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 III


Continued from On 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 wisdom of synchronized cardioversion without sedation.

Rogue Medic shares a comment from a reader who states, “I begged the worker not to shock me.”

If the patient begs you not to shock, you probably shouldn’t shock!

I agree.

Prophylactic sedation in preparation for possible deterioration in condition is a much better idea.

A far more egregious act than shocking without sedation is shocking against the expressed wishes of your patient, who I presume possessed decisional capacity!

This can be difficult to determine based on a memory of the event. What would an objective observer of this scene have concluded? We don’t know.

However, one thing that I have seen too often, is when the patient has any medical condition that could possibly affect the capacity to make an informed decision, no matter how remotely, that patient is automatically presumed to lack the capacity to make an informed decision, unless the patient asks for more treatment, rather than less treatment.

What? You don’t want to be intubated?

Clearly, your capacity to make an informed decision is impaired by hypoxia! Look. The Pulse Ox proves it!

Or –

What? You don’t want needle decompression of your chest?

Clearly, your capacity to make an informed decision is impaired by hypoxia! Look. The tachycardia proves it!

Do we use hypotension in the same way?

Do we use hypotension as an excuse to invalidate valid decisions made by patients?

Do we claim that hypotension prevents an informed decision?

Absolutely.

We should not.

The claim that hypotension prevents an informed decision is a lie.

Once you give a drug you can’t take it out. So if you push drugs that can negatively effect a patient’s hemodynamics and those hemodynamics are already compromised you are taking a risk.

Absolutely.

Of course, everything we do is taking a risk.

We use the phrase, First, Do No Harm! This is not possible. Everything has side effects.

Some side effects will cause unexpected harm from treatments we consider to be essentially harmless.

What is the benefit?

One benefit is a more cooperative patient, if the cardioversion is not successful on the first attempt. You made an earlier comment about not knowing if the cardioversion will work. Failed cardioversion is relevant to these patients.

Not sedating the patient is gambling that the first shock will be completely successful with no recurrences of the tachycardia that is presumed to have made the patient unstable.

Is there a benefit to not sedating the patient?

Is there good evidence that we should expect bad outcomes due to sedation for cardioversion?

Many things in EMS (and Fire) are risk/benefit.

Everything in life is risk/benefit. Just because we do not consciously evaluate the risks and benefits of all of our decisions, does not mean that they do not exist.

The laws prohibiting gambling make it difficult to explain this to people, because these laws suggest that engaging in risk/benefit scenarios gambling is somehow evil. Abuse of gambling is a problem, but gambling is just a tool that can be used to teach risk management. Gambling is ethically neutral.

I can conceive of circumstances within which I would shock a hemodynamically unstable patient who was not unconscious. I can conceive of circumstances within which that would be the best thing for the patient. I can conceive of circumstances within which that would be life-saving.

So can the AHA (American Heart Association), but the AHA still wants us to sedate these patients before cardioversion and only avoid sedation when sedation is not possible.

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]

Even with 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)

Hypotension does not mean Do not sedate!

Even acute altered mental status does not mean Do not sedate!

Like so many things in medicine, this is not a black and white issue.

The National Registry will be disappointed at this statement that does not support their idiotic insistence on accepting only the one best answer. 🙂

There are many ways of treating a patient and still having a good outcome. Much of what we do leads to the patient surviving to the hospital in spite of us, not because of us. We have few definite answers to what the best interventions are. We do know that ignoring the harm of our treatments is not good patient care.

If we are going to do something as painful as cardioversion to an awake and alert patient (an indication of adequate cerebral perfusion), we need to minimize the harm with sedation if possible.

If we, or our medical directors, are not comfortable with the drugs we have available for sedation in the actual conditions where these drugs are to be used (cardioversion), then we need to make better drugs available to EMS.

With etomidate (Amidate), or even better ketamine (Ketalar), there are other possibilities.

Ketamine can be given IM (IntraMuscularly), IV (IntraVenously) or IO (IntraOsseously).

Ketamine does not appear to cause vasodilation.

Ketamine works very quickly.

To be 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. Please foward this to the MAC for Pennsylvania and encourage them on the next protocol review to include Ketamine, remove Valium and require Fentanyl for narcs, oh yea and add blow darts to the combative patient restraint protocol.

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  2. […] – 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 to this Scallywag Medic Rogue Medic […]

  3. […] the relative wisdom of synchronized cardioversion without sedation – Part II, and most recently On the relative wisdom of synchronized cardioversion without sedation – Part III, which began my response to Tom Bouthillet, at Prehospital 12 Lead ECG, writing On the relative […]

  4. […] wisdom of synchronized cardioversion without sedation – Part II and later 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 […]

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