Rapid A-fib / Pneumonia / Cardizem

[Camulos]

Just some more on the point about treating the monitor vs. the patient. In cases where the pulse rate is within normal range, yet on the monitor you count a ventricular rate that is 3 times the normal limit, I would be inclined to treat with cardizem.

I would have huge reservations adopting this practice. I guess in the scenario you would have given the cardizem then as it is exactly the situation you describe above. I firmly believe that I would NOT give the cardizem in this particular pt and think you may open up a whole can of worms if you do. Indeed my established protocols would prohibit me from administering it anyway as the PULSE is less than 100bpm. So I can wash my hands of that one.

You state that you would be happy to give the cardizem if the pulse rate was within normal range but the monitor was ehibiting a RVR. I assume by "normal" rate you mean 60 - 100bpm. That being the case I am interested to know, would you be happy to give cardizem to a pt with a PULSE of 60bpm who exhibited a RVR on the monitor :?:

Interested to read your response.

Stay safe,

Curse :evil:

[Mateo_1387]

Most nursing home patients do present with multiple problems, which is why you treat the patient. This is the best example of cook-book I have seen in awhile:

The monitor says she has a rate of 200, lets cardiovert her or give her cardizem -- wait a minute, her mechanical pulse is only 88.

She's not hypoxic, because my pulse ox says 98%.

Havent seen anyone suggest treating her fever. I know a tylenol suppository or a shot of toradol isnt as sexy as cardizem, but it should be the "FIRST" treatment in this scenario (after O2).

I couldnt have written it any better.

You just flat out do not get it.

First, if your monitor is showing a ventricular rate of 200 yet the pulse rate is 88, then something is wrong. For some reason, the patient is not pumping blood normally. You cannot just ignore something like that. Well...you can....the rest of us will not.

You blame me for being a cook book medic for using my monitor as an assessment tool, yet you want to say just because the pulse ox says 98% that she is not oxygen deprived. Sounds like a double standard. I guess you are ignoring the fact she has lung infection/inflammation/excess mucus production/and probably edema in her lungs. But that is ok, just because your pulse ox says so, it will all be ok.

Wrong, your pulse ox is only a tool that fits into the big picture. Sure, it is showing that things are 'normal' but that does not mean things are 'normal'. Sure the pulse is 'normal' but since the monitor shows a ventricular rate of 200, it is not 'normal'. You need to see the big picture. Give her a coma cocktail, and we can call it quits......

[Mateo_1387]

I would have huge reservations adopting this practice. I guess in the scenario you would have given the cardizem then as it is exactly the situation you describe above. I firmly believe that I would NOT give the cardizem in this particular pt and think you may open up a whole can of worms if you do. Indeed my established protocols would prohibit me from administering it anyway as the PULSE is less than 100bpm. So I can wash my hands of that one.

You state that you would be happy to give the cardizem if the pulse rate was within normal range but the monitor was ehibiting a RVR. I assume by "normal" rate you mean 60 - 100bpm. That being the case I am interested to know, would you be happy to give cardizem to a pt with a PULSE of 60bpm who exhibited a RVR on the monitor :?:

Interested to read your response.

Stay safe,

Curse :evil:

Interesting questions bro...

First off.....I don't know :shock:

:arrow: Earlier in this thread, I was under the impression the patient had a pulse rate of 170 +.

Rather than just treat, I would want too try and figure out why this patient is having conducted complexes, but without a pulse. As I said earlier, listening to heart tones to establish if what is heard matches the monitor. In the case that it does not match, I don't know. If I had an extended transport time, I would like to go with medical control to figure out possibly what is going on, and maybe get some guidance on treatment. In the case that I did not have any OLMC, I probably would go ahead and give the cardiazem, as my best indication is that the heart is beating rapidly, though not producing pulses with every beat.

If the patient had a pulse rate of 60, I probably would not give the cardizem.

So I have a question for you, you are 3 hours from the hospital, and your patient has a pulse of 80, yet on the monitor a ventricular rate of 200. How might you treat the patient. Obviously, something just is not right.

Good question.

[crotchitymedic1986]

what if the monitor shows vfib but the patient is alert, talking, and normotensive ?

[p3medic]

Or in V-tach at 180 but you can only detect about half of those at the wrist.... :roll:

[Camulos]

I assume this still centres around the main point of whether to give cardizem or not. As such my answer to that question is still NO – I would not give it based on the limited info you gave me. First and foremost my main reason here is that my protocols don’t allow me too in the present situation you outline. So in that sense I would be stupid, and indeed reckless, to deviate from them.

I guess the other question is; do I think this protocol is correct? Well this is the area that is open to debate and I am happy to give you my personal feelings on the case.

