EMS patches into your ED

[a_ditchdoc]

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Actually electricity is safer than adenosine. There have been several case reports of adenosine-induced, aminophylline-resistant asystolic cardiac arrests.

I'd love to know what study this is from. I have loooked and have been unable to find anything that suggests that adenosine is less safe than cardioversion. I am not doubting you, but I would certainly have to read the stats to be firmly convinced (i.e. how many deaths associated with each). I saw someone die once from cardioversion. Perhaps watching it left a bad flavor in my mouth for the liberal use of the procedure. I just feel it is a painful procedure that should be avoided if possible. I have never had problems with adenosine...well... other than the fact it doesn't work sometimes. All else being equal, I would take my chances with adenosine.

 

[12R34Y]

Here are a few studies brought up on rounds about the safety of adenosine.

Pretty safe drug.

TAN, H.L., ET AL.: Adenosine Induced Ventricular Arrhythmias in the Emergency Room. While adenosine effectively terminates most supraventricular tachycardias (SVT), rare case reports have demonstrated its proarrhythmic potential, including induction of ventricular tachycardia (VT). The aim of this study was to define the proarrhythmic effects of adenosine in a large, unselected population. During a 5-year period, adenosine was used (average dose 9.7 mg) in the emergency room to manage 187 episodes of tachycardia in 127 patients. In two thirds of the cases, adenosine induced ventricular ectopy following successful termination of SVT, including premature ventricular complexes (PVC) and nonsustained VT. The adenosine induced PVCs and VT were transient and self-terminating. More than half had a right bundle branch block morphology with a superior axis that suggested an origin in the inferior left ventricular septum. In conclusion, although adenosine is commonly used in clinical practice to treat SVTs, we found that it induced PVCs and VT in two thirds of the patients. The high incidence of ventricular arrhythmias following adenosine infusion was surprising but did not require further intervention. These arrhythmias appeared to frequently originate from the inferior left ventricular septum, suggesting that this area may be particularly susceptible to the proarrhythmic effects of adenosine. (PACE 2001; 24[Pt. I]:450-455)


Prospective evaluation of adenosine-induced proarrhythmia in the emergency room.
European Journal of Emergency Medicine. 8(2):99-105, June 2001.
CAMAITI, A. 1; PIERALLI, F. 1 *; OLIVOTTO, I. 1; GRIFONI, S. 1; CONTI, A. 1; DEL ROSSO, A. 2; BERNI, G. 1
Abstract:
The arrhythmogenic hazard of adenosine treatment in an emergency room (ER) has not been established. Thus, in this study, we set out to prospectively determine the prevalence and clinical consequences of the arrhythmogenic effects associated with urgent adenosine treatment in the ER. One hundred and sixty consecutive patients treated with adenosine for regular wide or narrow complex tachyarrhythmias at our ER were included in the study. An initial bolus of 3 mg of adenosine was used, up to a maximum dose of 18 mg (mode 6 mg). Proarrhythmia was defined as the new appearance of any brady- or tachyarrhythmia within 1 minute from the bolus administration of adenosine. Of the 160 study patients, 84% had narrow complex tachycardia and 16% had wide complex tachycardia. Adenosine was effective in the diagnosis and/or treatment of the underlying arrhythmia in 92%. The overall prevalence of adenosine-induced proarrhythmia was 13%, including prolonged AV block inducing asystole >4 seconds (7%), paroxysmal atrial fibrillation (1%) and non-sustained ventricular tachycardia (5%). All adenosine-induced arrhythmias were transient and subsided spontaneously. It is concluded, firstly, that adenosine-induced proarrhythmia proved to be frequent in a consecutive ER series, and included potentially dangerous arrhythmias. Secondly, nevertheless, all adenosine-induced arrhythmias subsided spontaneously and did not require treatment. Therefore, urgent adenosine treatment is safe and can be recommended in an emergency setting, provided a strict protocol of administration under close monitoring by highly trained personnel.

later

 

[DropkickMurphy]

Actually electricity is safer than adenosine. There have been several case reports of adenosine-induced, aminophylline-resistant asystolic cardiac arrests.

The question that needs to be asked about that is how often does it happen? I mean several case reports might not mean much if it is several people out of several thousand or several tens of thousands of cases. Also how does this compare (as 12R34Y mentioned) to the safety of conscious sedation and cardioversion in an unstable patient? Both of these are procedures with good safety profiles but how does that stack up against adenosine?

