Synchronized cardioversion without sedation – Part II

Rogue Medic responds to my recent post here:

On the relative wisdom of synchronized cardioversion without sedation – Part I

And here:

On the relative wisdom of synchronized cardioversion without sedation – Part II

In Part II, Scallywag Rogue Medic writes:

“We are discussing the awake and alert patient with severe signs and symptoms related to a suspected arrhythmia (eg, acute altered mental status, ischemic chest discomfort, acute heart failure, hypotension, or other signs of shock).

Why do we presume that acute altered mental status automatically accompanies all of the other acute conditions?

What if the patient with ventricular tachycardia at a rate of 170 has severe crushing chest pain (ischemic chest discomfort), but is an awake and alert patient?

Is this a stable patient?

What if the patient with a sudden onset of crackles half way up and severe air hunger (what appears to be acute heart failure) also happens to have a ventricular tachycardia at a rate of 170 and further happens to be anawake and alert patient?

Is this a stable patient?

What if the patient with ventricular tachycardia at a rate of 170 has a blood pressure of 74/52 (hypotension) still manages to be an awake and alert patient?

Is this a stable patient?

What if the patient with ventricular tachycardia at a rate of 170 is extremely, drenched with sweat, and feels ice cold (other signs of shock), but is an awake and alert patient?

Is this a stable patient?

Accepting the fact that patients can be “unstable” for a multitude of reasons, let’s contend with the awake and alert patient who is showing sign shock related to a wide complex tachycardia at 170 BPM.

The fact remains that drugs like morphine or midazolam can further impair the patient’s hemodynamic status. In other words, they can cause harm.

We have competing goals here. One is to provide comfort and the other is to provide life-saving therapy.

Both are laudable goals but they are in conflict when the patient is hemodynamically unstable. To pretend that this tension does not exist is not helpful in answering the question, “What should a paramedic do?”

What are the possible outcomes?

Sedate the patient > cardioversion is successful > hemodynamics are improved > patient lives

Sedate the patient > cardioversion is unsuccessful > hemodynamics are further impaired > patient may die

Cardiovert without sedation > cardioversion is successful > hemodynamics improve > patient is traumatized but alive (happens all the time with ICD shocks)

Cardiovert without sedation > cardioversion is unsuccessful > hemodynamics do not improve but at least they do not get worse > patient is traumatized but alive

Reasonable people can disagree about how this situation should best be handled, but I would not call cardioversion without sedation a “sentinel event” requiring some type of inquiry or formal explanation.

Unless of course the patient begged not to be shocked and the paramedic shocked the patient anyway.

That’s a different kind of malpractice.

I’ll give Rogue Medic the last word.

5 Comments

  • thousand ways to skin a cat.

  • Kelly says:

    I think it is not that black and white. The goal in the field (correct me if I am wrong) is not moderate sedation, which is defined as suppressing level of consciousness however the patient can still respond to external stimulus and maintains hemodynamics, including airway. If the patient is truly hemodynamically unstable due to the arrythmia but remains awake and alert, the anxiety and stress of the situation may also have an adverse impact on the patient’s hemodynamics. I would recommend providing anxiolysis (defined as providing relief of anxiety, with minimal changes in sensorium) with low-dose Valium (Diazepam) or Versed (midazolam). It has been my experience that proper titration of medications for reducing anxiety or relieving pain can have minimal impact on hemodynamics and reduce oxygen consumption. A point that cannot be overlooked is that even if the unstable patient is awake and alert, they are most likely experiencing a certain level of anxiety and apprehension – it goes beyond providing ‘comfort’ but improving the overall quality of care delivered.

  • Rogue Medic says:

    My reply is at Synchronized Cardioversion Without Sedation – Part II Scallywag’s Response.

    In further reply to your original post, Tuesday morning I will post On the relative wisdom of synchronized cardioversion without sedation – Part III. Later will be On the relative wisdom of synchronized cardioversion without sedation – Part IV.

    Kelly makes some points that I am working toward. She does this more directly than I tend to.

  • Ben Waller says:

    You won’t find a bigger fan of situation-appropriate sedation and pain relief than me, but I agree with Tom. If the sedation may cause harm but the therapy will save the patient’s life with a little transient discomfort, then go straight to the therapy.

    Comfort is important, but it’s not nearly as important as a pulse.

  • Frank says:

    Been cardioversion while conscious. In the ER no other issues just 160bpm. I do have heart failure and been ablated. The propofol did not kick in.

    My point is it was not traumatic. I did scream and reflex to grab my chest. Maybe the propofol took of edge I don’t know but was awake. The scream and grab was reflexive sort of involuntary. Almost think my reflex disturbed those in the room more than I. 200 joules. It was so short or fast that while I felt it, it was done so fast offering relief. It would be torture if any kind of prolongation. I do mean it is unbearable when happening but so fast. Less than many other aspects of my heart failure.

    If you concur with me do what you think is best and do not over focus on sedation as a primary concern when it is contraindicated.

    Consider this thought. Just as the agony happens it is over so the brain and perception is relief. Put in perspective consider adhesives you guys put on our chest. Do you pull it off slow and gentle or rip fast and hard. Get my point?

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