PVC's....

[DwayneEMTP]

My general advice to you would be to treat the patient and not the monitor.

Can I ask a huge favor? Is it possible that we can get through a discussion of anything cardiac without the use of 'treat the pt, not the monitor' over and over and over? I mean, we've all heard this ol' saw from our first week of medic school, and many of us from our second or third week of BLS education. The OPs presentation seems to make it clear to me that he is in fact treating his pt, and not the monitor.

Why is it when we talk trauma we never hear, 'treat your pt, not the b/p cuff'? 'Treat your pt, not the ETCO2'? For some reason we use each of these tools, as with a monitor, to add to our assessments but aren't considered foolish or medically immature for referencing their data when discussing treatments.

Not trying to be a shithead everyone, truly I'm not, but I began to be offended for this poster after about the 3rd or 4th repetition of a phrase that he almost certainly didn't need to hear in the first place.

K, off of my soapbox now.

Imagine, if you will, that you were part of a BLS crew treating a SOB pt. Would you have treated the pvc's then. NO, of course not, because they were asymptomatic and so you would have had no notion of their presence.

I don't really get the logic here WM. So then, do I not get aggressive infact that fell off of the roof onto soft grass, is not 'appearing' hurt and his pulse rate is steady and within normal regulars? Do we not treat the female syncope because she isn't pale, diaphoretic, her pain isn't 'crushing or radiating' and is 'fine now' but 12 lead is showing a STEMI? After all, most BLS providers wouldn't have caught the implications that, in each, the lack of symptoms was possibly a very ominous sign.

It seems to me that he discovered what appeared to be an increasing ventricular pathology and was asking if he could have prevented further degradation by being proactive (An attitude that I like and respect a lot) or if waiting to be forced into treating it was more appropriate. Mainly, because I'm a chicken shit, I nearly always choose to be very aggressive where I can justify it as I friggin hate finding myself behind the eight ball when I could have avoided it. I think he posited an great educational question.

Relax, enjoy the ride and be good to your patient. Give them what they need, not what your cookbook says....

Awesome advice, but if I may, I believe that at times, if we pay attention, we can give our patients what they need before they really, really need it. Isn't that an example of the very best we can offer in medicine, and isn't that what this thread was really about?

Not meaning to snipe at you WM, it just happened I 'got going' on the other stuff after starting to respond to your post.. :-)

Dwayne

[Kiwiology]

No changes on 12 lead, not hypoxic, no haemodynamic compromise, no hyperkalemia so I am not concerned

Could it be that we have ants in our pants over *gush, something almost totally benign in the absense of any worrying S&S or pathology?

[HERBIE1]

My general advice to you would be to treat the patient and not the monitor. Imagine, if you will, that you were part of a BLS crew treating a SOB pt. Would you have treated the pvc's then. NO, of course not, because they were asymptomatic and so you would have had no notion of their presence.

That list of yours will stand you in good stead, I was going to post on VT salvo's but you already have the heads up there.

Relax, enjoy the ride and be good to your patient. Give them what they need, not what your cookbook says....

WM.

PS the word is aneurysm.

Relax, enjoy the ride and be good to your patient. Give them what they need, not what your cookbook says....

Best advice I've heard in a long time. Too often we get caught up in using our toys, pushing meds, and in general justifying all that money, time, effort, and studying we did for school. Sometimes the very best thing we can do for a patient is to NOT do anything for that patient(other than observe and monitor, of course).

Watch them, talk with them, and see how much of a difference a friendly ear can make. I have learned some amazing things from my patients and feel honored they were willing to share their thoughts with me.

[Kiwiology]

Watch them, talk with them, and see how much of a difference a friendly ear can make. I have learned some amazing things from my patients and feel honored they were willing to share their thoughts with me.

I second that; there are some really amazing people out there who all too often society in general but brushes over and doesn't take the time to recognise them.

