Complex cardioversion?

[1EMT-P]

I think we have to address the patient's A-fib, CHF and COPD if we are going to have a successful outcome. Instead of cardioverting the patient, I would rather control his rate, decrease his anxiety, decrease his hypoxia, decrease his symptoms and decrease the workload on his heart.

[ERDoc]

I think this case is actually a little more complex than what I originally thought. After reading a few people's post I was left wondering what they were thinking and where they got their information from. I went back and reread the OP. I must have misread it or something, because the second time around I was left wondering what was really going on. Complex for sure. I don't think there is any simple answer in this case and there may be more than one right answer, it's a personal prefernce type situation. I think this is one of those scenarios where actually being able to see and examine the pt might change your mind about your treatment. 1EMT-P, my comment about beta blockers was made under the assumption that this was pure COPD, a fact that I admit is probably not true. However, when you make an agruement that several studies have shown such and such, you need to reference those articles so that others may argue for or against them. Interesting case. I'd be curious to see what the workup shows.

[OVeractiveBrain]

Im not really sure where the complexity comes in.

The patient is is awake, alert, and in respiratory distress = high flow 02 (fixing hypoxemia)

The patient is in a narrow complex irregular tachycardia over 200 with a history of Afib. The patient is in a severely symptomatic, most-would-consider unstable narrow complex tachycardia with respiratory (and circulatory) compromise (not the depressed BP and cyanosis).

High flow 02 + cardioversion is straight out of ACLS. How can you as a provider discern whether or not this is respiratory or cardiac. Obviously no one wishes to be a see A do B medic, but Im having a tough time discerning other possible differentials.

(1) Worsening dyspnea over two days (like when some one goes into rapid afib and begins to get weaker and less able to support their own respirations)

(2) Hx of Afib with a narrow complex irregular heart rate

(3) Monstrous pedal edema indicative of insufficient filling time

(4) Cyanosis that shows this person is circling the drain.

COULD these signs and symptoms be part of a CHF / COPD? Of course, they add to one another. But is it more likely that an increased heart rate to an already old, feeble heart is adding to edema both peripherally and centrally? Filling time is lessened significantly to a failed heart with probable small ejection fraction. Again a cardiac problem causing a respiratory problem. Adressing the patient's CHF but ignoring the incredibly fast rate (keep in mind that physiologic responses to hypoxia put a heart rate ~220-age, and should be regular) will not aid their situation. But by looking at this patient, their history, and their compromised state, how could you deny this person cardioversion? What if their distress IS cardiac and you give the albuterol. Their lungs open up and their heart explodes, leaving them in a Vtach arrythmia that you caused. What if their condition IS respiratory and you cardiovert them while oxygenating and getting your cpap ready? Either they return to a rapid heart rate in a compensatory fashion to their hypoxia and you then go down secondary routes of fixing it (cpap, intubation). I know that A comes before C, but not when C looks like the problem. Clinical decisions are always made based on multiple factors (including distance to hospital) but the risk of circulatory and respiratory failure by not cardioverting far outweigh the risk of possible emboli formation by cardioverting. If some one is THAT symptomatic with a heart rate that fast, why would some one deny cardioversion?

The concept of preoxygenating a heart to have it responsive to cardioversion / defibrillation is valid only for a hypoxic heart. If this person has a pulse, and is perfusing distally, we can assume, at this time, the heart is perfused well enough to respond to electricity. The condition they are in however will not allow them to be there for long. Allowing them to maintain a heart rate that has such a high metabolic demand while suffering from respiratory distress can only lead to deterioration. To compound the potential cardiac dysrhythmia with Beta agonists seems folly to me.

In a patient with significant, multiple, compounding history one cannot possibly hope to have such an eagle eye as to say, "definitely respiratory." I must say in a clinch decision making time, Occam's razor wins: the simplest answer is the right one. It seems to me that most people would think cardiac here, especially reading the posts. Only after the fact, once we've been "zinged" by the "right answer" do people argue for the respiratory first.

Simply put: forget protocol HR > 150. Cause or effect, Presentation and history, benefit vs risk. You cant know whether the egg or the chicken came first (though probably the egg since most ancient creatures laid eggs, such as fish, before the chicken).

[firefighter523]

NICE!!! Bravo!! Well said!!!

[OzMedic]

But by looking at this patient, their history, and their compromised state, how could you deny this person cardioversion?

