Not sure who else to ask (clinical scenario)

[fiznat]

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*Question from a paramedic for the EM docs, if you would*

I've asked several of my local docs about this, but it seems either they don't have time to answer or simply don't care. I'd really like to get the most complete answer possible, so I would really appreciate it if you guys could help me out.

A paramedic friend of mine had a patient, 70ish y/o female with c/o 10-10 "crushing" chest pains unrelieved by NTG with associated SOB and weakness-- an acute onset while walking up stairs. No history of CAD, there is a history of HTN and high cholesterol.

VS:
BP 110/76
HR: 120
RR: 18

The medic checks the ECG and sees a ventricular bigeminy. 12 ECG shows no ST/T changes in the underlying (atrial) rhythm. ETA to the (cath lab capable) hospital is 10 mins.

This paramedic (and I swear it wasn't me) gave the standard O2/ASA/NTG, and then decided to go ahead with a bolus of lidocane for the ventricular ectopy. He maintains that prophylaxis against VT was one of his primary concerns being that the NTG (and ASA) were not helping with this (admittedly assumed) event. He also seems to feel that the bigeminy was not as hemodynamically efficient, and would have been better substituted for the underlying atrial rhythm.

Protocol aside, I disagree with this line of treatment on a few different levels. First, I don't think we should be treating hemodynamically stable dysrhythmias like these out in the field if we are so close to the hospital. Second, I feel like the bigeminy was probably secondary to an acute coronary syndrome/cardiac hypoxia, and to treat the rhythm in this case is missing the point--and perhaps dangerous.

What do you guys think? What would you do for this in the ED, and what would you expect as ideal prehospital care?

 

[DoctorMedic]

not an MD yet but I am a medic,

That close to PCI/cardiac hospital I would treat with ONA not morphine unless I was further from ED and monitor pt until arrival at ED. If the PVC's started to become a problem then medicate, but as long as they don't turn into little runs of V-Tach I would watch them like a hawk. :Lastly if there is ever any concern that is what Med Control is for 🙂

 

[Apollyon]

Wow - that is SO 20th century!

Wipe out the PVCs, you may end up with a 3rd degree block. Lidocaine for PVCs is NOT ACLS. This person got away with one, but needs to be reported to the training officer. Having been a street medic (as was southerndoc, Jeff698, and DocB was a firefighter - and there are many others among us), I saw someone also do that, and also got away with it (as far as the patient not decompensating). However, to paraphrase Charlie from "Top Gun", "We'll take that as a lesson what NOT to do." If this medic came in with this patient, and I was the doc, this medic and I would have a brief, quiet, to-the-point conversation.

 

[southerndoc]

I don't treat bigeminy.

 

[pianoman511]

*Question from a paramedic for the EM docs, if you would*

I've asked several of my local docs about this, but it seems either they don't have time to answer or simply don't care. I'd really like to get the most complete answer possible, so I would really appreciate it if you guys could help me out.

A paramedic friend of mine had a patient, 70ish y/o female with c/o 10-10 "crushing" chest pains unrelieved by NTG with associated SOB and weakness-- an acute onset while walking up stairs. No history of CAD, there is a history of HTN and high cholesterol.

VS:
BP 110/76
HR: 120
RR: 18

The medic checks the ECG and sees a ventricular bigeminy. 12 ECG shows no ST/T changes in the underlying (atrial) rhythm. ETA to the (cath lab capable) hospital is 10 mins.

This paramedic (and I swear it wasn't me) gave the standard O2/ASA/NTG, and then decided to go ahead with a bolus of lidocane for the ventricular ectopy. He maintains that prophylaxis against VT was one of his primary concerns being that the NTG (and ASA) were not helping with this (admittedly assumed) event. He also seems to feel that the bigeminy was not as hemodynamically efficient, and would have been better substituted for the underlying atrial rhythm.

Protocol aside, I disagree with this line of treatment on a few different levels. First, I don't think we should be treating hemodynamically stable dysrhythmias like these out in the field if we are so close to the hospital. Second, I feel like the bigeminy was probably secondary to an acute coronary syndrome/cardiac hypoxia, and to treat the rhythm in this case is missing the point--and perhaps dangerous.

What do you guys think? What would you do for this in the ED, and what would you expect as ideal prehospital care?

Agree with standard O2/ASA/NTG, obviously the patient had a perfusing rhythm - his BP was stable even after nitro. Maybe I would add morphine for the chest pain, but that would be about it.

 

[McPoyle]

Wow - that is SO 20th century!

Wipe out the PVCs, you may end up with a 3rd degree block. Lidocaine for PVCs is NOT ACLS. This person got away with one, but needs to be reported to the training officer. Having been a street medic (as was southerndoc, Jeff698, and DocB was a firefighter - and there are many others among us), I saw someone also do that, and also got away with it (as far as the patient not decompensating). However, to paraphrase Charlie from "Top Gun", "We'll take that as a lesson what NOT to do." If this medic came in with this patient, and I was the doc, this medic and I would have a brief, quiet, to-the-point conversation.

hahaha "20th century"

My partner brought in our guidelines from... well quite a while ago... and I swear lidocaine was in every treatment option, it was pretty funny to read. Also lots of bretylium and theophylline (remember those!).

Anyhow, ya where I am we haven't treated PVC's in years for many reasons. I would stick with the standard oxygen, IV, monitor/12-Lead, ASA, NTG, MS.

As an aside, what are the chances that PVC's are totally incidental, maybe this pt is regularly in and out of bijeminy, maybe associated with varying levels of hypoxia (maybe associated with COPD for instance). I guess what I'm asking is: is it likely that her symptoms are not actually cardiac in nature?

 

[Apollyon]

And don't forget Dilantin (phenytoin) 4th line for V-tach!

 

[southerndoc]

There's a good chance her bigeminy is old. Nonetheless, if it was cardiac related, I would imagine oxygen would help. If not, the cath lab will, but it didn't sound like she had EKG evidence of cardiac ischemia other than bigeminy.

 

[Painter1]

*Question from a paramedic for the EM docs, if you would*

I've asked several of my local docs about this, but it seems either they don't have time to answer or simply don't care. I'd really like to get the most complete answer possible, so I would really appreciate it if you guys could help me out.

A paramedic friend of mine had a patient, 70ish y/o female with c/o 10-10 "crushing" chest pains unrelieved by NTG with associated SOB and weakness-- an acute onset while walking up stairs. No history of CAD, there is a history of HTN and high cholesterol.

VS:
BP 110/76
HR: 120
RR: 18

The medic checks the ECG and sees a ventricular bigeminy. 12 ECG shows no ST/T changes in the underlying (atrial) rhythm. ETA to the (cath lab capable) hospital is 10 mins.

This paramedic (and I swear it wasn't me) gave the standard O2/ASA/NTG, and then decided to go ahead with a bolus of lidocane for the ventricular ectopy. He maintains that prophylaxis against VT was one of his primary concerns being that the NTG (and ASA) were not helping with this (admittedly assumed) event. He also seems to feel that the bigeminy was not as hemodynamically efficient, and would have been better substituted for the underlying atrial rhythm.

Protocol aside, I disagree with this line of treatment on a few different levels. First, I don't think we should be treating hemodynamically stable dysrhythmias like these out in the field if we are so close to the hospital. Second, I feel like the bigeminy was probably secondary to an acute coronary syndrome/cardiac hypoxia, and to treat the rhythm in this case is missing the point--and perhaps dangerous.

What do you guys think? What would you do for this in the ED, and what would you expect as ideal prehospital care?

if things had gone wrong as a consequence to the lidocaine, no one would be able to defend your friend. if it was bigeminy, treating with lidocaine would be considered malpractice. all one can do is learn from such experiences.

 

[Kubed]

There's a good chance her bigeminy is old. Nonetheless, if it was cardiac related, I would imagine oxygen would help. If not, the cath lab will, but it didn't sound like she had EKG evidence of cardiac ischemia other than bigeminy.

Tangent:

What about NSTEMI? I just looked and couldn't find a reference for new bigeminy in NSTEMI, but ACS is still high on my DDX given the history and onset.

 

[southerndoc]

Tangent:

What about NSTEMI? I just looked and couldn't find a reference for new bigeminy in NSTEMI, but ACS is still high on my DDX given the history and onset.

There's no indication of NSTEMI from what has been mentioned about the ECG. There's no ST depression nor any T-wave inversions from what I read.

 

[Jeff698]

Yep, back in the day when I was just starting as a paramedic (pauses to dramatically take deep breath while pulling up pants), we used to give lidocaine for damn near anything. Of course, several amps of bicarb at the beginning of a code and isuprel push were also still pretty hot therapies. Plus, parachute pants were still in style.

As for what I do now, if it ain't VT, I'm not pushing lidocaine.

What's the optimal field therapy for bigeminy? How do I treat it in the ED?

Both the same. I ignore it, other than to consider if there might be an underlying cause. In any case, I don't treat the monitor.

Take care,
Jeff

 

[Apollyon]

Yep, back in the day when I was just starting as a paramedic (pauses to dramatically take deep breath while pulling up pants), we used to give lidocaine for damn near anything. Of course, several amps of bicarb at the beginning of a code and isuprel push were also still pretty hot therapies. Plus, parachute pants were still in style.

Rampart, this is Rescue 51. We've resusciated the victim.

Dr. Brackett: 51, start an isoproterenol drip and transport immediately.

Gotta love it! And Emergency! on a Blu-Ray player, on a 55 inch LCD, is amazing!!

 

[Arcan57]

Did you see much in the way of accelerated idioventricular rhythm on patients s/p thrombolysis? On the helicopter it freaked me out the first time I saw it, but the patients BP and mental status (as assessed by being able to give a thumbs up when tapped on forehead) were fine. I've seen in 3-4 times since, and its always resolved without additional therapy.

 

[docB]

Of course, several amps of bicarb at the beginning of a code and isuprel push were also still pretty hot therapies.

Dude, you're really dating yourself with that.😀 That's before my time.

I agree with the others, don't treat bigeminy. It's some kind of EMS lore that never seems to die that bigeminy is a terribly malignant rhythm and has to be squashed no matter what the consequences.

Oddly enough it's always the guys who aggressively "treat" bigeminy that never want to aggressively treat the bad stuff. "Base this is squad X. I've got a 60 yo F with SVT at 180, cool, pale, diaphoretic with crushing chest pain, altered mental status and BP 60 over palp. I'm starting vagal manuvers and will try adenosine next. Please have an ice bath standing by for the patient's face. Over."