Pre-Intubation BP Management...

[thegenius]

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Curious what you guys would have done the same or differently (probably the latter...doh!)

This AM had a 87 yo man who aspirated at home, and his respiratory status was was so bad the EMT's couldn't take him to his normal hospital system that is 10 minutes from my hospital, and came to us.

He arrives ... RR 42, SpO2 65% on 100% FiO2 and 12/5 IPAP/EPAP. HR 110, BP is 100/60. He can't say a word he is breathing so hard. Markedly reduced breath sounds on the right. The EMTs mumble something about him being DNR, so before I move to intubate him I talked to his wife. We spent about 30 mins talking about next steps, she is very knowledgeable, and he improves (enough) where I took the mask off and he affirmed "yes to intubation".

Prior to, I turn up the PEEP to 10, sit him upright more...eventually his SpO2 climbs to the 90s. BP drops to 90/60. One reading was 75/50. I decided with ketamine/sux for RSI. So I get the push-dose pressors ready prior to the tube.

Now I usually use epinephrine and give 10-20 mcg/push and have predictably reliable results. The RN though looks at me like I'm from planet Zutar, and she said "You practice such odd medicine Dr. XXXX. Can we just run peripheral levophed prior to intubation?" I said "good! let's do that..." and I look up push-dose norepi from our favorite friend Dr. Weingart. pulmcrit.org said 0.5-1 ml of norepi (16 mcg/ml concentration) which we have exactly.

So we start periperal levo....no change in BP. Give one push norepi, no change. I end up giving 5 pushes of norepi over 10 minutes and his BP is staying between SBP 75-85. Very frustrating! All the while he has peripheral levo running at 20.

At this time I mix push-dose epi, and give like 3 doses of that...and finally I get a systolic of 110. Tube went fine, and predictably, his BP drops to 50/30 after tube and I'm pushing more epi and finally get a satisfactory BP while I'm placing a central line. Mind you he still has levo running.

Question...
1) in any of our experience is norepi a lousy drug for push-dose pressors? It's probably the first time (or handful of times, I can't remember) that I've used it. Just lousy overall. Did not get the response I wanted. Or perhaps he was just getting sicker. The PIV was good, it was briskly taking the IVF.

2) any of you just reach for phenylephrine? I like using it especially if your heart is strong enough...but I didn't know anything about this guy at all prior to coming in.

 

[deleted109597]

Some people are going to die no matter what. Not sure Neo adds much compared to Levo, based on physiology. This isn't herniation.

 

[Radetzky]

I woulda used push dose epi- you've used it before, you know what effects you're gonna get, as opposed to using something you have to look up.

Also how much ketamine?

 

[Libertas]

As an anesthesiologist, when I was a resident we used some push norepi in cardiac or other big cases. 6mcg was plenty usually. Also push dose vasopressin, ~1u to start. A 20u vial goes in a 20ml syringe of saline nicely.

 

[deleted859535]

Curious what you guys would have done the same or differently (probably the latter...doh!)

This AM had a 87 yo man who aspirated at home, and his respiratory status was was so bad the EMT's couldn't take him to his normal hospital system that is 10 minutes from my hospital, and came to us.

He arrives ... RR 42, SpO2 65% on 100% FiO2 and 12/5 IPAP/EPAP. HR 110, BP is 100/60. He can't say a word he is breathing so hard. Markedly reduced breath sounds on the right. The EMTs mumble something about him being DNR, so before I move to intubate him I talked to his wife. We spent about 30 mins talking about next steps, she is very knowledgeable, and he improves (enough) where I took the mask off and he affirmed "yes to intubation".

Prior to, I turn up the PEEP to 10, sit him upright more...eventually his SpO2 climbs to the 90s. BP drops to 90/60. One reading was 75/50. I decided with ketamine/sux for RSI. So I get the push-dose pressors ready prior to the tube.

Now I usually use epinephrine and give 10-20 mcg/push and have predictably reliable results. The RN though looks at me like I'm from planet Zutar, and she said "You practice such odd medicine Dr. XXXX. Can we just run peripheral levophed prior to intubation?" I said "good! let's do that..." and I look up push-dose norepi from our favorite friend Dr. Weingart. pulmcrit.org said 0.5-1 ml of norepi (16 mcg/ml concentration) which we have exactly.

So we start periperal levo....no change in BP. Give one push norepi, no change. I end up giving 5 pushes of norepi over 10 minutes and his BP is staying between SBP 75-85. Very frustrating! All the while he has peripheral levo running at 20.

