My cardiologists and my hooks...by MAB32
 

Here is a story from MAB32 - posted here at his request :munchin



Here is some stuff along similar lines that happened to me that you might get a kick about too!

Drove myself to the hospital one evening with a tachicardia of, no lies now, 312 bpm. I felt like I was running away from an F-15. Wasn't too light headed or dizzy, just darn uncomfortable. The cardiologists (read: 2) come in and tell me that cardioversion is the safest means to convert the heart back to normal rythym. I say "NICE" what are you going to do to me before you give me the paddles? They said, well, we are going to give you Verced and when you wake up you won't remember a thing and your heart rate should at least drop down to below 100 bpm. We have a success rate of over 90-100% with this means versus IV drugs (antiarrythmias). I agree and they start the IV push. I am out or so I thought within what seemed like a few minutes. The first hit with the paddles I sat straight up in bed, screamed "OUCHHHHH!" and took a swing at the doctor on my immediate left. I connected. The second jolt was a repeat of the first only this time I connected to the doctor on my right. You know I can still see their "horror" in their eyes to this day. Anyways I convert back to normal later after about an hour of 80-90 bpm. The next day I hear my cardiologist (doctor #1 on my left) just outside my door asking the nurse if I remember anything about last night and if so what? I hear her tell him: "I think you better ask him that! He is not happy!" He walks in very sheepishly and starts apologizing up and down. Now mind you I have two perfect burn marks from those paddles and they are really bothering me so I am in no mood for BSing. He tells me that initially when they started the Verced push I wasn't responding and was still awake. He then ordered more Verced. Then more. Then more. I ended up receiving a record dose of Verced in that hospital and still not responding well to it on top of the fact they were very concerned with respiratory failure with such a high dose. He said they had a respirator and Narcan standing by in a syringe. I didn't think Narcan would work on Verced but I guess it helps restore diaphram functioning. A few days later I call up my other cardiologist at the Cleveland Clinic(they are the absolute best in the world) and he tells me I should sue them because Verced is very old school. They ( The Clinic) use Valium and Demerol and it is all over in less than 5 minutes and the patient ends up waking up and telling the doctor(s) they are ready to be converted. This was over 9 years ago and to this day I have a very bad phobia with any defibrilator I see!

Ive seen Docs use versed to convert but usually accompanied with fentanyl. Ive used propfol if theyre vented-

ccrn

CCRN,

Well, I WISH THEY WOULD OF USED THAT TOO and maybe even double dosed the Fetanal!!! :D

By the way, no vent as I was alert and was not in any distress except when they rolled in the Defibrilator. Then my BP went up another 10-15 points along with rapid breathing and me shouting to all there "What the F___K is that doing here, I'm fine, look I can walk!"

During that fateful morning I have learned to HATE electricity to the point that I sweat profusely, become dizzy, and actually hear in my mind somebody screaming out loud "CLEAR" when I change a light bulb or especially when I change a wall outlet. :boohoo

Must of did something to my Cerebal functioning too because I now remember vividly and in living color coming out of my mother's womb. :D


Anyways, to all you 18D's and MD's out there, when you fellows have had to cadiovert somebody say for V-fib, how many of them have remembered getting paddled? :munchin

My 2 year old son has SVT. He has had to have conversions done twice, once at 2 months (hr was 310bpm) and once at 11 months. Both times conversions were done via IV. Scariest two days of my life. He hasn't had one in more than a year, but he's on Digoxin. The first medicine was Propanalol after his second episode, and that was the worst month. He was not the same little boy, didn't sleep, he would wake up screaming, it was very traumatic.

His cardiologist says if he has repeated episodes, that he would have a catheter ablation when he is 7.

bberkley,

I understand somewhat of what you are going through. I had "Dual AV Nodal Reentry Tachycardia" that was ablated the same day that hurricane Andrew hit Florida. Mine was done at Cleveland Clinic and at that time it was "experimental". That was over 11 years ago and I am doing fine by the Grace of God. I am sure that the doctors who would do it if need be to your son are well versed in this art and have plenty of ablations under their belt. By the way, how much Lanoxin/Digitalis/Digoxin is your son on?

