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

- Rogue Medic

Ambulance Mistake Killed Teen After Skateboard Accident

Here is an article about the death of a kid that raises a lot of questions.

The article does not answer many of those questions.

What happened?

Melvin says Carteret General sent a respiratory therapist along in the ambulance because they decided to put a breathing tube down the child’s throat. He says Drew was not properly sedated, woke up and pulled out the tube.[1]


Not properly sedated?

Unfortunately, this does happen. Dr. Scott Weingart has a couple of podcasts where he rants about this problem.[2],[3]

Why avoid sedation?

Maybe the patient is allergic.

Use a different sedative. There are dozens available.

Maybe the patient’s blood pressure is low.

Use ketamine.

What if the patient stops breathing?

Really. This is an excuse that I have encountered with several intubated patients.

Just how stupid are some of the people who graduate from medical school?

The patient is already intubated and on a ventilator (or being ventilated by BVM [Bag Valve Mask] resuscitator).

What do we do for someone who stops breathing?

Ventilate – for example by BVM until an endotracheal tube is placed.

If an endotracheal tube has already been placed, does anyone really care if the patient stops breathing?

And . . .

. . . ketamine.

Ketamine is a sedative that usually does not depress the patient’s respiratory drive.

And there is one more minor point to consider.

Most patients are intubated with the assistance of not just sedatives, but also paralytics.

If you are breathing after receiving a paralytic, somebody did something wrong. A paralytic is supposed to stop every muscle in the body from contracting – except the heart.

It could be that there was an omission of adequate doses of more than two types of drugs – sedatives and paralytics and, as Dr. Weingart will point out, pain medicine, because sedatives do not usually provide pain relief . . .

. . . except for ketamine.

It is a versatile drug, that ketamine.

The patient woke up and pulled the tube out.

Which would make you happier?

1. I have to ventilate this patient through the tube that is already in place.

2. I have to place the tube back in the trachea during transport because you neglected to provide adequate sedation. Even if reintubated excellently, intubation has many complications.

That should be the antidote to the argument that sedation is a bad thing (what if he stops breathing?), because it should be obvious that not breathing, but being ventilated is much better than not being sedated and being so agitated that the patient removes his airway.

Just put it back in!

That is the response, except . . .

The attorney says when those in the ambulance re-inserted the tube, it went into the teen’s esophagus, rather than his trachea.[1]


That happens.

Esophageal intubation is no big deal.

Just ventilate and place the tube in the trache. If the tube cannot be properly placed, we can use the BVM for ventilation or perform a crichothyrotomy. Both are acceptable means of ventilation.

He says Drew was given sedatives, and the teen, unable to breathe on his own, went without oxygen for about 35 minutes.[1]


Not recognizing a tube that has been placed in the esophagus, or one that has migrated to the esophagus, is just plain bad patient care.

Nobody should be intubating without waveform capnography to confirm placement.

Even without waveform capnography, there should not be a problem. All intubated patients should have continual assessment, which should identify a problem long before brain death.

Again, the worst case is that the patient is ventilated by BVM or crichothyrotomy.

We do not have details about what happened, but the patient appears to have arrived at the hospital without brain function. Was that due to the original injury, with the esophageal intubation only complicating matters?

There is not enough information to tell, but when the tube is left in the esophagus, it is kind of like leaving your fingerprints all over a knife sticking out of a dead guy’s chest. People are not going to spend a lot of time looking for another cause of death.

Capnography has been recommended in ACLS (Advanced Cardiac Life Support) since 2000, if not earlier.[4]

How difficult is assessment for an improperly placed tube (all tubes should be considered improperly placed and continually reassessed)?[5]

Melvin says the ambulance crew diverted to CarolinaEast in New Bern, and the ER doctor there immediately recognized the tube was in the wrong place.[1]


We like to find evidence that confirms what we believe. (I believe that the tube is where I want it to be. I saw the tube go through the cords.)

This is dangerous.

We need to look for evidence that we are wrong.

