Complex cardioversion?

[JPINFV]

:roll: So, people with DNRs (many have a provision against cardioversion) or who are against medicine for religious reasons aren't sound of mind?

[1EMT-P]

Oh Say It Isn't So = Oxygen Saturation, Suction Equipment, IV Line, Intubation Equipment & Sedation & Possible Pain Medication.

[sledogg1]

If the pt has time to be sedated prior to cardioversion Versed 2.0 mg over 1 min every 2-3 mins up to 10.0mgs, Valium 5.0 to 10.0 mgs over 1 min. I go AC IVP fast and quick. But life over limb..............its sucks not sedate it seems cruel but you have to do what u have to do.

Good Luck and Happy Zapping

[firefighter523]

You should NOT let them decide, that is what you are there for. You are the professional, and are the one that is supposed to know what to do. Make a decision and go with it. Just hope it is the right one. This pt sounds like they are unstable. I would cardiovert, if vitals and and pt impression indicate. Blue lips, resp distress with rapid A fib would get electricity.

[ERDoc]

You should NOT let them decide, that is what you are there for. You are the professional, and are the one that is supposed to know what to do. Make a decision and go with it. Just hope it is the right one. This pt sounds like they are unstable. I would cardiovert, if vitals and and pt impression indicate. Blue lips, resp distress with rapid A fib would get electricity.

So you are willing to take away your pts autonomy, their right to make an informed decision and possibly commit battery? You are correct when you say that you are supposed to know what to do, but being a professional also means being able to fully inform the pt of what is going to happen in terms that they can understand and allowing them to make an informed decision. Not doing so means you are acting as a technician.

[Laura Anne]

I went back and reread the article in reference to the last few posts. Just wondering..... it said he has an Altered Mental Status. How altered is it? Is it altered due to an injury/illness; dementia, previous stroke which very possibly be due to the A-fib hx, or is it just because he is hypoxic? Regardless of the altered status and capability of deciding legally of the treatment rendered, I'd still do my best to provide some analgesic of some sort prior to cardioversion if that's what the patient was to receive. Even if this was my loved one who was altered due to some sort of illness(Alzheimers) and I was the POA, I'd like them to have some management of their pain/distress. As compassionate as this sounds, I do understand the choice of cardioversion w/o sedation and could not fault someone if a patient was this critical.

Also, I wonder how compliant this patient was with his meds, if he took any and how often. After all, he had severe COPD, emphysema/CHF and still smoked.

[ERDoc]

I went back and reread the article in reference to the last few posts. Just wondering..... it said he has an Altered Mental Status. How altered is it? Is it altered due to an injury/illness; dementia, previous stroke which very possibly be due to the A-fib hx, or is it just because he is hypoxic? Regardless of the altered status and capability of deciding legally of the treatment rendered, I'd still do my best to provide some analgesic of some sort prior to cardioversion if that's what the patient was to receive. Even if this was my loved one who was altered due to some sort of illness(Alzheimers) and I was the POA, I'd like them to have some management of their pain/distress. As compassionate as this sounds, I do understand the choice of cardioversion w/o sedation and could not fault someone if a patient was this critical.

Also, I wonder how compliant this patient was with his meds, if he took any and how often. After all, he had severe COPD, emphysema/CHF and still smoked.

I admit, I missed the AMS part of this also until Laura pointed it out. I still think this pt needs some form of sedation and analgesia. Something quick on, quick off would be appropriate such as propofol or etomidate, but you do have to keep the BP in mind.

[firefighter523]

Yes sir you are right about letting them know what is going to happen. I guess that came out wrong, If they are that critical, there decision should not dictate your treatment. You are just delaying the inevitable. That is what I meant, but yes, you are right, about letting them know. That is just common sence. I have cardioverted atleast 4 pts and not one of them I told that it was going to hurt, you know why? They couldn't HEAR nor SEE me, because there eyes were rolled to the back of there head!! This is not the ER, and the conditions out here arent the same as in the controlled environment that you are in. Sorry about the confusion!!

[ERDoc]

Yes sir you are right about letting them know what is going to happen. I guess that came out wrong, If they are that critical, there decision should not dictate your treatment. You are just delaying the inevitable. That is what I meant, but yes, you are right, about letting them know. That is just common sence. I have cardioverted atleast 4 pts and not one of them I told that it was going to hurt, you know why? They couldn't HEAR nor SEE me, because there eyes were rolled to the back of there head!! This is not the ER, and the conditions out here arent the same as in the controlled environment that you are in. Sorry about the confusion!!

I know the conditions you work in. I was there for 10+ years prior to med school and on occasion I still get to go out into the field. They are not as dramatic as you make them out to be. A good provider will always be able to maintain a controlled environment in the ambulance if they are competent and knowledgeable (with the exception of violent situations). The pt's decision should always dictate your treatment, otherwise like I said you are taking away their autonomy and committing battery. If the pt says no, then it is no. It sucks as a provider to watch someone go down the drain, but as a professional you are required to honor the pt's wishes if they have the capacity to make their wishes known. The pts you describe obviously do not have the capacity to make their own decisions.

[OVeractiveBrain]

I am under the assumption that if we have the capacity to allow the patient's autonomy to deny cardioversion, they are most likely not symptomatic enough to indicate cardioversion. This was one of the points I tried to stress in my reply post (about 10 ago). IF you are going to cardiovert in the prehospital setting, there better be one hell of a good reason. Otherwise, try something else; we have the options to do so. Since in THIS particular case the patient was altered and, instead of repeating all the symptoms again, "circling the drain" cardioversion is indicated and should be given.

That being said, I agree with ERDoc that you can both maintain a calm environment and control a situation in an ambulance. The only difference should be the number of people you have to help (obviously in a serious case you can always have more hands in an ER where you can be limited to just yourself and maybe your partner in prehospital care). However, I do not see the use of cardioversion when indicated "against a patient's decision" as a removal of their autonomy. If they are not of a competent mind (AMS being one of the strongest indicators for compromised circulation and the need for cardioversion) it should be up to the provider to decide. I think in every post I make i say that "it depends." If the family is against it, and the patient is, and your partner and the police officer behind you, ok, maybe you dont. But in most cases the decision is not so clear and we must use our judgement. But Ill say it again, if cardioversion is indicated in the prehospital setting, the patients condition is probably such as NAME so eloquently described: so altered that they cannot decide themselves. Even if it were not as extreme as "eyes rolled back in their head" some one who has been cardioverted without sedation in the past certainly has a conditioned response to fear and pain when they hear cardioversion, and may be able to express "i dont want to be hurt" but it will come out more like "no." So, if altered, light em up. If not altered, though severely symptomatic, a judgment call is necessary. I would say to have the pads on ready to shock, but dont, since they are mentating well, and treat with other medications.

not in response to cardioversion but just in general treatment plans, I am not a fan of ASKING permission when giving a therapy, especially in the acute setting. I always say what Im going to do, what it is for and what might happen, but I pitch in a way that says "im going to do this, so if you dont want me to, you better say so now cause here it comes" and its done. Personally, Id rather not give a med or perform a therapy other than saline if I dont have to. So if Im giving one, the patient needs it, so theyre going to get it. Obviously this is my own practice and highly circumstantial, but I would rather inform and give rather than wait for permission. I dont want anyone to think I go around giving patients treatments without their consent, I just get it by explaining how much they need it; selling a definite one-sided pitch, implying their is no other option.

On a final note about DNRs (which i saw a ways back) there is definitely some controversy over how much a patient can or cannot allow based on predetermined decisions and a living will. in fact, Im going to start a thread of the same subject right now.