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

- Rogue Medic

Synchronized Cardioversion Without Sedation – Part II Scallywag’s Response


In Synchronized 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 to this Scallywag Medic Rogue Medic post. Now that the cast of posts has been introduced, what does Tom write?

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.

This is possible, but not certain.

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

I don’t think that those goals are competing.

I would describe the different goals as delivering a potentially life saving treatment in an extremely painful way and delivering a potentially life saving treatment with some pretreatment to minimize the pain.

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?”

Now we get to the essence of the disagreement.

Does sedation increase the possibility of a bad outcome?

Based on what?

Research?

Case series?

Any case reports?

What are the possible outcomes?

These are limited examples that assume a lot.

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

That is a possibility. Do we know that the patient would have died without cardioversion?

We do not. We assume the patient lives because of cardioversion.

What is the rate of spontaneous remission/improvement in this patient population?

Is it 0%?

Is it 20%?

Is it 50%?

Is it completely unknown?

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

I thought that we were already assuming, by referring to the patient as unstable, that the patient may die.

Are we assuming that the hemodynamics are further impaired because of the sedation?

Are we assuming that the hemodynamics are further impaired because of the cardioversion?

Are we assuming that the hemodynamics are further impaired because of the continuing instability?

Are we assuming that the hemodynamics are further impaired because of some combination of these?

Why?

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

ICD (Implantable Cardioverter-Defibrillator or Internal Cardiac Defibrillator) shocks are much lower energy levels than the initial levels used for cardioversion.

What percentage of patients are shocked into a significantly better perfusing rhythm with the first shock and do not return to their unstable condition prior to arriving at the hospital?

Do they sedate patients prior to emergency cardioversion in the hospital?

The common complaint with ICD shocks is that they produce anxiety about future shocks, not that ICD shocks produce the kind of pain that would have us preferring to die.

Transcutaneous cardioversion is very different from cardioversion with wires implanted directly ino the heart.

Consider how much more painful transcutaneous pacing is vs. pacing by an implanted pacemaker. The difference is tremendous.

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

Is there any good reason to believe that the hemodynamics do not get worse?

Weren’t you presenting emergency cardioversion as something so important, that if the patient didn’t receive cardioversion right now, the patient is likely to die.

Or are you suggesting that the patient would die, but not have a deterioration in hemodynamics? 😉

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.

If my sentinel event comment is what inspired this, then I should point out that I think that every intubation should be treated as a sentinel event – up until the EMS agency can be shown to consistently intubate successfully in over 95% of attempts with zero unrecognized esophageal intubations.

EMS has a horrible reputation for intubation airway management.

One thing we are worse at than intubation is oversight. If we wish to improve develop quality of care, we need to take oversight seriously.

We allow medics to get away with very poor care with minimal oversight.

We allow medical directors to get away with providing imaginary oversight.

Both need to be stopped.

Treating all serious interventions as serious interventions is important.

Treating all serious interventions by prehospital personnel as sentinel events is only being reasonable.

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.

I also have On the relative wisdom of synchronized cardioversion without sedation – Part III scheduled for Tuesday morning. I have not yet written On the relative wisdom of synchronized cardioversion without sedation – Part IV.

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Comments

  1. If your worried about the hypotensive properties of versed, maybe you should buy the one that doesn’t have hypotensive properties!

    AHA 2010 research text shows that the cause of the hypotension was caused by the suspension the med was placed in, not the med itself. Studies show that versed used in a different suspension had very minimal hypotensive effects

    I believe that pain is significantly undertreated in EMS today. The fact that the patient is “unstable” shouldn’t negate sedation. Sure he might become more hypotensive but who’s to say it was caused by the drug or its caused by the heart failing further to act as a pump.

    All I’m saying is pain needs to be treated in my opinion. I wouldn’t use morphine due to the histamine release causing vasopermeability but if I didn’t have versed id use fentanyl.

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