Rapid A-fib / Pneumonia / Cardizem

[Camulos]

To give or not to give? That is the question.

Would I have given the cardizem?

Well my answer to this is yes providing;

• No history of WPW or obvious delta waves on the monitor. Mind you, at this rate you would have to be pretty good to see these.

• Pt is not currently on beta blockers. I would be particularly suspicious in this pt given the history of AF and HTN.

• Ventricular rate > 100bpm

• Systolic BP > 100mmHg

My main reason for using the cardizem whilst the pt is still relatively stable is to provide some ventricular rate control BEFORE the pt becomes hemodynamically unstable. I understand how some are reluctant to treat this pt in the setting of no current signs of rate related cardiovascular compromise. However my fear at not treating the ventricular rate EARLY would be that the pt would eventually become hemodynamically unstable. You then have the scenario of an unstable pt in a narrow complex tachycardia which may mandate attempts at synchronised cardioversion. Not ideal in someone who has not been appropriately anti coagulated beforehand. So I believe this is a case of treat early as the consequences of not treating will be much worse.

Stay safe,

Curse :evil:

[CTXMEDIC]

CTX grow the hell up and stop acting like an arrogant <..........> Your type is the main reason why we're not looked @ as a profession..... cocky, arrogant, and failure to see the big picture.

Now, what in the OP suggests this patient is not hypoxic?? Is it just because "she's @ 98% on 4 lpm"? Are you even seriously thinking this through. A normal person would not need supplemental oxygen @ 4lpm to have their O2 saturations @ 98%. The damage the chronic pneumonia has caused to the lungs is already enough to suggest VERY mild hypoxia under normal conditions. Now with her lungs compromised by the infection again and not to mention tachypnic why would she not be hypoxic?? Oh my bad, you don't treat the monitor (aka magic box as you call it). But it sure as hell sounds like it to me.

The whole compensatory tachycardia added : "don't touch it", does not apply here. A-fib and a compesatory tachy are two seperate things. Just because she has a high HR with "stable" vital signs (which is what your getting stuck on), does not mean its a compensatory tachy. But when you decide to ignore it and she becomes hypotensive, AMS, cyanotic with circumoral cyanosis, your causing harm that could of been avoided. As ERDOC put it, Good Luck with trying to defend a Tort Law case. Your arse will go through the ringer.

wow, youre driving the short ambulance, huh?

why dont i think shes hypoxic? Gee, i dunno, 98% O2 sats, aox4, NO OTHER COMPLAINTS, no cyanosis, No ALOC. Silly me for 'getting stuck on' stable vital signs. I could hold my breath and get 'VERY mildly hypoxic'.

Just because she has a high HR with "stable" vital signs (which is what your getting stuck on), does not mean its a compensatory tachy

Thanks for agreeing with me.

When i ignore what? Read the mans question again befor you try and cure a patients chronic afib. Do you know anything about her meds or are you just assuming that cardizem is appropriate? what if shes on beta blockers? you gonna block the calcium channels as well? this should be good. Is she on Digoxin?

also, NOWHERE in this guys post is a statement regarding ventricular rate he only states that his MONITOR is giving readings in the high 100's to low 200's when he looked at it. No 12 lead..no strip info, NADDA. Maybe YOU need to kick back and actually THINK about this.

[CTXMEDIC]

To give or not to give? That is the question.

Would I have given the cardizem?

Well my answer to this is yes providing;

• No history of WPW or obvious delta waves on the monitor. Mind you, at this rate you would have to be pretty good to see these.

• Pt is not currently on beta blockers. I would be particularly suspicious in this pt given the history of AF and HTN.