If we are not constantly looking for evidence that we are wrong, we will make a lot more mistakes than we should.

Science is a method of looking for evidence that we are wrong. That is why science keeps improving.

We need to take a more scientific approach to patient care. . .

. . . and have I mentioned ketamine? Science shows that ketamine is safe and effective.

I have more information here – Further Details on ‘Ambulance Mistake Killed Teen After Skateboard Accident’


[1] LAWSUIT: Ambulance Mistake Killed Teen After Skateboard Accident
Updated: Wed 9:14 PM, Nov 06, 2013

[2] Intubated ED Patients are Still Not Receiving Sedation
by Scott D. Weingart, MD.
Podcast page

[3] ED patients being intubated and then not sedated or pain-controlled
by Scott D. Weingart, MD.
Podcast page

[4] You had me at ‘Controversial post for the week’ – Part I
Tue, 22 Oct 2013
Rogue Medic

[5] More Intubation Confirmation
Sun, 27 Apr 2008
Rogue Medic


Serious adverse events during procedural sedation with ketamine – Part I


What contributes to adverse events with the use of ketamine for PSA (Procedural Sedation and Analgesia) in children?

The pre-PSA use of fentanyl or morphine or concomitant use of midazolam and/or atropine was not associated with an increased in adverse event in either IM or IV ketamine (Table 1).[1]

However, there was a trend toward different rates of adverse events with the use of some medications in addition to ketamine. A larger study would be able to tell if these trends are real or just normal statistical variation.

The use of morphine, fentanyl, and midazolam would be expected to cause some adverse effects, but midazolam seems to provide protection from adverse events.

Morphine and fentanyl were used so infrequently, that drawing any conclusions from such small numbers is a bad idea.

Why does midazolam appear to protect against adverse effects?

Even more interesting is the possible harm caused by atropine.

Why would atropine increase the rate of adverse events?


Why do we give atropine to children?

To prevent ourselves from being able to see the effects of hypoxia on the child’s heart rate.


We give children atropine to prevent their heart rates from dropping when we are doing things that are expected to occasionally result in hypoxia.

The child’s heart rate is a great indicator that we are making the child hypoxic, but we prefer to not know about the hypoxia.

Should we also avoid pulse oximetry?

We even delay our ability to identify hypoxia with pulse oximetry by using supplemental oxygen. That doesn’t mean that we should not use supplemental oxygen, only that we should assess ventilation with a measurement that is not affected by supplemental oxygen – waveform capnography.

Atropine should not be used to keep the pediatric heart rate from responding to hypoxia.

The way to prevent pediatric bradycardia is to prevent hypoxia, not to put lipstick on the hypoxia.

Image credit.

What hypoxia? No hypoxia here. Just a pulchritudinous paramedic.

Atropine is also used as an antisialog, which means that it decreases salivation. That can be an appropriate use, but if the atropine prevents the recognition of hypoxia, some saliva in the mouth may not be that important or we should use suction (just as the dentist does).

However, the study was not designed to look at that and the numbers never reached statistical significance. Does that mean that we should continue to use atropine for something that is not beneficial?

Where is the evidence that there is any benefit to anything other than the ego of the person pushing the atropine?

Oh, look! Better numbers on the monitor.

We should not be harming our patients with drugs.

To be continued in Part II, which looks at the actual IM vs. IV results.

Thank you to Peter Canning, of Street Watch: Notes of a Paramedic, for this journal article.


[1] Serious adverse events during procedural sedation with ketamine.
Melendez E, Bachur R.
Pediatr Emerg Care. 2009 May;25(5):325-8.
PMID: 19404223 [PubMed – indexed for MEDLINE]

Melendez E, & Bachur R (2009). Serious adverse events during procedural sedation with ketamine. Pediatric emergency care, 25 (5), 325-8 PMID: 19404223


How to Torture Patients

Perhaps, you have watched all of the parts of Saw and wished that you could have some of that kind of fun, too. Even though we are supposed to be having the opposite effect on patients, some of us do cause that kind of pain and psychological abuse.