At this time I mix push-dose epi, and give like 3 doses of that...and finally I get a systolic of 110. Tube went fine, and predictably, his BP drops to 50/30 after tube and I'm pushing more epi and finally get a satisfactory BP while I'm placing a central line. Mind you he still has levo running.

Question...
1) in any of our experience is norepi a lousy drug for push-dose pressors? It's probably the first time (or handful of times, I can't remember) that I've used it. Just lousy overall. Did not get the response I wanted. Or perhaps he was just getting sicker. The PIV was good, it was briskly taking the IVF.

2) any of you just reach for phenylephrine? I like using it especially if your heart is strong enough...but I didn't know anything about this guy at all prior to coming in.

1: I've used peri-intubation norepi and/or peripheral norepi in various types of shock without issue. I can't say I've used it as a push-dose pressor very much, though. More like just starting the drip and titrating as needed.

2: On occasion (which gets me the funny looks you mentioned). I'm one of the few in my area that still likes phenylephrine for the people where I feel the pure alpha agonist activity could be useful, or if for whatever reason, I don't want to give a beta-adrenergic medication and thus am trying to stay away from epi/norepi to avoid direct cardiac effect. This is exceedingly uncommon, but I've done it on more than a few occasions. Much more frequently, people just end up on norepi.

Anecdotally, I've had good experiences with people with softish blood pressures but who are otherwise asymptomatic with their AF/RVR getting the usual IVF, and actually small amounts of push or even brief drips of phenylephrine in conjunction with diltiazem, for those borderline cases of "if this gets any worse, I'm going to cardiovert this person, but I may not need/want/they don't want to right now", etc. Constrict peripheral vasculature, transiently buffers BP versus the transient BP decrease with an AV nodal blocker, just enough for rate control and subsequently improved filling to then lead to an increase in stroke volume/CO which then increases pressure, and you don't need any pressors anymore. Done, quickly.

Epi would be my "push-dose pressor" too, but I've found that actually needing to use a push-dose agent is more and more uncommon. With your guy, I probably would've just hung norepi, +/- push-dose epi, kind of like you ultimately did. Difficult to say whether there would have been any particular benefit to phenylephrine for him. When you say "if your heart is strong enough," I assume you mean in relation to the increased afterload?

 

[deleted547339]

Push dose levo is fine although I don’t use it often. I would have just titrated the levo drip to hemodynamic stability then induced without it. May have been dry. But it sounds like you did a very reasonable job and provided better than standard of care.

 

[southerndoc]

We have premixed phenylephrine in our trauma Pixis. I usually give 100-200 mcg prior to etomidate/rocuronium and possibly some immediately after.

 

[FirstNobleTruth]

I've found norepi to be the least commonly used push-dose pressor, when in comparison to epi/phenyl. Anecdotally I've also found it less helpful.

As someone mentioned above - what dose ketamine did you use? I would've dropped my induction dose quite a bit in this patient.

Sounds like a great job overall, and someone that certainly a patient that might have had a peri-intubation arrest with a different team.

 

[RoyBasch]

First off, this guy sounds like he's going to have a rough outcome no matter what. Patient has a terrible disease process and the deck is stacked terribly against you.

I think you did a pretty heroic job optimizing his pre-RSI hemodynamics and oxygenation. I think ketamine/sux is a good hemodynamically cautious RSI choice. Increasingly for the sake of simplicity sometimes I stick with etomidate but just use very low dose (0.05-0.1mg/kg) so 5-10mg. Usually these patients are already pretty encephalopathic from their shock state and don't need much sedation.

I think giving fluid in addition to pressors is helpful. I start 2L running wide open. Stepping on the gas doesn't help much if your tank is empty. Furthermore you might raise your MAP, but if you are intravascularly depleted you are worsening the tissue level hypoxemia and worsening lactic acidosis.

Maybe I'm a barbarian, but when I use epi as a push dose pressor, particularly pre-intubation I go big. I use 50-100mcg. I don't bother with diluting or making my own epi, I just take a cardiac epi ampoule out of the crash cart and give 0.5-1 mL. I've never used levophed push dose, but I do like starting the drip. I think if you are using it peri-intubation, better to go big and start at 10mcg/min or 0.1-0.2mcg/kg/min.