You know I used to hate elder-care facilities, rest homes etc I was niave and looked upon them as boring or somehow sub-par to you know, doing IVs and dealing with people who are really crook. Now, I've done a 180° and asbolutely love going to them and have started to visit my Nana each weekend in her home; the people are just fantastic and you can often get roped into talking with 'em about all sorts of really cool stuff.

Same goes for all patients not just old folk; kids have a wonderful way of talking and looking at the world and you can get some really interesting stuff out of them too. You have some sort of skermish, send in a 12 year old to sort it out and he'll have everybody happy-as-larry playing four square in no time!

One of the biggest things that we forget is that patients are people too, Lord knows I have done it!

[Mark the O]

No changes on 12 lead, not hypoxic, no haemodynamic compromise, no hyperkalemia so I am not concerned

Could it be that we have ants in our pants over *gush, something almost totally benign in the absense of any worrying S&S or pathology?

So in the interest of keeping the conversation going....with the pt's Hx, age, and cardiac findings (occasional PVC's to increasing PVC's to trigeminy) is not chest pain/discomfort, and sudden SOB not a significant finding that could be either a result of the pain and SOB or a cause? And maybe im mistaken but isnt the progression of the ventricular ectopy a change on the EKG including the 12 lead?

In general, I was not very worried about the pt. She was in some amount of distress but I (eventually) did not feel that she needed immediate treatment. With that said, I like the way someone else put it....Could I have prevented something that potentially happened or could have happened an hour after I dropped her off?

PS. ... Im begining to detect some tension in this post.....CHILLLLLLL, maybe we should get a 12 year old to post and solve this issue.

[Kiwiology]

So in the interest of keeping the conversation going....with the pt's Hx, age, and cardiac findings (occasional PVC's to increasing PVC's to trigeminy) is not chest pain/discomfort, and sudden SOB not a significant finding that could be either a result of the pain and SOB or a cause? And maybe im mistaken but isnt the progression of the ventricular ectopy a change on the EKG including the 12 lead?

In general, I was not very worried about the pt. She was in some amount of distress but I (eventually) did not feel that she needed immediate treatment. With that said, I like the way someone else put it....Could I have prevented something that potentially happened or could have happened an hour after I dropped her off?

PS. ... Im begining to detect some tension in this post.....CHILLLLLLL, maybe we should get a 12 year old to post and solve this issue.

The only tension up in here will be whether we play four square or rockem-sockem robots, maybe after that we can go watch Rugrats; OK I'm showing my age or lack thereof.

It is possible she is having a fresh cardiac event which is causing an irritable ventricular foci or increased cardiac automasticity and wow there's the ubiquidose 400 causes for each of those. The shortness of breath and/or chest pain could be causing increased sympathetic nervous tone which would increase circulating levels of adrenaline (possibly some other catecholamines too) and this may explain the PVCs.

Concerning however is the regularity of the ventricular trigeminey .... I would learn more towards some sort of fresh cardiac event here causing increased automasticity, perhaps even an NSTEMI but that'd be a bit of a reach although .... elderly, female, you know where this is going.

The hypoxemic infarcting muscle reverting to anaerobic metabolisim releasing lactic acid would cause chest pain and increased automasticity of that particular area creating the ventricular ectopics.

Worth a look at the ho'biddle anyway.

[BoCat9]

Ok, we're doing this in class right now, so I'm going to attempt this. I didn't look past the scenario, so I'm not just going but other peoples answers. Let me know if I'm right or wrong, please.

Ok, PVC's...

O2 first to try to knock out the PVC's.

Place the pt on a monitor, if the occurrence of the PVC's is less than 6 per min, no couplets, monitor the pt closely. Get IV access to give meds if necessary.

If PVC's are occurring over 6 times a minute or I see runs of PVC's I would look at the actual heart rate, if knocking out the PVC's would make the pt bradycardic, maybe try TCP? I'm not really sure. Don't want to administer Lidocaine due to possibility of additional bradycardia.

I don't know where to go from there, sorry.