Not saying that I disagree but just out of interest how would you go about cardioverting this patient? Would you sedate them and if so with which drug and what dose? What are you aiming for with sedation LOC wise? I'm just interested to hear your views as I often find this scenario difficult from a decision making perspective. Remember we are talking about a patient that is poorly perfused but still conscious say GCS 13-15. How do other people go about preparing these patients for cardioversion?

[Thunderchild145]

If they absolutely need cardioversion, forget sedation. Just do it.

Obviously give them a little heads up that this will hurt. A lot. And even that is an understatement.

[OVeractiveBrain]

It always depends, right? But if they need cardioversion, they get "this is going to hurt" while the machine is going :DODODODODODODODODODO: If they hate me for it, too bad.

As the placard mounted on my medic instructor reads, "this wont hurt me a bit."

Alternatively, have them looking at your PARTNER while you shock, that way they'll hunt HIM down after they gets out of the ER.

I haven't ever sedated, nor have seen another provider sedate, nor really even heard of fellow providers sedate prior to cardioversion in the prehopsital or ER setting. The scenarios I have heard of it being done is the non-emergency setting, like with the cardiologist after a sustained stable vtach or in an ICU. I know AHA recommends sedation prior to cardioversion, but if they are bad enough to require cardioversion prehospitally (with all the risks of embolism etc for this patient) then they get a whole lot of electricity. If they are stable enough for you to suppress their respiratory drive and wait for the effects of a benzo, you probably could try other meds first.

A bit of anecdotal evidence from an ER:

We had a patient who was in a sustained ventricular tachycardia, diaphoretic but pink, no ALS, slightly out of breath. As medication was going in his mental status changed from alert to a little out of it. The GCS fell to about 13. The doctor pushed us out of the way, jumped to the lifepack and discharged. Granted he was a little skittish and probably could have not pushed us out of the way en route to the paddles, but the point is if they're bad enough to need it, just give it.

[ERDoc]

Im not really sure where the complexity comes in

The fact that you fail to recognize the complexity of this pt says a lot. Nothing I will get into here though.

The patient is in a narrow complex irregular tachycardia over 200 with a history of Afib. The patient is in a severely symptomatic, most-would-consider unstable narrow complex tachycardia with respiratory (and circulatory) compromise (not the depressed BP and cyanosis)...

(4) Cyanosis that shows this person is circling the drain...

The concept of preoxygenating a heart to have it responsive to cardioversion / defibrillation is valid only for a hypoxic heart. If this person has a pulse, and is perfusing distally, we can assume, at this time, the heart is perfused well enough to respond to electricity.

You contradict yourself here. So is this pt perfusing well enough or not? He is obviously not "perfusing distally" if he is hypotensive and cyanotic.

(1) Worsening dyspnea over two days (like when some one goes into rapid afib and begins to get weaker and less able to support their own respirations)

As well as when a pt has CHF, COPD, asthma, pneumonia and a plethora of other things.

What if their distress IS cardiac and you give the albuterol. Their lungs open up and their heart explodes, leaving them in a Vtach arrythmia that you caused.

To compound the potential cardiac dysrhythmia with Beta agonists seems folly to me.

Nope. As stated before, his heart is already maxed out. Depol/Repol is occuring as fast as it can. You could give epi and not increase the rate any further. Giving albuterol will not hurt the heart any more that the rate is and it will help open the airways.

Clinical decisions are always made based on multiple factors (including distance to hospital) but the risk of circulatory and respiratory failure by not cardioverting far outweigh the risk of possible emboli formation by cardioverting.

Easy to say when you are not the one that will be left paralyzed or unable to speak. If there are other available therapies that may not end with brain damage, would it not be prudent to consider them? Just because we can do something doesn't mean we should. The values that you put on certain risks and benefits may not be the same that the pt or another provider would put on them. Medicine is not black and white. There are often several ways to get to the same end. With a little more experience you may soon realize this.

[ERDoc]

As the placard mounted on my medic instructor reads, "this wont hurt me a bit."

Your instructor mounted a placard on himself???? :shock:

Sorry, just couldn't let this one get by.

I also get the impression that several people here are suggesting that we not allow a pt to make an informed decision and give informed consent to a painful and invasive procedure. Is this what people are getting at?

[Thunderchild145]

Pain is temporary. Death is permanent. I think just about any person of sound mind is going to elect cardioversion over death, but for the sake of arguement, yes, I would allow them to decide until such point as they became unresponsive in the back of my abbulance and at that point, if I didn't have it in writing, I would be forced to decide for them.