Heart rate: 310

[ladybear]

Place patient on the hands-free pads, Add Oxygen to compensate for the cardiac work, Drop the largest line you can and add a deisel bolus to land at the nearest appropriate facility. Be prepared to administer Amiodarone and possibly shock patient enroute. If possible, please attempt to obtain as much prior medical history as possible.

Also, have the patient blow through a straw, or try to blow up a glove.. it might slow his heart down. That's what we do while attempting to place the lines.

[zzyzx]

Wouldn't we suspect WPW? So what about trying adenosine?

[AZCEP]

Wouldn't we suspect WPW? So what about trying adenosine?

No we should not suspect WPW. We should KNOW that this is WPW with a rapid ventricular response, and it cannot be anything else. The rate tells us this.

Adenosine works by blocking the AV node. Doing this to an accessory pathway tachycardia is a good way to cause cardiovascular collapse. The benefit is the short duration of the drug. The down side is, well, you might not be able to get them back.

[zzyzx]

So we should not use adenosine for WPW?

The authors of this article seem to say so. They recommend amiodarone or lidocaine and rapid transport. But about adenosine they write, “Adenosine should never be used in a wide-complex tachycardia because it “stuns” the AV node, thus preventing further AV conduction for a short period of time. This can result in diverting electrical transmission through the bypass tract and increasing the heart rate, potentially converting a stable tachycardia into an unstable one. It’s also especially dangerous if PSVT is in reality very fast atrial fibrillation that appears regular due to the extreme rapidity of QRS complexes.”

Here’s what the ACLS protocols say about adenosine in this regard. “Adenosine is contraindicated in wide-complex tachycardias unless they are know to definitely be re-entrant in origin.”

On the other hand, the drug insert that I have with my adenosine preload (made by Astellas) says, “Adenocard slows conduction time through the AV node, can interrupt the re-entry pathways through the AV node, and can restore normal sinus rhythm in patients with PSVT, including PSVT associated with WPW.”

It goes on to say, “Adenosine is not effective in converting rhythms other than PSVT, such as atrial flutter, atrial fibrillation, and ventricular tachycardia. To date, such patients have not had adverse consequences following administration of adenosine.”

So is there no consensus on using adenosine for WPW, and whether it’s safe to use with a wide-complex tachycardia? Or are the authors of this article just wrong? I would tend to believe the drug manufacturer more than anyone else since the manufacturer has the most to loose if they were wrong.

[AZCEP]

You've answered your question in a round about sort of way, and it is encouraging that you are thinking the situation through.

If you can determine with certainty that the rhythm is caused by a re-entrant mechanism, Adenosine will work just fine. With the rate discussed, there is no possible way that re-entry alone is causing it. The physiologic slowing the AV node renders won't allow it. In this case there has to be an accessory pathway involved.

Jumping to treatment in the face of a stable patient can be tempered with some time. Cardioversion would be the treatment of choice, if you can accurately determine how long this patient has experienced this dysrythmia.

[Richard B the EMT]

Also, have the patient blow through a straw, or try to blow up a glove.. it might slow his heart down. That's what we do while attempting to place the lines.

LadyBear, I'll presume you to be Paramedic, and I advise that I am an EMT of 34 years experience. Under local protocols (New York City, New York), we are instructed, with at least hyperventilation, never to have the patient re-breath their air using a bag or glove.

(I had an instructor actually say "Bags? Bad!, " to which I responded, "The bag isn't bad, just misunderstood", to a lol from everyone including the instructor.)

Could you elaborate a bit on your local protocol that, if I am reading correctly, seems to say to use the re-breather method?

[devildoc0908]

First of all, when you have someone who has a HR above 180, acording to every class I have ever been to says, while you are getting the IV prepared have the patient do "Vagal maneuvers FIRST" If that doesn't slow the HR then look to Adenosine, but since the patient is obviously is symtomatic, the look of the patient gives you that, you need to go to direct cardoversion. First, Valium or Versed, your local protocols take affect, then shock. The use of "Amiodarone 150mg over 10 min., repeat x1" what does Ami do? It helps speed up the heart, exactly opposite of what your trying to do, slow do the heart.

[spenac]

LadyBear, I'll presume you to be Paramedic, and I advise that I am an EMT of 34 years experience. Under local protocols (New York City, New York), we are instructed, with at least hyperventilation, never to have the patient re-breath their air using a bag or glove.

(I had an instructor actually say "Bags? Bad!, " to which I responded, "The bag isn't bad, just misunderstood", to a lol from everyone including the instructor.)

Could you elaborate a bit on your local protocol that, if I am reading correctly, seems to say to use the re-breather method?

I believe she is using a method of vagal maneuver, the effort to do either would stimulate the vagal response. I do not think she was doing the old breath in bag for hyperventilation. I may be wrong.

[JPINFV]

I believe she is using a method of vagal maneuver, the effort to do either would stimulate the vagal response. I do not think she was doing the old breath in bag for hyperventilation. I may be wrong.

I read it as a vagal maneuver as well.

[devildoc0908]

Yes I am a paramedic for 10 years and i was an EMT for 7 years before that, what I mean by "vagal maneuvers" is that you "have the patient bare down like they have to take a dump". Example, have you ever went to a patient that was sitting at the toilet and passed out? They stimulated there VAGUS Nerve that runs beside the heart, in doing so they stimulated it, causing the heart to stop causing them to black out. With a vagal maneuver with a patient who has a HR of 310 a good vagal simple maneuver MAY slow the heart rate down.