AZCEP

The danger that calcium-channel and adenosine carry is exactly the same. The big difference is the duration of action of the two. Adenosine will not break the circus re-entry, because WPW does not work under this mechanism. What it will do, just like the calcium-channel blocker of choice, is to slow conduction through the AV node. The accessory pathway will remain open, and willing to conduct every impulse around the AV into the ventricles at exceedingly fast rates. The ventricles will be unable to handle to barrage of stimuli, and VF will result. On the plus side, it will only last a few seconds, or a lifetime, depending on your perspective. We already know that this is WPW with a rapid response. We should be well aware that adenosine will not be helpful for this situation. I'd agree with Ruff and suggest holding any specific medication and closely monitoring the patient for the short bit of transport that remains. A beta-blocker would be a good idea, but it won't be near as effective at converting the rhythm now that it has recurred. If we could have given one during the period it had slowed down, it would have been a good thing.

One more specialty center to add to all of the others. Let's see: Trauma Cardiac Stroke Ortho Poisoning Neonatal With these types of suggestions, is it any wonder that doctors don't want us to think for ourselves?

From the brief reading I've done in it, your situation is near terrifying. I do not want to sound cruel, or uncaring, but the concerns of EMS providers would be to manage the symptoms as they present. I've come across many cases of near terminal patients that the family had so much more information than I did, or do. I will ask the family what works best for the situation at hand, and allow the family to help if they are able. It can be very easy to drown in the details, when all that is needed is an open mind/heart.

I truly appreciate the fact that you are questioning the validity of the suggestion fiz. Atta boy. Is it reasonable? Probably, but it does carry some danger with it. There is no benign medication. They all act in ways to alter normal physiology. If they didn't we wouldn't use them. There are clear indications, contraindications, and suggested times for and against everything we carry. Your concern for "sloppy medicine" is a good thing to carry with you. Just as you could justify using something, you could also justify not. Welcome to the gray area. There's plenty of room.

If the patient is alert enough to take something by mouth, why do people feel a need to jab them with a needle? There is little reason to do this.

The additional ECG's confirm that this is NOT ventricular tachycardia. As P3medic related, this is WPW. Amiodarone is the best option for emergent management, but with a five minute ETA if the patient can remain vitally stable we can justify close monitoring only.

So we are sure it's not an AV block, or Atrial flutter, or P-mitrale. Until a strip is posted, we are left grabbing at straws. What is the P-P interval? Does it remain the same for every interval, or does it change? What is the P-R interval? Does it remain the same as well? Is the R-R interval identical? Is there a clearly defined T wave? Are you certain the "extra P" is not a U-wave? What is the heart rate while this is happening?

This patient was already conscious, with the ability to protect their own airway, and the suggestion to treat a hypoglycemic event was made. There is no reason to use Glucagon, or start an IV. This patient, from all appearances of the scenario presented, is able to eat something without causing their airway to become occluded. READ the scenario. It is evident that this patient does not absolutely need IV anything, much less an IM medication. Yes, for this patient, in this scenario, I would suggest using oral D50. Even better would be to find some FOOD.

Glucagon is not a quick fix, and for the conscious patient able to maintain their own airway providing something with nutritional value beyond sugar is a better method. Many ALS services do not carry the glutose gel, but all have D50. Using the resources that are available means you might have to improvise a bit. Ideally, there would be some food to supplement the sugar.

It is quite apparent you did not read the initial situation, or perhaps forgot what it was. This patient was capable of communicating, was maintaining their own airway, and the question was would oral D50 or oral glucose paste increase the blood glucose level faster. I don't believe that anyone is suggesting to give anything by mouth to someone that is unable to follow commands.

Yes, air support does have a place in medical calls. Even for your "stabilizing" treatments, if you can deliver to definitive care in a similar timeframe, why wouldn't you? Strokes, acute MI, and surgical abdomen are just a few that will benefit. The threat of reducing atmospheric pressure enough to cause a clot to dislodge is pretty minimal based on the altitude change that most EMS aircraft will operate at. We definitely need an update on what this patient is doing, since the discussion has gone decidedly off the rails.

