learn the hard way.

[Just Plain Ruff]

again, you refused to answer how long you've been a medic.

If you read the article posted above you would see that the patient got better, or apparantly you glossed over that. have you ever thought that the rhythm was caused by the respiratory problem and not the heart itself. Oh wait, that would go away from letting you use your fancy new toy.

I didn't realize that you skip over airway, then breathing. What the heck, why don't we also skip over circulation and just transport. Oh wait a minute, that wouldn't let you use your fancy machine to cardiovert.