In your scenario we are 3 hours from hospital. That in itself does cause concern and generally when placed in that situation I believe we feel we need to do something more definitive for the pt as the hospital is so far away. In some circumstances and scenarios there is certainly a valid reason to provide care that we might not otherwise provide if the ED was just around the corner. In this case though I am happy that the protocol says NOT to give the cardizem at this stage. My reason for this is that the pt is not exhibiting overt physical signs of cardiovascular compromise. Don’t get me wrong, the ventricular rate of 200bpm would certainly concern me and I would be monitoring this pt quite judiciously. Damn – I’m in for a long three hours. Now if we are talking about the original pt in this thread and applying them to this scenario I would suspect that this particular pt , who from memory was in their seventites, would not be able to sustain this rapid ventricular rate for very long before the physical signs started to manifest. When the physical signs start to show in the pt well then I could consider treatment with cardizem providing my protocol criteria were fulfilled.

I would also wonder why there was such a mismatch between the monitor and the pt. We spoke earlier about the high probability of this pt being on beta blockers. I guess this may be one possible cause of why the physical signs are not manifesting themselves. However in this situation the answer on cardizem is again very simple. I would NOT give it here if the pt was on beta blockers. I feel the risk of profound hypotension and complete AV nodal block is just too great.

I guess at different points during any scenario, the treatment we provide all comes down to a risk v benefit analysis. I feel that the risks associated with giving the cardizem at a pulse rate below 100bpm outweigh the benefits and therefore feel it is appropriate to not give it. There are other physical signs I would obviously take into consideration when making this decision of course but this was the only one I was provided with. I must stress though that I understand the decision to not give the cardizem is fraught with danger. Even though the pt is stable now, well as far as physical clinical signs go, does not mean they are just going to fall in a complete heap. In my experience this is usually not the case with adults and instability is a progressive process, in this sort of scenario anyway. There are always exceptions to this rule though that come up and bite you on the arse and this rule does certainly NOT apply to trauma or children. Those little buggers compensate so well for so long and then it all just turns to crap. :x

If this pt were to completely drop her bundle well I guess you are faced with a situation of whether to cardiovert or not. The indications for this are pretty rigid though and it is usually not a hard decision to make when the signs are there. Don’t get me wrong, I would have HUGE reservations cardioverting this pt – particularly if not normally on anticoagulants.. However sometimes you just find yourself in a crappy situation and have to do what you have to do.

I’ve ranted on enough and have to get ready for work now. Hope this answer has stimulated some further discussion here as I have certainly enjoyed this topic so far.

Stay safe,

Curse :evil:

[backinboston]

If you take a look at most patients meds now days you will find it is quite common to have Calcium Channel blockers and Beta blockers combind.

You treat this patient with cardizem although she is not showing the cookbook style S/S because your lucky she is in a compensating state. You TREAT this afib, slow down the rate and monitor there reaction. your job is to know these things and take care of the best interests of the patient. If you want to just know they have an IRR HR that is fast and want to just drive to the hospital with O2 on then pick up a BLS shift.

Personally, I have Cardizem on standing order and when called upon in the clinical setting I have no fear in using it. I have had great results and a Hx of Afib does not mean you withold cardizem by any means. Yes maybe on a daily basis there HR is mildly Irr in the 80-110 range. There is NO WAY that this patient on a daily basis is in the 160-210 range. There is no way to sustain their cardiac output with there ventricals getting such a minimal output.

If anything you would withhold the albuterol due to the cardiac issues, because they are breathing and within the Er they will get the needed antibiotics. PNE is something they can live with for some time and will make it to the hospital, an unstable HR (Not unstable pt) will not last long in this condition.

[Arizonaffcep]

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.

Here's a real-life scenario that happened early this AM...we had a 92yof who had AFIB with RVR...given Beta Blockers to no avail...About the only thing we did different in flight from the ED was upped her O2 from 2lpm via N/C to 15 via NRB. Which, after about 2 minutes...converted her to sinus tach at 110. The point...she was hypoxic with a POx of 98-100% on the 2lpm, but with an increased O2, she converted.

[Arizonaffcep]

what if the monitor shows vfib but the patient is alert, talking, and normotensive ?

Easy...VFIB is "road-noise," as true VFIB is non-conducive to life. Anyone ACTUALLY in VFIB is a code. Take your monitor leads off the boney prominances...lift the monitor off the metal cot and see what happens.

[fiznat]

I'm a little late to this one but I think I'm joining the "would give cardizem" camp. A 70 year old with a heart rate over 200 needs rate control, regardless of whether she is hemodynamically stable at that precise moment in time. A person's max heart rate is 220bpm minus their age. This woman is exceeding her max by about 33%, which is significant in someone like this who is predisposed for cardiac disease. The pulse rate, while interesting, is irrelevant (imho) to this decision because we are worried about cardiac work and O2 demand, which is a larger consideration than simply looking at pulse-producing contractions. We have standing orders for cardizem, and I think I probably - barring some other finding - would have given it a shot.

Let's not forget that this provider indicated that Cardizem would have been an on line medical control order. While I respect his decision to remain conservative in light of the physical presentation, I think at LEAST a discussion with the doc on the radio was warranted. I think if anything, the extensive discussion on this board has proven that the decision is not clear cut. The OP probably should have consulted with the doc about it.