With regards to pheynlephrine, No I don't think in this case it would have helped very much. It tends to be a weaker pressor overall compared to epi and levo. The only time I use it is fast AF with RVR and I think poor diastolic filling is contributing to the shock state. If the pt was AF with RVR and a HR in the 150+ then I would probably use phenylephrine for fear that levo and epi in particular are going to further drive the tachycardia and worsen perfusion.

 

[Fox800]

I

First off, this guy sounds like he's going to have a rough outcome no matter what. Patient has a terrible disease process and the deck is stacked terribly against you.

I think you did a pretty heroic job optimizing his pre-RSI hemodynamics and oxygenation. I think ketamine/sux is a good hemodynamically cautious RSI choice. Increasingly for the sake of simplicity sometimes I stick with etomidate but just use very low dose (0.05-0.1mg/kg) so 5-10mg. Usually these patients are already pretty encephalopathic from their shock state and don't need much sedation.

I think giving fluid in addition to pressors is helpful. I start 2L running wide open. Stepping on the gas doesn't help much if your tank is empty. Furthermore you might raise your MAP, but if you are intravascularly depleted you are worsening the tissue level hypoxemia and worsening lactic acidosis.

Maybe I'm a barbarian, but when I use epi as a push dose pressor, particularly pre-intubation I go big. I use 50-100mcg. I don't bother with diluting or making my own epi, I just take a cardiac epi ampoule out of the crash cart and give 0.5-1 mL. I've never used levophed push dose, but I do like starting the drip. I think if you are using it peri-intubation, better to go big and start at 10mcg/min or 0.1-0.2mcg/kg/min.

With regards to pheynlephrine, No I don't think in this case it would have helped very much. It tends to be a weaker pressor overall compared to epi and levo. The only time I use it is fast AF with RVR and I think poor diastolic filling is contributing to the shock state. If the pt was AF with RVR and a HR in the 150+ then I would probably use phenylephrine for fear that levo and epi in particular are going to further drive the tachycardia and worsen perfusion.

I like this. Often we know that the patient is going to be intubated but it hasn't be done *right this second*. You have 10-15 minutes to give some crystalloid, even start peripheral norepinephrine. Stack the deck in your favor. Push dose epi is a great option because it's always right there. I tend to like ketamine/succ or ketamine/rocuronium. Weingart favors giving half dose of your induction agent and double the dose of your paralytic in shocked patients, but I'm not sure how much science is behind that. Agree that you don't need as big a dose of an induction agent if the patient is semi-responsive/encephalopathic.

 

[thegenius]

Also how much ketamine?

I think I used 100 mg. I can't remember but that sounds about right. 150 mg sux. This is not the kind of tube you want to mess around with. I want it in as fast as possible given his profound shunt. I considered etomidate...I think I chose Ketamine because I recall it raises BP slightly which is what he needed.

Some people are going to die no matter what. Not sure Neo adds much compared to Levo, based on physiology. This isn't herniation.

Yea at the end of the day I agree he was just super sick. The more I reflect on the case, you do the best you can.

2: On occasion (which gets me the funny looks you mentioned). I'm one of the few in my area that still likes phenylephrine for the people where I feel the pure alpha agonist activity could be useful, or if for whatever reason, I don't want to give a beta-adrenergic medication and thus am trying to stay away from epi/norepi to avoid direct cardiac effect. This is exceedingly uncommon, but I've done it on more than a few occasions. Much more frequently, people just end up on norepi.

I came close to pulling out the phenylephrine. Problem is we don't have sticks of that and I have to dilute it from 250 ml concentrations into those NS syringes, and I didn't want to fiddle with that in the middle of this process.

Anecdotally, I've had good experiences with people with softish blood pressures but who are otherwise asymptomatic with their AF/RVR getting the usual IVF, and actually small amounts of push or even brief drips of phenylephrine in conjunction with diltiazem, for those borderline cases of "if this gets any worse, I'm going to cardiovert this person, but I may not need/want/they don't want to right now", etc. Constrict peripheral vasculature, transiently buffers BP versus the transient BP decrease with an AV nodal blocker, just enough for rate control and subsequently improved filling to then lead to an increase in stroke volume/CO which then increases pressure, and you don't need any pressors anymore. Done, quickly.