If a patient is in VF... he is unconscious within a few seconds of onset. There will be no memory as there is not adequate bloodflow to retain consciousness or life.

He takes 1cc twice a day. He has to have his liver function checked twice a year too.

They are also probably checking his Digoxin level to make sure it stays within safety parameters.

I had to pick myself upoff the floor after reading that


Technicaly for V-fib (and pulseless V-tach) we defibrillate 200,300,360 joules. I know some Docs that will just use 360 to hell with the lower settings. 100,150,200 J for Biphasic.

Most of the pts Ive defibrillated were pretty FUBAR'd and they didnt remember much. A couple said they remembered being shocked. Im mot sure if I believe them.

Ive had pts tell me they remember the shock when cardioverted. That I believe-

ccrn

I will tell you this, I have been hospitalized for many things over the years and some of them were for pain related diseases or injuries, but I have never experienced pain like that before and pray to the Lord that I don't again unless I am out like a...,well, a light. Oh boy here we go again.

Can one of you MD's send me a list of "pre-meds" and a list of meds to be administered during the procedure in case I have to have it done again? I will make it into a little laminated card that I will duct tape to my chest when ever I am out of the house, carry extras in my wallet.... wait a minute, I can get them tattood to my chest, that would be an even better idea wouldn't it?

Something Like:


NOTE: Patient has been paddled before, does not like it, but will take it if it means saving his life. USE THE FOLLOWING MEDICATIONS ONLY before "jump starting":

1)
2)
3)
4)
5)
etc.,
etc.

ALSO NOTE AND CAUTION: Patient will know if you are not following the above mentioned protocal as he will yell and swing at random after each jolt and yes he will be trying to cause serious physical harm to anybody within reach!
:D

MAB32 I am sorry to read about your experiences, hopefully my experiences will be helpful.

Your experience with "conscious sedation" was clearly inadequate. As I've been trained, the goals of conscious sedation are sedation, analgesia, and amnesia such that a patient can undergo an otherwise painful (physical or mental) procedure without interim or post procedure anguish. The limitation is trying to avoid airway management issues by keeping the patient "conscious."

Versed is an extremely popular and prevalent choice for conscious sedation given its quick onset and relatively quick offset as a benzodiazepine. We use it all the time in the ICU, bronchoscopy and endoscopy suites, and the ER. In fact, in large doses, it can be used to render patients unconscious for intubation. In no way is it an irresponsible choice for your procedure, although ITS EFFECTS ARE DIFFERENT ON DIFFERENT PEOPLE. That is, if you were fully awake after receiving ridiculous amounts, your docs should have picked something different.

As for suing your docs for using versed, that's plain ridiculous. In fact, your cleveland cardiologists advice of using demerol and valium seems VERY strange to me- valium first of all is in the same class of medications (benzodiazepines) which is to say that if versed doesn't float your boat, valium won't do it either. Valium also has a MUCH LONGER half life- that is to say that you will now create a much longer recovery time which can translate into needing to be admitted for recovery, greater risk for aspiration syndromes, among other things. I don't know ANY conscious sedation protocol that recommends the use of valium- the pharmacologic properties of the drug are simply all wrong for this type of scenario! He IS right in that they should have added a narcotic like fentanyl or demerol to the cocktail (assuming your BP wasn't too low).

As an aside, I will add that heavy drinkers commonly are tolerant to benzos- that is to say that they can take a lot more of the drug with less effects. That's not a personal jab, by the way.

In my opinion, though, in an ICU setting or a setting where the patient is well monitored, the best drug to use on ANYBODY for a very quick procedure is propofol. It is ideal due to its EXTREMELY rapid onset and offset - we are talking minutes instead of hours like versed (or MANY hours like valium). Thus a bolus can be given and the patient monitored for breathing and vital signs- if awake, you can push more, if not, do the procedure and know that the drug will be gone in a few minutes and the pt will wake up. If you give too much, the patient again will be ok in a few minutes provided you don't let them get hypoxic on you in the interim.