• Ventricular rate > 100bpm

• Systolic BP > 100mmHg

My main reason for using the cardizem whilst the pt is still relatively stable is to provide some ventricular rate control BEFORE the pt becomes hemodynamically unstable. I understand how some are reluctant to treat this pt in the setting of no current signs of rate related cardiovascular compromise. However my fear at not treating the ventricular rate EARLY would be that the pt would eventually become hemodynamically unstable. You then have the scenario of an unstable pt in a narrow complex tachycardia which may mandate attempts at synchronised cardioversion. Not ideal in someone who has not been appropriately anti coagulated beforehand. So I believe this is a case of treat early as the consequences of not treating will be much worse.

Stay safe,

Curse :evil:

Good post and i agree. My hang up on this is that we do NOT have enough information to say whether or not cardizem is indeed indicated. we can ASSUME that because she is a chronic a-fibber that shes on an anticoagulant, shes on some sort of beta blocker or CCB or Didge. We have NO ventricular rate information, blood pressure, and palpable pulse. Whats going to happen if we do as some suggest and we give her the CCB and shes already on beta blockers? how about we take a pulse and match it to the monitor? gee, what an idea. are the qrs's matching what we feel? how about listening to the heart? match what you hear to what you see on the monitor. IF we can confirm that indeed this actually IS RVR, THEN we can treat it appropriatley. to treat for RVR in a stable patient without knowing JACK about her meds and history because the magic box is giving us high, INCONSISTENT readings while showing A-FIB is STUPID and IRRESPONSIBLE. :?

[ERDoc]

CTX, you are clearly missing the big picture here. I will concede and agree with you on one point. We do not know if the pt is on Dig. I will agree that if she is, she should not get a CCB. That is about where your correctness ends. So what if she is on beta blockers? You can give both to a pt. I've done it plenty of times. I would prefer to give something that the pt is already taking, but if you don't carry beta blockers, then there is no problem giving CCBs. We need to assume that the info the OP is giving us is accurate. If we are being told that the ventricular rate is 180-210 we need to assume this to be true for the sake of this thread. We can start another thread to argue whether the monitor is able to accurately detect the ventricular rate. Making those assumptions for this case, you are required to treat it. This is where you are failing to see the big picture. You can check any pulse you want, but it doesn't matter. It does not give you an accurate assesment of what is truely going on. This pt's heart is being beaten at 3 times what it was designed to do. It is under a great deal of stress and needs to be helped before it is too late. Just because each impulse that is reaching the ventricle is not producing a palpable pulse does not mean that the ventricles are not contracting and being stressed. Quite the opposite, they are working more than they ever have before. Never assume that a chronic afib pt is on an anticoagulant. There are plenty out there that are not because the risks outweigh the benefits.

You are a very concrete thinker, which is a bad thing for someone in medicine. When you give your report you tell the doctor/RN. He's in afib with RVR with a rate of 180-210. Sounds kinda simple, huh? I NEVER said to cardiovert this pt. I said to give the cardizem to provide rate control, which is a whole other thing. What I said was that by trying to control the rate, sometimes you will cause conversion. On a personal note, I could give 2 shits whether you want to be in my good graces or not. This ain't preschool. My concern is correcting the incorrect information that you are providing. Quality education in EMS is difficult to come by so to have someone spouting such falsehoods makes it difficult for those that are trying to learn to know the real deal.

"So, let me this straight. My clients heart was being stressed because it was working 3 times was it is supposed to be. You had the medications in your bag to fix the problem. You state that you did not trust what you were seeing on your equipment. If your equipment is not functioning properly, why are you not putting your unit out of service? Why are you using equipment that is know to be faulty on a very sick person? If you don't trust it, why are you using it in the first place? You say to treat the pt and not the monitor. Is that what you did when my clients heart finally stopped beating? You decided to shock her several times based on what you saw on the monitor. Did it suddenly start working properly? She was down so long that she had a stroke and is now paralysed and unable to talk. Pity for someone that was so active in her community. Dr. Heart over here says that if you had treated her properly she never would have had the stroke and would be leading a normal life right now. Can you tell me why Dr. Heart would have given a medicine that he says was so desperately needed but you chose not too? My client will be more than happy to take her payout in cash or certified check. You can leave your card with the judge."