EDIT: Guess I should read to the end of a thread before posting....

 

[blotto geltaco]

"there is very little reason to give adenosine pre-hospital."

I was on the meat wagon for a number of years before med school and I gave adenosine many times, never had a problem. I think it is completely reasonable for EMT-P's to push it in the field.

 

[Jeff698]

"we held the beta blocker because she has a history of asthma."

At least that's better than the primary team we were consulting with on a patient who were witholding metoprolol because the patient was bradycardic....with nice, pretty pacer spikes.

As funny as I thought that was, I just read some of my dictations from last shift and am certainly not feeling all that smart anymore. Damn, I say some silly things when I'm tired.

Take care,
Jeff

 

[docB]

Well I certainly broke the first rule of EMS which is never tell a paramedic that they shouldn’t have some modality that they want. I stand by my assertion that Beta Blockers don’t need to be given during a transport. If someone is unstable then they get shocked. Adenosine is fine while you’re putting the paddles on.

This starts to sound more and more like those calls you get where medics are reporting what they’re worried may happen. I got a call recently from someone who said “I’ve got a bad COPDer who needs to be tubed so I want to give Mag.” I denied it and said that if the pt needs to be tubed then tube them. The medic came in and was livid. He was adamant that he had seen Mag work lots of times and I was stupid to not let him give it. You know, if he had said “I’ve got a COPDer who is on nebs and I want to try Mag.” I’d have said whatever, and wave some voodoo beads over her too. Knock your self out. But if the decision tree is intubate now or try Mag as some hail Mary just tube. This discussion sounds like people are worried about being on a long transport with a pt who might deteriorate over time and they are supposing that that could be avoided by giving Lopressor prophylacticly. Whatever. If it’s in your protocols go for it.

 

[12R34Y]

Off the topic completely. do yo like mag for bad asthma? I've seen it used quite a bit for bad asthma. just curious.

later

 

[a_ditchdoc]

Well I certainly broke the first rule of EMS which is never tell a paramedic that they shouldn’t have some modality that they want. If someone is unstable then they get shocked. Adenosine is fine while you’re putting the paddles on .... If it’s in your protocols go for it.

Of course, you should be applauding me for not wanting to "Light up" the patient with a few hundred joules, instead choosing the conservative approach. I just think adenosine is safe, more patient friendly, and should be used before trying to cardiovert...assuming you have the time. The most trouble I ever had with it was a brief asystole/block that the patient didn't even notice, and of course the occasional failure to work.

"Unstable" can be defined in a number of ways. Unstable as in they look like they might not survive to the hospital...thats really unstable. Unstable due to a "little chest pain" is a different matter. Hell, they are gonna have a "lot" of chest pain when you put the paddles on...

Anyway, didn't mean to get your goat...

 

[bartleby]

No one here is arguing that adenosine is not a useful drug. The point is that if you have stable SVT (which is by its very definition a condition you would consider using adenosine to treat) it rarely _needs_ to be treated immediately in the field. If the patient is unstable (i.e. hypotensive), you should not be taking the time to screw around with a pharmacologic agent while the patient is going down the pipes.

I think I'd rather have a 20 y/o paramedic in the field giving someone 6 of adenosine rather than sedating them with versed, giving narcs (now you have a potential airway problem as well) and then cardioverting them!

 

[QuikClot]

No one here is arguing that adenosine is not a useful drug. The point is that if you have stable SVT (which is by its very definition a condition you would consider using adenosine to treat) it rarely _needs_ to be treated immediately in the field. If the patient is unstable (i.e. hypotensive), you should not be taking the time to screw around with a pharmacologic agent while the patient is going down the pipes.

If you already have the IV, adenosine is going to go down faster than strapping on the pads, sedating and shocking. You can always work up to electricity.

Stable SVT may not remain stable for long. It can cause intermittant hypotension or degenerate into some other bad AR. Better to treat it as you find it than sit on it for a half an hour or more.

Back on the thread topic for a minute; everybody understands that medics don't decide on the spur of the moment what to include in a hear report, right? They get taught a model and they use it. We use ETA/Age/Sex/CC/Vitals/Treatment, takes about 30 seconds. Some people go off-message (and sometimes there's a good reason to), but if _every_ medic is giving you more information than you want, it's because they've been told to. Take it up with the medical director.

