cardiac case senario(not a real patient)

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you are a cct nurse enroute to nearest cardiothoracic center with a 51y male patient new dx acute mi. your patient's rhythm changes from sinus rhythm to vtach rate of 166. according to nursing text books lidocaine is not the drug of choice. what would you do if the patient is symptomatic(aloc) with weak pulse. and what would you do if the patient is awake with pulse?

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Specializes in Cardiology.

Symptomatic vtach? Synchronized cardioversion. Drug of choice: amiodorane.

Asymptomatic vtach? Crash cart ready, pads on chest, calling MD STAT.

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Specializes in Flight, ER, Transport, ICU/Critical Care.

Lets get to the point.

V-Tach -

Although altered LOC a pulse remains. (Vtach with a Pulse!)

I would give the drug du jour (versed, fentanyl, valium, morphine) that could be tolerated by the patient (if he had a BP, etc) and then proceed to synchronized cardioversion as indicated. (Most patients can at least tolerate Fentanyl even with low BP, usually versed too)

* The reason to medicate here is to alter patient perception of just how much the cardioversion is gonna hurt. IT STILL HURTS! I'd just medicate to try and limit the myocardial oxygen demand that will surely increase in the conscious patient with the cardioversion. Of course, there are a few patients that can become obtunded so quickly that pre-medication is not possible and immediate cardioversion is the ONLY option. So....

As to medication therapy.

Not too sure why lidocaine falls in and out of favor. It is my understanding that you may use lidocaine OR amiodarone as the anti-arrhythmic of choice and then hang a drip of the medication that terminates the arrhythmia. The KEY here is that you not mix. Don't give lido then amiodarone then hang a lido drip. Bad juju there!

My SOP's allow for either. I have seen good and bad results with either. So, it really can be a local preference. Amiodarone is not a benign drug - has a long half life and there are issues with toxicity. I look for the AHA to continue to change things - they have for 16 years, so I suspect it will always continue.

Bottom line:

Your patient has an evolving MI - he is chewing up heart muscle. I'm going to do ANYTHING I can to limit his myocardial oxygen demands/consumption. This is a younger patient and does not have the benefit of collateral circulation. I would also look at the overall health status and co-morbid factors that may effect his survival. Since respiration uses up approx 60% of cardiac output, if necessary I'll help him with the that via RSI and a ventilator. Although I do consider RSI an aggressive step - it would reduce the work load on his heart considerably --- while maximizing oxygenation. Also, then you have to consider the work of the heart itself - you have to be able to maximize cardiac output to maintain good perfusion. It is a delicate balance.

Terminate the arrhythmia. Minimize myocardial oxygen demands. Maximize cardiac output.

Treat the patient - never treat a monitor.

This patient needs the services of a great cardiothoracic team and interventional reperfusion. If you are on the ground with a long transport, I'd look at the possibilities of getting air support to intercept the ground unit. What he really needs is a critical lifesaving drip of diesel or Jet-A, the faster the better.

Practice SAFE!

;)

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If u witness it on the monitor, can't u just "thump" them???

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If u witness it on the monitor, can't u just "thump" them???

Not recommended if they have a pulse. I believe AHA considers it Class IIb in situations where the pt is pulseless and there is no defibrillator immediately available.

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Specializes in Peds/Neo CCT,Flight, ER, Hem/Onc.

Our policy. Lido first because it's easy to administer quickly followed by Amio bolus which technically should go over 15 minutes and is a pain to mix (all that foam) followed by Amio drip. NREMT-P/RN is right. Once you start Amio you can't go back but you can start with Lido and move forward. As far as intubating, I'm 50/50 on that. It all depends on the patient. If they look like they're going to crap out it's way easier on the heart to do an RSI rather than a crash intubation. In the meantime maximize oxygenation-no measly nasal cannula. 15lpm by NRB!!!! And watch that BP.

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thanks i will email american heart and see what they say.

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Our policy. Lido first because it's easy to administer quickly followed by Amio bolus which technically should go over 15 minutes and is a pain to mix (all that foam) followed by Amio drip. NREMT-P/RN is right. Once you start Amio you can't go back but you can start with Lido and move forward. As far as intubating, I'm 50/50 on that. It all depends on the patient. If they look like they're going to crap out it's way easier on the heart to do an RSI rather than a crash intubation. In the meantime maximize oxygenation-no measly nasal cannula. 15lpm by NRB!!!! And watch that BP.

Our Paramedics either use lidocaine or conversion. They say they could give amiodarone but they cannot make a drip (900mg in a glass bottle is a lot and glass in an ambulance is difficult at best)

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