Dr. Weingart gives us a piece of his mind on this topic in Pain and Terror as Effective Pressors.

Does this go well with scrubs, or with an EMS uniform?

Image credit.

But what about the hypotension and hypoxia that occur with fentanyl?

Click on images to make them larger.[1] [2]

There is a 97% chance that, after administration of fentanyl to a critical trauma patient who is not hypotensive, the patient will still be not hypotensive.

There is a 47% chance that, after administration of fentanyl to a critical trauma patient who is hypotensive, the patient will stop being hypotensive.

If we did not have so much anxiety about fentanyl, we might consider making it the standard of care for hypotension following trauma.

Should we be double-teaming these patients with both pain and the terror of awareness during intubation with a long-acting paralytic? It probably isn’t any worse than what the traumatically paralyzed patient experiences with intubation, but that should only encourage us to be more aggressive with pain management for these patients. This is not an excuse to be tolerant of iatrogenic pain and anxiety.

Pain management in EMS seems to keep improving, but we still have a long way to go.

Pain management in the ED (Emergency Department) seems to keep improving, but we still have a long way to go.

I currently do have a protocol that allows me to give post-intubation sedation. This was only added to my protocols in the past 5 years, but it is a start. Before that, medics had to be aggressive enough to ask for medical command permission for a treatment that was outside of protocol. Treatments that are outside of protocol are discouraged.

The problem with post-intubation pain (and the expected agitation that goes with pain) this pain management sedation is not a recent development.

In an earlier podcast, Dr. Weingart describes the problems with using sedatives, rather than pain medicine, for post-intubation PAIN.

EMCrit Podcast 7 – Sedation Tirade – and listen to his other sedation podcasts.

Why do we think that a patient does not have pain unless that patient is writhing in pain?

With a paralytic on board, especially a long-acting paralytic, and even more so with a large dose of a long-acting paralytic, these patients will not writhe.

This brings up some questions –

How much evidence do we need that many of our patients are in a lot pain?

How easy is it to ignore the severe pain of our patients?

I do have one criticism.

The dose of sarcasm could be increased. This is no time to be stingy with the sarcasm treatment. I could be wrong.

Go listen to the brief Wee podcast and decide for yourself.


[1] Fentanyl in the out-of-hospital setting: variables associated with hypotension and hypoxemia.
Krauss WC, Shah S, Shah S, Thomas SH.
J Emerg Med. 2011 Feb;40(2):182-7. Epub 2009 Mar 27.
PMID: 19327928 [PubMed – in process]

Full Text PDF Download at medicalscg.

Fentanyl Study: EMS Research Episode 9
EMS Research Podcast
Podcast page

[2] Chart Version – Fentanyl in the out-of-hospital setting: variables associated with hypotension and hypoxemia
Sun, 05 Jun 2011
Rogue Medic


Excited Delirium, Sedation, and Comments – Part III

There are some more responses to the comment of Shane to ‘Hog-tying’ death report faults Fla. medics.

Why do I write so much about excited delirium?

Few of our patients will have any kind of life-or-death intervention from EMS. These are some of the patients. We can make the difference between life and death.

These are also some of the least likable patients we will deal with – they are often attacking us. How do we protect ourselves and protect our patients?

Some people continue to tell us that sedation is evil.

This is from kindofafireguy

Granted, I’m no lawyer, but it seems to me the greatest potential for liability is when the standard of care is NOT met, as opposed to when it is.

So if you have protocols for chemical restraint (as my region does), to me that would imply greater liability for not restraining a patient in need of it and said patient wreaking mayhem and injuring people.

But that’s just me applying common sense. So it’s probably wrong.

I am not a lawyer, either. I think that we have too many people telling us what a jury will do, when we do not know what a jury will do. The jury determines what is the standard of care and whether that standard was met. Trying to predict what 12 people (or six) will agree on – after listening to very biased, but antagonistic descriptions of the same events and expert testimony that is similarly antagonistic – is not something intelligent people should do.

