Without evidence of benefit, an intervention should not be presumed to be beneficial or safe.

- Rogue Medic

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


Continued from On the relative wisdom of synchronized cardioversion without sedation – Part I, which began my response to Tom Bouthillet, at Prehospital 12 Lead ECG, writing On the relative wisdom of synchronized cardioversion without sedation.

Let’s pause for a moment and acknowledge that there are degrees of stability/instability.

Yes.

I’m talking about the peri-arrest patient.

If the patient cares that much about whether or not you are shocking them, I have questions about how “unstable” they really are.

Precisely.

If the tachycardic patient is unstable 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), immediate cardioversion should be performed (with prior sedation in the conscious patient) (Class I, LOE B).[1]

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 an awake 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?

Is there anything about ischemic chest discomfort that requires the patient to be confused or unconscious?

Is there anything about acute heart failure that requires the patient to be confused or unconscious?

Is there anything about hypotension that requires the patient to be confused or unconscious?

Is there anything about other signs of shock that requires the patient to be confused or unconscious?

Furthermore, this does not even state that we should not sedate the patient with acute altered mental status.

If the tachycardic patient is unstable 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), immediate cardioversion should be performed (with prior sedation in the conscious patient) (Class I, LOE B).

In the absence of an advance directive, we should not accept a refusal of treatment from a patient with acute altered mental status. This does not mean that we should inflict severe pain, just because the patient is confused.

Should I be permitted to cause unnecessary extreme pain to my patient just because I can beat the patient at Battleship, Trivial Pursuit, or Poker?

What does unnecessary mean?

To be continued in On the relative wisdom of synchronized cardioversion without sedation – Part III and even later continued in On the relative wisdom of synchronized cardioversion without sedation – Part IV.

Footnotes:

[1] Overview
2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care
Part 8.3: Management of Symptomatic Bradycardia and Tachycardia
Free Full Text Article with links to Free Full Text PDF download

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Comments

  1. I have found the exchange on synchronized cardio version without sedation interesting. Some have referred to the procedure as being very painful for the patient, even traumatizing. I have opted to have 2 cardio versions without sedation because of my aversion to sedation. The experience was highly uncomfortable but I would not describe it as painful, and I was not traumatized by the event. Hopefully, I will not need another cardio version, but if I did I would opt for no sedation. I share this information with the intention of dispelling some of the assumptions being made about the level of pain that the patient will necessarily experience. I am not suggesting that the procedure should be done without sedation on every patient. I am suggesting that if a patient needs cardio version and sedation is too risky, then sedation should not be used and the procedure without sedation should be positioned with the patient as being a very uncomfortable one that is very short-lived and will be completed in the blink of an eye. My sense is that administering the cardio version without sedation is somehow more psychologically painful for the administrator than it is physically painful for the unsedated patient. If some doubt my point of view, simply submit yourself to an unsedated cardio version to experience the sensation so the you can make a better informed decision about whether to sedate or not sedate an unstable patient.

Trackbacks

  1. […] Cardioversion Without Sedation – Part II, Tom Bouthillet responds to my posts Part I and Part II (I haven’t even posted Part III or Part IV, yet), responding to his earlier post responding […]

  2. […] the relative wisdom of synchronized cardioversion without sedation – Part I, then followed by On the relative wisdom of synchronized cardioversion without sedation – Part II, which began my response to Tom Bouthillet, at Prehospital 12 Lead ECG, writing On the relative […]

  3. […] be continued in On the relative wisdom of synchronized cardioversion without sedation – Part II and later to be continued in On the relative wisdom of synchronized cardioversion without sedation […]

  4. […] the relative wisdom of synchronized cardioversion without sedation – Part I, then followed by On the relative wisdom of synchronized cardioversion without sedation – Part II, and most recently On the relative wisdom of synchronized cardioversion without sedation – Part […]

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