[DartmouthDave]

Ok, we're doing this in class right now, so I'm going to attempt this. I didn't look past the scenario, so I'm not just going but other peoples answers. Let me know if I'm right or wrong, please.

Ok, PVC's...

O2 first to try to knock out the PVC's.

Place the pt on a monitor, if the occurrence of the PVC's is less than 6 per min, no couplets, monitor the pt closely. Get IV access to give meds if necessary.

If PVC's are occurring over 6 times a minute or I see runs of PVC's I would look at the actual heart rate, if knocking out the PVC's would make the pt bradycardic, maybe try TCP? I'm not really sure. Don't want to administer Lidocaine due to possibility of additional bradycardia.

I don't know where to go from there, sorry.

Hello BoCat9,

No need to be sorry about anything. Posting is hard sometimes. In fact, I have been mostly a lurker since 2005! =)

There are a great deal of possible causes of PVC's as you know.

In the case of a AMI PVS's typically are left alone. Relaxing the patient (being kind and maybe an Ativan) can help reduce PVC. As well as oxygen in and pain control. Though not a concern in the EMS setting lytes play a key role in reducing PVC. AMI patient typically have their K and Mag kept the high end of normal as well. Plus, if there are no signs of failure IV Metoprolol helps sooth things as well.

Cheers....

[Kiwiology]

Ok, we're doing this in class right now, so I'm going to attempt this. I didn't look past the scenario, so I'm not just going but other peoples answers. Let me know if I'm right or wrong, please.

Ok, PVC's...

O2 first to try to knock out the PVC's.

Place the pt on a monitor, if the occurrence of the PVC's is less than 6 per min, no couplets, monitor the pt closely. Get IV access to give meds if necessary.

If PVC's are occurring over 6 times a minute or I see runs of PVC's I would look at the actual heart rate, if knocking out the PVC's would make the pt bradycardic, maybe try TCP? I'm not really sure. Don't want to administer Lidocaine due to possibility of additional bradycardia.

I don't know where to go from there, sorry.

You need to look at the context of the PVCs. If they in somebody who is nauseated, grey and sweaty, doubled over and saying "why is Kiwi's pet elephant, Stanley, sitting on my chest?" then it's probably not a good thing. On the other hand somebody who has a stubbed toe and a few PVCs because of the pain is increasing sympathetic stimulation eh, no biggie.

Amiodarone might be warranted in the cardiac patient who is having runs of PVCs with ST changes on a 12 lead and screaming chest pain becuse the underlying cause for the PVCs is likely to be ischemia and this guy is at risk of going into VT or VF and dying whereas the patient with a stubbed toe isin't.

[DartmouthDave]

So this particular pt had vitals all within normal ranges. I did mean 12 lead by the way. Got several of them on the way (while stopped). there was no other abnormal findings on that.

Her history was somewhat troubling. she had an aortic anyerism (spelling?) that was being monitored, 3 MI's and a long list of other things. after debating wether or not to treat, I decided to be more conservative due to there being no other changes in her status (monitor changed...pt did not change). The thing that kept ringing in my head was the list of things that make PVC's dangerous....the list i learned in school 5 years ago. Multifocal PVC's, more than 6 a minute, R on T, runs of V-Tach...she was sure having more than 6 a minute. Oh and FYI, she was being treated for CP and SOB with O2, IV, ASA, Nitro and of course the EKG. other comments....................I have had several pt's like this and Im still trying to form a general idea of wether to be more aggressive or not.

Hello,

The Aortic Aneurysm could be the cause of the chest pain as well. A Thoracic Aortic Aneurysm (TA)can present with SOB, coughing and chest pain. As opposed to the tearing type lower back pain of a AAA. Basically, a TA can pain fairly convincing AMI picture. In fact, Thoracic Aneurysm (TA) is a DDX that one must rule out in the hospital setting before TNK is given or the more aggressive treatments for a AMI.

Sometimes, in theory, their can be a difference in BP from arm to arm in a TA. However, I have never seen this myself.

Cheers....

Edited March 14, 2010 by DartmouthDave