The only legal advice that makes sense to me is –

Do what is best for the patient.

The problem is that we do not always know what is best for the patient, but –

If the patient is excited, with all other patients, we would be trying to calm the patient down. With excited delirium, we seem to be going out of our way to make them even more sedated. Here are some nice soothing leather restraints.

If we follow the physical restrain promptly with chemical restraint, that is patient care.

If we do not follow the physical restraint with chemical restraint, how is that patient care?

This is from Kelly Grayson of A Day in the Life of an Ambulance Driver

“By Chemically Restraining a patient you open yourself and your EMS/Fire Department to lawsuits and losing your license.”

How… quaint.

Don’t know what hospitals Shane is dealing with, but virtually every hospital I take patients to has virtually done away with leather restraints, partly because of Joint Commission requirements, but also because they’d much prefer to sedate.

Let me repeat that: MUCH prefer to sedate.

There are EMS agencies near me that do not aggressively sedate agitated patients.

As our medical protocols become more and more aggressive, that is changing, but we still have to wait for some of the old medics (and old medical directors) to die off. Being treated according to their own protocols may be the best way to do that. If it does not kill them, being treated by their own protocols may convince them that their approach to patient care is not good patient care.

They’d much rather use a B52, or Geodon, or Zyprexa, or increasingly, ketamine, and they’re tickled pink if we get a head start on that before we even arrive.

B52 refers to a mixture of B (Benadryl – diphenhydramine) 50 mg, haloperidol (Haldol) 5 – 10 mg, and lorazepam (Ativan) 2 mg. These doses are not limits, but starting points for sedation. We can always give more, even if we have to make a phone call while in the middle of wrestling with the patient.

The Haldol does not get the recognition it deserves, but that is what is doing the most to knock the patient down – not knock the patient out. Knocking the patient down has little to do with gravity. Knocking the patient down means getting rid of the patient’s combative behavior.

The diphenhydramine is there both as a sedative and as prophylaxis against extrapyramidal symptoms.[1]

This is from an article in Emergency Medicine News on treating excited delirium –

Regardless of one’s choice of medication, the key to success is to use enough drug. Internist- and pediatrician-type doses usually don’t cut it. The PDR is clueless about effective doses for our purposes, and safety caveats in that publication are merely fodder for lawyers, not information for clinicians. The best guideline is to give enough to achieve the intended result.[2]


Regardless of one’s choice of medication, the key to success is to use enough drug.


Why do so many of us attempt to justify giving an inadequate dose?

Image source.

See also –

‘Hog-tying’ death report faults Fla. medics.

Excited Delirium, Sedation, and Comments – Part I

Excited Delirium, Sedation, and Comments – Part II


[1] Extrapyramidal symptoms

[2] Rapid Tranquilization of Violently Agitated Patients
Roberts, James R. MD
Emergency Medicine News:
November 2007 – Volume 29 – Issue 11 – p 15-18
doi: 10.1097/01.EEM.0000298833.70829.ad
Free Full Text from Emergency Medicine News


Excited Delirium, Sedation, and Comments – Part II

Others responded to the comment of Shane to ‘Hog-tying’ death report faults Fla. medics.

CombatDoc wrote –

Why are medics so scared of sedation?

This is the main problem.

Ignorance leads to fear.

But this does not lead to Yoda quotes.

We should not be arrogant, assuming that we know everything about the drugs we use. That can be just as dangerous as ignorance, but we need to learn more about the medications we use.

Too many people tell us that sedatives and opioids are dangerous. These are probably the safest drugs we use. They have well known side effects, but the side effects are not remotely as common as the Just say No people would have us believe.

We need to base our treatments on understanding, not fear.

If we understand what we are doing, we will continually reassess our patients, but we should do this with every treatment, not just the treatments portrayed as evil.

My favorite comment in a chart of a patient that I suspect of ED is, “Pt arouses to voice and is resting comfortably on the cot.” That is a properly treated patient.