 

[beriberi]

When hospitals do reviews of medication errors, beta blockers are one of the most commonly involved substances. Doctors prescribe it wrong, nurses give it wrong, and results can be disasterous. This occurs not just on the floors but also in the ED and the Units. If people who use a drug daily commonly make mistakes with it, it will be even more difficult to use in prehospital setting--where there is less provider familiarity and certainly less controlled circumstances to give it. It came up recently at a pre-hospital agency meeting and the physicians/rns present gave a resounding no.

Also--do paramedics in y'alls neck of the woods sedate before shocking? Is it required?

 

[DropkickMurphy]

It's not a requirement but if there is time most medics around here will sedate before hand. The ONLY real excuse IMHO for not giving sedatives prior to cardioversion is a crumping patient.

 

[a_ditchdoc]

Yeah, we sedate. But i my opinion, sedating an unstable patient is more risky than chemical cardioversion. Of course, if they lreally look like crap, or have an altered LOC, we skip the sedative...

 

[bartleby]

There is a circularity to this discussion which is becoming tiring, but lest people who have not administered adenosine get the wrong idea, this is not a "pop and it's in" kind of drug. It needs to be administered as a rapid bolus and be followed immediately by a flush. If it is not pushed quickly enough, it will not work. Furthermore, those who forget that all drugs have associated risks and side effects proceed at their own (and their patients') peril.

If you already have the IV, adenosine is going to go down faster than strapping on the pads, sedating and shocking. You can always work up to electricity.

Supraventricular tachycardias do not have a high propensity for degenerating into malignant rhythms. SVT is not akin to ventricular tachycardia leading to fibrillation, and is a separate issue entirely. People live with atrial fibrillation, which is a "supraventricular" tachycardia, for decades without any increased risk of sudden cardiac death. The SVT which is amenable to treatment with adenosine, AV nodal re-entrant tachycardia, is uncomfortable for patients due to the associated rapid HR and is thus more of a nuisance than anything.

If a patient is experiencing hypotension in the setting of SVT, it is most likely rate related (which reduces ventricular filling during diastole and thus knocks down your cardiac output) or due to a secondary cause. In this case, the patient is unstable, and you should bypass a cardiac depressent agent such as adenosine in favor of syncronized cardioversion.

Stable SVT may not remain stable for long. It can cause intermittant hypotension or degenerate into some other bad AR. Better to treat it as you find it than sit on it for a half an hour or more.

 

[edinOH]

I haven't read this entire thread so forgive me if I'm off topic...

I for one wish EMS would learn the art of the ten-word patch.

Just tell me the facts and get the hell off the radio!

I swear sometimes third year medical students could give a more succinct report.

Do the medics get paid by the word?

 

[Emergency!]

I haven't read this entire thread so forgive me if I'm off topic...

I for one wish EMS would learn the art of the ten-word patch.

Just tell me the facts and get the hell off the radio!

I swear sometimes third year medical students could give a more succinct report.

Do the medics get paid by the word?

To repeat Bartleby and others . . . . most medics/EMT's give detailed reports because THAT'S HOW THEY ARE TAUGHT TO DO IT. If everybody in your facility has a problem with EMS patches being too long, then put together a little synopsis of what you want and pass it along to the crews that frequent your ED.

On another note, having worked in several different systems and regularly transported to several different hospitals - different hospitals want different things called into them. Most medics/EMT's I know err on the side of giving too much info on a call in, rather than get ripped upon arrival for not giving enough. Sometimes, there is no winning. If I give a detailed report, I arrive and it seems like nobody has any freaking clue that I was even coming in. If DON'T give a detailed report, I get ripped to shreds for not giving enough info.

My strategy, upon going to a facility that I was not familiar with was to give a quick synopsis - age, sex, why they are being transported, last set of vitals, and ETA - and then ask "Do you have any questions or orders?". For those who don't want more, they can say "Nope - see you in ten", those who want more can say "Give us more".

😎 Just my perspective . . .

 

[basementbeastie]

"Sometimes, there is no winning. If I give a detailed report, I arrive and it seems like nobody has any freaking clue that I was even coming in. If DON'T give a detailed report, I get ripped to shreds for not giving enough info."

HEHEHE....NO DOUBT!!!!


"My strategy, upon going to a facility that I was not familiar with was to give a quick synopsis - age, sex, why they are being transported, last set of vitals, and ETA - and then ask "Do you have any questions or orders?". For those who don't want more, they can say "Nope - see you in ten", those who want more can say "Give us more". "

THAT IS A PERFECT STRATEGY....