[Camulos]

to treat for RVR in a stable patient without knowing JACK about her meds and history because the magic box is giving us high, INCONSISTENT readings while showing A-FIB is STUPID and IRRESPONSIBLE. :?

Agree. Having read the posts I’m not sure who you think was suggesting that though.

I just want to understand your stance on this topic. So if the pt had no contraindications and did clinically have a RVR would you then be happy to give the cardizem?

Stay safe,

Curse :evil:

[Camulos]

So what if she is on beta blockers? You can give both to a pt. I've done it plenty of times. I would prefer to give something that the pt is already taking, but if you don't carry beta blockers, then there is no problem giving CCBs.

Whilst I have agreed with most of your postings on this topic I do disagree with this particular statement. Just because you have “done it plenty of times” I don’t believe that should be your sole motivation for continuing this practice. Indeed I am sure it is not your sole motivation and was perhaps just the way it came across here. Having said that though there are some limited controlled trials that cardizem, when given concomitantly with beta blockers, is USUALLY well tolerated. I don’t like that word “usually” though and as such I would not have the balls to tempt this pre hospital. Indeed we have beta blockers as a documented contraindication to cardizem so the decision is out of my hands any way. In hospital I don't consider it an option because there are many alternatives.

Although there are trials reporting concomitant use is of cardizem and beta blockers is usually OK, there are also reports of the combination causing profound hypotension with the added possibility of complete AV nodal block. As such I don't think it can be truly said that "there is no problem giving CCB's".

Stay safe,

Curse :evil:

[crotchitymedic1986]

erdoc completed school in guatamala i guess

[medic112]

WOW, thanks for all the responses. Her "pulse" rate radial was 88 bpm, systolic bp was 130. i dont remember off the top of my head if she was currently taking any beta blockers. i think she was. And i did follow up with the doctor that i transferred care to at the hospital. pt was admitted with sepsis, secondary to pneumonia (again). Pt was given fluid bolus's in the ED and her rapid atrial rate did resolve, cardizem was not used and the doc said he would have been very hesistant giving me the orders to administer it, if i would have called command.

Thank you everyone for posting, it helped.

[CTXMEDIC]

Agree. Having read the posts I’m not sure who you think was suggesting that though.

I just want to understand your stance on this topic. So if the pt had no contraindications and did clinically have a RVR would you then be happy to give the cardizem?

Stay safe,

Curse :evil:

Yes, absolutley without a doubt. But when we have a poster that says his monitor is showing an irregularly irregular rhythm, the numbers it throws up as a rate mean squat. every and i mean EVERY patient i have had in a-fib shows 'rates' all over the map..anywhere from 120 to 300 something and i will NOT EVER use those numbers as a basis to treat a stable patient for a 'maybe'. i dont push drugs because i can or because the good book says so. our 'doctor' is telling us that matching a pulse to the monitor is a dumb idea. so basically if i feel a nice strong radial pulse and it matches exactley what my monitor is presenting as a rhythm, 1 QRS per pulse, im not to believe it. this guy must be a proctologist.

[CTXMEDIC]

WOW, thanks for all the responses. Her "pulse" rate radial was 88 bpm, systolic bp was 130. i dont remember off the top of my head if she was currently taking any beta blockers. i think she was. And i did follow up with the doctor that i transferred care to at the hospital. pt was admitted with sepsis, secondary to pneumonia (again). Pt was given fluid bolus's in the ED and her rapid atrial rate did resolve, cardizem was not used and the doc said he would have been very hesistant giving me the orders to administer it, if i would have called command.

Thank you everyone for posting, it helped.

Thank you. Good job 'DOC', you just killed your patient. Notice the part where he says ATRIAL RATE

Your CCb's caused vasodilation and hypotension, and combined with her beta blockers caused a bradycardic rhythm in a hypotensive patient. good work stud!