As do I! Phenylephrine is great. Push 200 mcg at a time. Often causes reflexive bradycardia too which is a benefit in those AFib with RVR cases. Frankly, what I really would like to do is drip in 20 mg diltizaem over 10 minutes, but the nurses and pharmacy get all in a tizzy about that too. So I'll push diltiazem and 100/60 drops to 80/40, the HR drops...and then it's a game of "do I have the balls to wait for the BP to increase because I have increased their LVEDV," or do I give more fluids or fiddle with CaGlu or whatever to increase their BP. Neo to the rescue in my opinion.

Epi would be my "push-dose pressor" too, but I've found that actually needing to use a push-dose agent is more and more uncommon. With your guy, I probably would've just hung norepi, +/- push-dose epi, kind of like you ultimately did. Difficult to say whether there would have been any particular benefit to phenylephrine for him. When you say "if your heart is strong enough," I assume you mean in relation to the increased afterload?

Right...cardiomyopathy is a relative contraindication for phenylephrine because increasing afterload in someone with EF 20% is no bueno. But this guys afterload was always going to be weak...so maybe I didn't have to worry about it.

I think giving fluid in addition to pressors is helpful. I start 2L running wide open. Stepping on the gas doesn't help much if your tank is empty. Furthermore you might raise your MAP, but if you are intravascularly depleted you are worsening the tissue level hypoxemia and worsening lactic acidosis.

Yea he did get 2L up front, probably could have used more.

Maybe I'm a barbarian, but when I use epi as a push dose pressor, particularly pre-intubation I go big. I use 50-100mcg. I don't bother with diluting or making my own epi, I just take a cardiac epi ampoule out of the crash cart and give 0.5-1 mL. I've never used levophed push dose, but I do like starting the drip. I think if you are using it peri-intubation, better to go big and start at 10mcg/min or 0.1-0.2mcg/kg/min.

Well....that is a hefty dose of epi. Do you find you get a lot of tachycardia with that as well? How long do you have if you give 50 mcg?

I love that idea...while I think it's fun mixing drugs in the ED I'm not a ****ing alchemist in 1870. I just want the med ready to go most of the time.

I like this. Often we know that the patient is going to be intubated but it hasn't be done *right this second*. You have 10-15 minutes to give some crystalloid, even start peripheral norepinephrine. Stack the deck in your favor. Push dose epi is a great option because it's always right there. I tend to like ketamine/succ or ketamine/rocuronium. Weingart favors giving half dose of your induction agent and double the dose of your paralytic in shocked patients, but I'm not sure how much science is behind that. Agree that you don't need as big a dose of an induction agent if the patient is semi-responsive/encephalopathic.

Agree with that brotha. There are very few cases where you have to be tubed NOW or else the guy is going to die. Most of the time you have time to optimize everything. I remember in residency there were people who came in with flash pulm edema or unconscious but breathing and my senior residents are saying "WHAT ARE YOU WAITING FOR!!! TUBE HIM NOWWWWW!" It was ridiculous.


At the end of the day the pt I had was put on comfort care about 8 hours later and he didn't last much longer after that.

 

[deleted109597]

We do what we can. It's an impetus to learn, reflect, and ask others. Nothing would have changed, but maybe your efforts can change the outcome for the next patient. You're a good doctor.

 

[bigtuna]

Was this guy really acidotic? That could be why the pressors werent working well. Sometimes some bicarb and calcium chloride work well in this situation

 

[Rendar5]

I think I used 100 mg. I can't remember but that sounds about right. 150 mg sux. This is not the kind of tube you want to mess around with. I want it in as fast as possible given his profound shunt. I considered etomidate...I think I chose Ketamine because I recall it raises BP slightly which is what he needed.



Yea at the end of the day I agree he was just super sick. The more I reflect on the case, you do the best you can.



I came close to pulling out the phenylephrine. Problem is we don't have sticks of that and I have to dilute it from 250 ml concentrations into those NS syringes, and I didn't want to fiddle with that in the middle of this process.



As do I! Phenylephrine is great. Push 200 mcg at a time. Often causes reflexive bradycardia too which is a benefit in those AFib with RVR cases. Frankly, what I really would like to do is drip in 20 mg diltizaem over 10 minutes, but the nurses and pharmacy get all in a tizzy about that too. So I'll push diltiazem and 100/60 drops to 80/40, the HR drops...and then it's a of "do I have the balls to wait for the BP to increase because I have increased their LVEDV," or do I give more fluids or fiddle with CaGlu or whatever to increase their BP. Neo to the rescue

You’re doing way too much thinking here in my opinion. I’ve never had to give neo for your standard afib with rvr and hypotension. If the pressure is low give either half of your cardizem dose or just don’t bolus it. Nothing wrong with skipping a bolus of it and simply starting a cardizem drip at 5mg/hr and titrating get it up. As the rate drops the pressure improves.