Nutrition 101 coming back on me. The sugar that is found in most food is not dextrose specifically. Most will be fructose or sucrose, which will require some degree of catabolism before the body can use it. As I can understand it, using D50 P.O. will reduce the amount of the dextrose that is absorbed, thereby reducing the expected increase in blood glucose level. It will work, just not to the degree that IV will. Pizza is a good mix of the major macronutrients and is often quite easy to convince someone to eat. Peanut butter and jelly is a reasonable alternative, but keep in mind there is more of a sugar load that can wear off a bit faster. I've found it works very well following the use of Glucagon though.

You've obviously never ingested corn syrup, which measures out to roughly D98. D50 taken orally will not cause tissue necrosis. It will increase their blood glucose level, but there would be a number of better ways to accomplish it if available. Just for flavor, grape or apple juice will do just as good a job. Orange juice is absorbed more slowly due to the acidity of the solution, so don't use it if you don't have to. Also, for the love of all that is holy, DO NOT add sugar to O.J. It won't speed up the process, and tastes horrible. Pizza does the best job of raising and maintaining a blood glucose level. Particularly one that has more than just cheese and sauce on it. If the patient can follow commands, go this route.

You've obviously never ingested corn syrup, which measures out to roughly D98. D50 taken orally will not cause tissue necrosis. It will increase their blood glucose level, but there would be a number of better ways to accomplish it if available. Just for flavor, grape or apple juice will do just as good a job. Orange juice is absorbed more slowly due to the acidity of the solution, so don't use it if you don't have to. Also, for the love of all that is holy, DO NOT add sugar to O.J. It won't speed up the process, and tastes horrible. Pizza does the best job of raising and maintaining a blood glucose level. Particularly one that has more than just cheese and sauce on it. If the patient can follow commands, go this route.

I agree with you ERDoc. However it would seem that the patient's level of consciousness is decreasing to a point that we need to move quickly, and may not have time for the happy drugs to be effective. I would be willing to give a dose of etomidate though.

I will guess that you have gotten the idea of Adenosine being dangerous from the description you quote. Truth be told, it is probably the safest medication to use for a tachydysrhythmia that is commonly available. It's effects are self-limiting due to it's extremely short half-life. Take a moment to look at the strip, then look for an image of ventricular tachycardia. You will notice that they are very similar. This patient still requires immediate rhythm conversion, and not a medication.

It may well be, but it is more common for this rhythm to be ventricular tachycardia. Without cardioversion you have to be extremely careful which route you take. The AV blocking agents (Cardizem, B-blockers, Adenosine) can make this situation worse. Lidocaine, Procainamide, and Amiodarone would be the most useful, safest agents to choose from. Because of this patient's instability, none of these is a great choice. Synchronized cardioversion may be challenging to accomplish as well. Some monitors have difficulty synchronizing with wide QRS complexes. In that instance, turn the "SYNC" off and defibrillate. This patient needs rapid resolution of this rhythm.

Moving off the fence would constitute disturbing a crime scene. If you could open the airway without removing, then you might be justified in doing a resuscitation. Nice twist on the legal/ethical concerns.

Adenosine is indicated for RE-ENTRY narrow complex tachycardias. Being able to identify the re-entry portion can be challenging, so most just fall back to the narrow complex. It will be ineffective for this patient, and will take time away from what is needed-->immediate conversion of the rhythm. Unfortunately for your situation Anthony, your medics are severly hamstrung if they are not allowed to cardiovert. This is one of the simplest, most effective, least dangerous modalities to treat these patients. All of the different medications carry much greater risk of worsening the situation. Procainamide or Amiodarone can be effective for this rhythm, but the patient doesn't really have the time to wait for them to reach an effective threshold.

Excellent re-interpretation of what was attempted to be delivered.

Look at the strip. Based on the patient's condition, and the ECG provided, this patient is not going to be receiving any medications until after the heart rate is controlled. Wide complex tachycardia + unstable patient = cardioversion

Would one keg suffice?

And I have a huge urge to tell you something that I'm not willing to sully the forum with, so I won't. His curiosity is all well and good, but the fact remains the new provider should focus on the things they will likely see, not some remarkable disease process that they never will. He mentioned he was a new provider, and instead of directing him to information that will only clutter his thought process, I suggested he make an effort to determine the situations he is more likely to find himself in. REAL professional of you to suggest he waste his time.

Or any of a thousand different things that could provide a little nutrition with it. Nah, that's just to bloody simple.

Can't really prove it wasn't there to begin with though. :oops: