zzyzx Posted March 26, 2008 Author Posted March 26, 2008 CHBARE: Thanks for the EMedicine link. The article supports what you are saying about not using adenosine for WPW: "Although a therapeutic trial of adenosine had previously been advocated by some for both irregular and regular tachycardias and in some cases to distinguish SVT with aberrancy from ventricular tachycardia, this has fallen out of favor recently because of the possibility of degradation of the rhythm to ventricular fibrillation when used indiscriminately." It is surprising though that the drug insert doesn't mention any of this. The insert talks about avoiding the use of adenosine on patients with COPD and especially on patients with asthma, but it doesn't say not to use it with WPW. It seems like this could open them up to a lawsuit. FYI, the EMedicine article makes no mention of amiodarone. They mention procainamide but caution against its use except in some circumstances.
firedoc5 Posted March 27, 2008 Posted March 27, 2008 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. Vagal maneuvers is the key words I was looking for at first while reading down the line. I have seen 300+ rates, cardioversion followed with Lido once in ER. Hx of MVP at one time?
chbare Posted March 28, 2008 Posted March 28, 2008 http://www.emedicine.com/MED/topic2417.htm Take care, chbare.
EMS49393 Posted March 28, 2008 Posted March 28, 2008 Last year I had a patient with a complaint of sudden onset chest pain and shortness of breath. 12-lead showed patient to be in a narrow complex tachycardia at 303 bpm. It also had the header of "acute MI suspected." Fortunately, I'm able to interpret a 12-lead in a rapid fashion, thanks to the greatest multi-lead instructor in the world. No delta wave, so I was not concerned with WPW. In gathering a history, patient states he drinks "a lot" of coffee, and smokes even more cigarettes. This had happened to him before, and he was treated at the ER, however he can't tell me what treatment he received. I established an IV rapidly, and went with a trial of Adenosine. I converted him on the first dose of 12 mg. He had relief of of all symptoms after conversion. From that I made the differential diagnosis of PSVT. His post conversion 12-lead showed no evidence of STEMI. I transported him, uneventfully, to the ER. I'm pretty sure I have both the pre and post conversion ECG's and I'll post them when I find them. I'm currently at work. With a 12-lead, a provider should be able to determine if a tachycardia is ventricular in nature. I was taught, unless there is evidence of WPW on the 12-lead, adenosine is the appropriate treatment in narrow complex tachycardia. It slows conduction through the AV node and hopefully slows the rate down enough to determine what the underlying rhythm is. I was also taught to try hard not to have to electrocute someone that was conscious and talking to me. Now, I could have been taught incorrectly, but I doubt it. My paramedic cardiology didactic was over 400 hours in length, and that was after a thorough A&P course. Bob Page taught all 400 hours of my cardiology, and I doubt he would steer me wrong. I'm always willing to learn, and I welcome any valid correction to what I was taught. I promise I won't run to Bob. (Well, I sort of promise. )
AZCEP Posted March 28, 2008 Posted March 28, 2008 12-lead showed patient to be in a narrow complex tachycardia at 303 bpm...I established an IV rapidly, and went with a trial of Adenosine... From that I made the differential diagnosis of PSVT... I was taught, unless there is evidence of WPW on the 12-lead, adenosine is the appropriate treatment in narrow complex tachycardia. What exactly does this have to do with the scenario presented? Nowhere is this situation discussing a narrow-complex tachycardia.
EMS49393 Posted March 28, 2008 Posted March 28, 2008 Stable tachycardia grants the luxury of time. At that rate, there is only one possibility for what the rhythm can be and it is not ventricular. Avoid all AV nodal blocking agents while moving quickly to the hospital of choice that has the capacity for radio frequency ablation. Seems to me, you, yourself stated that you felt this rhythm would not be ventricular in nature, thus being a "narrow-complex" tachycardia, as the wide-complex tachycardia would be ventricular. Also, you need not be so snotty in your reply. I presented my case for forum members to learn by. I had every intention of posting the ECG's surrounding this patient as well. I'll refrain, since by your opinion I have nothing to offer the scenario presented.
akroeze Posted March 28, 2008 Posted March 28, 2008 Seems to me, you, yourself stated that you felt this rhythm would not be ventricular in nature, thus being a "narrow-complex" tachycardia, as the wide-complex tachycardia would be ventricular. Also, you need not be so snotty in your reply. I presented my case for forum members to learn by. I had every intention of posting the ECG's surrounding this patient as well. I'll refrain, since by your opinion I have nothing to offer the scenario presented. If you are set on not posting them then could you at least send them to me in a PM? I'd love to see them.
AZCEP Posted March 28, 2008 Posted March 28, 2008 Seems to me, you, yourself stated that you felt this rhythm would not be ventricular in nature, thus being a "narrow-complex" tachycardia, as the wide-complex tachycardia would be ventricular. In the very first post, zzyzx noted that the rhythm was a "wide complex tachycardia". There are a good number of wide complex tachycardias that do not originate from the ventricles. No where did I say anything about this being ventricular tachycardia. Also, you need not be so snotty in your reply. I presented my case for forum members to learn by. I had every intention of posting the ECG's surrounding this patient as well. I'll refrain, since by your opinion I have nothing to offer the scenario presented. I was not being "snotty". I was calling your attention to the fact that this scenario had already had bypassed the direction you thought it was going. If you want to post your scenario and ECGs then feel free to start another thread. Adding them to this discussion may well be counterproductive.
EMS49393 Posted March 28, 2008 Posted March 28, 2008 My most humble apologies for being "counterproductive." I have sent a PM to the administrator requesting he remove all of my posts and delete my username in full. Congratulations on running off yet another member.
mobey Posted March 28, 2008 Posted March 28, 2008 My most humble apologies for being "counterproductive." I have sent a PM to the administrator requesting he remove all of my posts and delete my username in full. Congratulations on running off yet another member. This action is not necessary. Part of being on public forums is knowing when to stop reading. I have been following this thread and I gotta say I do not see the hostility that you are seeing. I think you are mistaking terms like "counterproductive" for terms like "You are screwing up the thread". Personaly I would like to run your scenario especially if you have ECG's, you have alot to offer to us. I believe there has been alot taken out of context and we would be disapointed if you left due to a misunderstanding.
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