Or consider digoxin.

 

[RoyBasch]

You’re doing way too much thinking here in my opinion. I’ve never had to give neo for your standard afib with rvr and hypotension. If the pressure is low give either half of your cardizem dose or just don’t bolus it. Nothing wrong with skipping a bolus of it and simply starting a cardizem drip at 5mg/hr and titrating get it up. As the rate drops the pressure improves.

Or consider digoxin.

I think people with "soft" but normal BP like 90s systolic if you give cardizem slowly generally you are right, the HR will fall, the end diastolic LV filling will rise and that will off set the hypotension from the cardizem; however, if the pt is already profoundly hypotensive (SBP 70s, MAP less than 60) I think you are at high risk of dropping coronary perfusion pressure too rapidly and precipitating a cardiac arrest. I think Neo among other options is a very good choice here.

I have mixed feelings about dig, it used to be a main stay of my practice but I have gotten away from it mostly. The problem I see is that with this type of patient we are talking about you need to start medicating immediately, and you don't have a lot of information. I don't think dig is super safe if the patient doesn't have normal renal function. Usually at the point of care, unless you have I-STAT you don't know that. Furthermore, many of these pt's even if they have normal renal function will be acutely impaired when they are this sick. Furthermore, the pt may already be on dig, and you may not know (pt coming from home without a med list, too encephalopathic to answer), and further IV dig puts them at risk of overdose.

Thus I really only use dig now if the cardiologist tells me to and I have my Cr back already.

 

[RoyBasch]

Well....that is a hefty dose of epi. Do you find you get a lot of tachycardia with that as well? How long do you have if you give 50 mcg?

I love that idea...while I think it's fun mixing drugs in the ED I'm not a ****ing alchemist in 1870. I just want the med ready to go most of the time.



Agree with that brotha. There are very few cases where you have to be tubed NOW or else the guy is going to die. Most of the time you have time to optimize everything. I remember in residency there were people who came in with flash pulm edema or unconscious but breathing and my senior residents are saying "WHAT ARE YOU WAITING FOR!!! TUBE HIM NOWWWWW!" It was ridiculous.

Well you yourself said you re-bolused about 5x, so pretty similar dose ultimately. You do definitely get tachycardia, but usually it only lasts about 5 minutes because no matter how much epi you give, the half life is still short.

Using push dose epi is not part of my standard RSI or premedication, we are talking about an unusually hypotensive patient refractory to fluids who needs to be emergently intubated, so I think benefit outweighs risk, but understanding this is a super sick patient and all of your options are going to have some potential risk/downside.

In general I had the same experience, as a resident my staff were always like ¡GET THEM INTUBATED RIGHT NOW! before the patient was even on the monitors or had an IV. I agree rarely is this a good course of action and raises stress unnecessarily. That being said, the one main exception is refractory hypoxia. If you cant raise the sat despite maximally aggressive bagging (2 person, both hands on face, BL NPA, OPA, PEEP valve, and 100% FiO2) then yeah, you just gotta go.

 

[Radetzky]

I think I used 100 mg. I can't remember but that sounds about right. 150 mg sux. This is not the kind of tube you want to mess around with. I want it in as fast as possible given his profound shunt. I considered etomidate...I think I chose Ketamine because I recall it raises BP slightly which is what he needed.

For sure, nothing wrong with that. But one option is to consider halving that ketamine dose. Ketamine may raise your blood pressure in a hemodynamically stable patient but in someone who is shocked it will drop it, just like any induction agent.

Interesting talk about phenylephrine and cardiomyopathy. I don't think it's necessarily that much of a contraindication if used to rescue the BP, where the main problem is vasodilated shock: your afterload is already low, and what will kill the cardiomyopathic heart faster is a poor aortic root pressure to drive coronary flow. Depends on the situation I guess.

 

[BoardingDoc]

I think people with "soft" but normal BP like 90s systolic if you give cardizem slowly generally you are right, the HR will fall, the end diastolic LV filling will rise and that will off set the hypotension from the cardizem; however, if the pt is already profoundly hypotensive (SBP 70s, MAP less than 60) I think you are at high risk of dropping coronary perfusion pressure too rapidly and precipitating a cardiac arrest. I think Neo among other options is a very good choice here.