The other drug that I like, and is my choice for induction for intubation is etomidate- works with the least cardiac side effects (hypotension), although is not as convenient as propofol given a longer half life.

So, the bottom line as far as I am concerned for drugs that you personally would need for cardioversion would be either propofol or etomidate + a quick acting narcotic like fentanyl. I would reiterate that versed would also be a number one choice for me for longer procedures- but you have shown that you personally are tolerant to it- and that counts for something as well. But I wouldn't blacklist it given the hundreds of people I have used it on with fantastic results. Just not on you!! :D

Hope this helps, I know it's long, but I'm having a REALLY slow day!!

-G

ps. If you come in unstable- chest pain/hypotension/decreased consciousness almost nobody is going to "waste" time on sedation- you're gonna get cardioverted STAT.

pps. Narcan won't reverse benzos, flumazenil will (that's prob what was really in the syringe)

ppps. The really nice thing about the benzos is a phenomenon known as retrograde amnesia- that is, if someone is cardioverted, and they go "Owie!!" you can push benzos in an attempt to delete that memory, even though it occured prior to receiving more drugs. It works very well (although again, not in you I guess).

:) greg c,

Thanks for info buddy, things are becoming much clearer now.

I had no idea that Versed was in the benzodiazepine class of meds. When I looked it up years ago they had it catorgorized as a "hypnotic drug". Not sure of the real difference between the two categories. The doctor that pushed the Versed had given me a bolus of something sometime before the procedure. I cannot remember how far in advance it was given to me before the push of Versed. I automatically thought it would of been something like either Valium or Lorazepam which we both know are Benzo's. I beleive the goal of the pre-med was to get me to relax because I really did told them I felt great after seeing the Defib get pushed in. You know just like in Monty Python & The Holy Grail: "Bring out your dead! I am not dead, I am filling better now!" I think they thought that I was not going to cooperate and run off as I was not in any distress other than feeling like I could out run a Cheetah.

Funny how he could of pushed more meds to make me forget that it had all happened and didn't (?).

I had no intentions of suing the doctor as he is a freind of mine. Doctor's have it ruff these days just like us Cops. Everybody expects nothing short of working miracles, being patient, take the abuse, don't ever make any mistakes, and remember you probably will get sued at least once in your career for doing your job!

:)

I havent seen etomidate used for cardioversion yet.

Ive seen it used countless times for intubation, and I know that its being studied for procedures both prehospital and inhospital.

It seems to have a lot of promise. I know of flight programs that are using it for extrication assists, reductions, chest tube placements etc-

ccrn

MAB32- glad the info was of use to you. The retrograde amnesia stuff likely wouldn't have worked on you given the lack of effect the intial doses had. Stay safe, buddy.

CCRN: here are some interesting links regarding etomidate in cardioversion- etomidate has really been making the rounds... Actually MAB32- you should eyeball these as well- note that in the multiregimen trials that versed (midazolam) is included as a standard of care protocol.

http://www.ncbi.nlm.nih.gov/entrez/q..._uids=15173551

http://www.ncbi.nlm.nih.gov/entrez/q...t_uids=1768820

http://www.ncbi.nlm.nih.gov/entrez/q..._uids=14634601

http://www.ncbi.nlm.nih.gov/entrez/q..._uids=12719046

greg c,


This study was the most interesting to me:

http://www.ncbi.nlm.nih.gov/entrez/q..._uids=12719046

Thanks for the info!

Also, in order to avoid a Pulmonary Embolism during cardioversion, I spent the 24 hours before taking Coumadin and getting stuck every so many hours to check my count. That was just generally a pain in the butt. Question for you however, why don't they do another venipuncture on the arm and take blood from that catheter for your clot time instead of drawing it constantly from the Basilic and Median juncture(s)? I would think you could get away with doing that and still receive accurate results. It is probably a dumb question but I am curious as to why or why not.