I have mixed feelings about dig, it used to be a main stay of my practice but I have gotten away from it mostly. The problem I see is that with this type of patient we are talking about you need to start medicating immediately, and you don't have a lot of information. I don't think dig is super safe if the patient doesn't have normal renal function. Usually at the point of care, unless you have I-STAT you don't know that. Furthermore, many of these pt's even if they have normal renal function will be acutely impaired when they are this sick. Furthermore, the pt may already be on dig, and you may not know (pt coming from home without a med list, too encephalopathic to answer), and further IV dig puts them at risk of overdose.

Thus I really only use dig now if the cardiologist tells me to and I have my Cr back already.

If they're that hypotensive (SBP in the 70s) in afib with RVR you should be electrically cardioverting them. I feel like we're taking a very simple topic and trying to make it overly nuanced. Throw pads on patient in afib with RVR. If systolic > 80, give dilt. Likely successful. If unsuccessful or if BP < 80 systolic, they are unstable. Zap them.

 

[deleted109597]

If they're that hypotensive (SBP in the 70s) in afib with RVR you should be electrically cardioverting them. I feel like we're taking a very simple topic and trying to make it overly nuanced. Throw pads on patient in afib with RVR. If systolic > 80, give dilt. Likely successful. If unsuccessful or if BP < 80 systolic, they are unstable. Zap them.

You can also bolus Calcium, as it blunts the peripheral hypotensive effects without affecting the chronotropic effects. They all get Ca from me if they are less than 100mmHg.

 

[deleted859535]

You can also bolus Calcium, as it blunts the peripheral hypotensive effects without affecting the chronotropic effects. They all get Ca from me if they are less than 100mmHg.

I've done this many times to good effect as well. Though the one paper I've seen on it didn't show any proven benefit. Haven't searched on the matter in about a year.

 

[deleted109597]

Better studies with verapamil, but if you use smaller doses of dilt it likely works. Calcium before Diltiazem may reduce hypotension in rapid atrial dysrhythmias

 

[thegenius]

Better studies with verapamil, but if you use smaller doses of dilt it likely works. Calcium before Diltiazem may reduce hypotension in rapid atrial dysrhythmias

Appears to be a fair amount heterogeneity in that paper above. Maybe a slight benefit. Don't know if having a SBP go up by 2-4 pts is clinically meaningful. Perhaps.

In any event I use diltiazem almost exclusively for these rapid afib patients. I find pushing lopressor provides really lousy results.

 

[thegenius]

If they're that hypotensive (SBP in the 70s) in afib with RVR you should be electrically cardioverting them. I feel like we're taking a very simple topic and trying to make it overly nuanced. Throw pads on patient in afib with RVR. If systolic > 80, give dilt. Likely successful. If unsuccessful or if BP < 80 systolic, they are unstable. Zap them.

Yea if it's in the 70's then cardioverting them is right. But most of these patients that come in are little old ladies that weigh a buck 10. Their HR is 145, Bp 95/65, they have no symptoms, don't understand why they are in the ER.

Son: "MA!!!! Our primary care doc said we need to be here! MA!!! Can you hear me?? Are you using your hearing aid MA? WHERE IS YOUR HEARING AID???? MA!!!!!!!!!!! It's me your son Jimmy!!!!!!!"
I
LOL

I really try hard not to cardiovert these patients and would rather go very slow in treating them.


On another topic, SVT, that is something where I'm really using less and less adenosine and nowadays just give diltiazem, especially if their BP is OK. Works like a charm. No awful feeling of dread, impending doom. You can have a crappy line in the finger. Nurses aren't going crazy with rhythm strips and blah blah. Just given them diltiazem 10-20 mg x1 or 2, you don't even need to hang out at the bedside for a long time.

 

[Hamhock]

I don't think dig is super safe if the patient doesn't have normal renal function.

Thus I really only use dig now if the cardiologist tells me to and I have my Cr back already.

Repeated dig loading doses may not be safe in patients with renal failure (or severe hypokalemia). However, I doubt you will be giving much more than the first dose without knowing the creatinine (at least) in the ED.

Unless the patient is coming in with digoxin toxicity, hypotension, and Afib RVR, I highly doubt a single 125 or even 250 of dig will be harmful.

That said, it's unlikely to save a patient in the super acute phase (in the ED first 30 minutes)....but it may help the admitting docs down the line.

I guess, I am just saying: don't be so afraid of -- but don't depend on -- a little dig.

If they're that hypotensive (SBP in the 70s) in afib with RVR you should be electrically cardioverting them. I feel like we're taking a very simple topic and trying to make it overly nuanced.

Actually, this is not a simple topic. It's a simple to get the ACLS merit badge.

It's not simple in real life. Many many of the hypotensive Afib RVR patients are not just a bit arrhythmogenic. There's often acute and chronic underlying disease (typically at least chronic Afib with remodling and CHF that you will not just "cardiovert") contributing, if not the primary etiology.

I would argue a deep understanding of Afib RVR and the typical therapeutics (and adjuncts) is required EM knowledge.

HH

 

[Hamhock]

On another topic, SVT, that is something where I'm really using less and less adenosine and nowadays just give diltiazem, especially if their BP is OK. Works like a charm. No awful feeling of dread, impending doom. You can have a crappy line in the finger. Nurses aren't going crazy with rhythm strips and blah blah. Just given them diltiazem 10-20 mg x1 or 2, you don't even need to hang out at the bedside for a long time.

Sure, just make sure it's "regular SVT"...and not irregular, atypically fast/slow, or hiding underlying WPW or severe valvular disease.

HH

 

[deleted109597]

I don't give adenosine. Period. Nobody likes it.
I give calcium, but I also hold it until they drop their pressure in some cases. Even the transient BP drops improve once their filling times increase with rate control, so I don't lose a lot of sleep of it.

 

[RoyBasch]

If they're that hypotensive (SBP in the 70s) in afib with RVR you should be electrically cardioverting them. I feel like we're taking a very simple topic and trying to make it overly nuanced. Throw pads on patient in afib with RVR. If systolic > 80, give dilt. Likely successful. If unsuccessful or if BP < 80 systolic, they are unstable. Zap them.

Problem is DCCV is not likely to be successful. If the patient has been in permanent AF since Clinton was president they are not going to convert now today when they are in severe sepsis/septic shock. That being said, I think its worth a good college try.

 

[RoyBasch]

You can also bolus Calcium, as it blunts the peripheral hypotensive effects without affecting the chronotropic effects. They all get Ca from me if they are less than 100mmHg.

Haven't seen any literature to back this up, but I do it as well. Anecdotally it seems to work/help.

 

[RoyBasch]

Repeated dig loading doses may not be safe in patients with renal failure (or severe hypokalemia). However, I doubt you will be giving much more than the first dose without knowing the creatinine (at least) in the ED.

Unless the patient is coming in with digoxin toxicity, hypotension, and Afib RVR, I highly doubt a single 125 or even 250 of dig will be harmful.

That said, it's unlikely to save a patient in the super acute phase (in the ED first 30 minutes)....but it may help the admitting docs down the line.

I guess, I am just saying: don't be so afraid of -- but don't depend on -- a little dig.

Fair point.

 

[Rendar5]

Never had a complaint with adenosine. I always warn the patient how it will feel and reassure them. I always have happy patients afterward. If I didn’t explain in detail how they would feel, I’m sure I’d have several complaint letters.

 

[MedicineZ0Z]

thoughts on giving a push of Mg as an adjunct?

 

[thegenius]

thoughts on giving a push of Mg as an adjunct?

As an adjunct to what? I don't understand the question...

 

[MedicineZ0Z]

As an adjunct to what? I don't understand the question...

To diltiazem. Or any anecdotes for its use with afib rvr.

 

[deleted109597]

Never had a complaint with adenosine. I always warn the patient how it will feel and reassure them. I always have happy patients afterward. If I didn’t explain in detail how they would feel, I’m sure I’d have several complaint letters.

Have you ever had someone ask for it a second time though? I haven't. But I have had a bunch of people say they don't want it, and usually they preface it with "that drug that made me feel like I was dying". Notwithstanding that CCBs are actually more effective at an hour.

 

[thegenius]

Have you ever had someone ask for it a second time though? I haven't. But I have had a bunch of people say they don't want it, and usually they preface it with "that drug that made me feel like I was dying". Notwithstanding that CCBs are actually more effective at an hour.

The reason why I don't like adenosine is all the rigamarole that goes along with trying to get a good IV, oh the 20g in the antecube just doesn't push fast enough, then the RN's fumble around with a 18g elsewhere....then 6 mg IVP doesn't work, then 12 IVP might seem to do something but doesn't terminate the arrhythmia. I've heard some doctors give 18 mg, even 24 mg at once but I don't feel like doing that.

Yea I've never had a patient say "Hey Doc! I can't wait for you to give adenosine! I love that s*h*i*t!!!"

 

[thegenius]

To diltiazem. Or any anecdotes for its use with afib rvr.

Nope, as far as I know there is no role in giving Mg in this case. Mg, in high doses, can cause hypotension which isn't helpful here.

I'll only give Mg if I later find that they are deficient in it, but its not to abort the afib.

 

[DrDrummer]

To diltiazem. Or any anecdotes for its use with afib rvr.

It seems to help in my limited experience, or at least not lead to disasters. I don't know if it really gets you anything extra though. A recent study that got some attention looked at fairly high doses as adjuvant for usual care, though the "usual care" in this included a lot of Dig.

 

[Rendar5]

Have you ever had someone ask for it a second time though? I haven't. But I have had a bunch of people say they don't want it, and usually they preface it with "that drug that made me feel like I was dying". Notwithstanding that CCBs are actually more effective at an hour.

The only complaints I’ve heard about it in patients familiar with the drug who are about to get a dose is when they complain that no one warned them how it would make them feel last time.
I have had people ask for it because it has helped them in the past.

 

[deleted547339]

If they're that hypotensive (SBP in the 70s) in afib with RVR you should be electrically cardioverting them. I feel like we're taking a very simple topic and trying to make it overly nuanced. Throw pads on patient in afib with RVR. If systolic > 80, give dilt. Likely successful. If unsuccessful or if BP < 80 systolic, they are unstable. Zap them.

Not true. It is very nuanced. We just reviewed a case where this happened and it led to cardiovascular collapse/PEA. BP ok-> dilt. BP drop. Electricity -> attest.

The question to ask is whether the af RVR is the disease or the symptom. If it’s the symptom and you treat it, you’re asking for a world of hurt. If you have cardiogenic shock and are vasoconstrictors with some semblance of a normal BP and have chronic AF, dilt will kill them (see above).

 

[deleted547339]

Nope, as far as I know there is no role in giving Mg in this case. Mg, in high doses, can cause hypotension which isn't helpful here.

I'll only give Mg if I later find that they are deficient in it, but its not to abort the afib.

I give a lot of mag in the icus. Patients that are hypomag like to stay in fib.

 

[Apollyon]

The only complaints I’ve heard about it in patients familiar with the drug who are about to get a dose is when they complain that no one warned them how it would make them feel last time.
I have had people ask for it because it has helped them in the past.

Same. I've never had (I'll trade anecdote for anecdote) someone refuse adenosine due to side effects.

 

[MedicineZ0Z]

How frequently do you guys use amio when your BP is borderline? In my limited experience, I've seen it work very quickly.. especially when the afib is the symptom of a disease.

 

[deleted547339]

How frequently do you guys use amio when your BP is borderline? In my limited experience, I've seen it work very quickly.. especially when the afib is the symptom of a disease.

Amio is a decent drug, the problem is that it is both a rate and rhythm control drug. If you don’t know how long you’ve been in fib, amio might chemically convert. Obviously, some people convert when you slow them down enough, too. I use it upstairs all the time; downstairs I use it rarely.

 

[RoyBasch]

How frequently do you guys use amio when your BP is borderline? In my limited experience, I've seen it work very quickly.. especially when the afib is the symptom of a disease.

I use it a fair amount. I think its definitely a good choice with borderline BP. Sometimes I'll use it in lieu of low dose cardizem or slow drip cardizem. I will use it in tandem with neo synephrine. This is Scott Weingart's approach for crashing A fib resistant to DCCV (amio + neo). I agree with Times New Roman, its important to try and determine if the AF with RVR is a symptom or a cause; but that being said, regardless of the underlying situation, HR > 150 is usually contributing to the shock state/low perfusion and some degree of rate control is probably necessary/helpful.

 

[nimbus]

You can also bolus Calcium, as it blunts the peripheral hypotensive effects without affecting the chronotropic effects. They all get Ca from me if they are less than 100mmHg.

I've done this many times to good effect as well. Though the one paper I've seen on it didn't show any proven benefit. Haven't searched on the matter in about a year.

I use it all the time in vasoplegic post-CPB patients in the OR. Definitely effective but the effects are very transient so it’s no surprise it does not modify outcome.