The purpose of sedation is to sedate.

That is a description of a sedated patient. We are not supposed to be producing awake and alert and cooperative patients. That is asking the impossible.

We are supposed to be sedating the patient to the point of both no longer being a danger to himself and no longer being a danger to others. Awake and alert have nothing to do with that.

I have had very good results with initial doses of 5mg IN or IV of Versed and 10mg IM Versed. I always followed up the IN/IV with an IM dose since studies, cannot find the original one, have shown IM as a better route with less resedation needed.

I would prefer to use IV (IntraVenous) midazolam over IM (IntraMuscular), because it wears off pretty quickly when given IV, especially with the exaggerated metabolism of excited delirium patients. The reality of excited delirium is that an IV is usually not practical, so I have to settle for longer duration and less predictable absorption.

I like the idea of the sedative wearing off quickly, because some patients just need to have their excited delirium interrupted. After a period of sedation, some are able to be reasoned with. Some will ask for more sedation, because they realize they cannot control they way their body is acting. This can be like a panic attack. The patient would like to control it, but does not do well without sedation. It should not be a surprise that benzodiazepines are commonly used for panic attack.

How have your results been with IN (IntraNasal) midazolam for excited delirium?

I know there are risks and apnea is one. Not a fan of doing that on purpose but, we can all handle that.

If a medic cannot handle respiratory depression, or apnea, by BLS (Basic Life Support) methods, should that person be allowed to use any ALS (Advanced Life Support) treatments?

We can’t handle simple cases of respiratory depression, but we should still be allowed to play paramedic?


Absolutely not.

I am seeing more and more of these patients and more and more are ending up chemically paralysed on ventilators until the Spice or Bath Salts are out of their system.

I was wrong about bath salts. I did not think this would become a big deal. Maybe I am just getting old and do not understand how stupid people will be to get a high. Maybe I need to chase some kids off of somebody’s lawn, somewhere. 😳

I guess the doctors just don’t have enough faith in the power of leather restraints./

Maybe someday my medical director will give us Ketamine….

That would be great.

Sedation has so many uses, that we our patients are really missing out on an excellent treatment for a variety of conditions.

Shane, so you have a stance that the hyperthermia, lactic/metabolic acidosis, rhabdo, dehydration, extreme hypertension, etc. that leads to renal failure, MODS, cardiac dysrhythmias, stroke and sudden death is not something that needs to be worried about? Last I checked most of those can kill pretty quickly. All those are a direct result of the patient that is out of control and fighting and struggling. My guess is you have never walked in the house to see every piece of furniture, every appliance, bathroom fixtures, windows, etc. all destroyed by a 150lb guy standing there naked and ready to fight. Not a fun call and a VERY dangerous situation for all involved.

The people who deny excited delirium exists are not the people who work in EMS, emergency medicine, or the police.

The people who deny excited delirium exists are the people who deal with patients who have already been sedated by EMS and the ED (Emergency Department).

If we do not sedate these patients, we may miss the last opportunity to save their lives.

All for a lack of understanding of sedation.


Excited Delirium, Sedation, and Comments – Part I

It isn’t my birthday. Still, Shane decided to provide me with plenty of giggles in his response to ‘Hog-tying’ death report faults Fla. medics.

Shane wrote –

I think you might want to review your comments and think before making some statements.

I already made the statements, so I cannot review the statements again before making those statement, unless I repeat the same statements. Based on what you wrote, I will have to repeat some comments. I should probably strengthen, and add to, other comments, because you do not appear to understand.

At first, I thought this comment was a joke. After thinking about it for a while, I suspect that you work for the QA/QI/CYA department of an EMS agency (or maybe you are an absentee medical director). Those are positions that seem to be filled with the most blatant promoters of misinformation. You comment is full of misinformation.

99% of the time, Chemical Sedation is NOT a good practice or recommended to control your patient.

According to whom?

Based on what?

You make bold statements, but you do not provide anything, not even a note from your kindergarten teacher, to support your uninformed assertion.

There are many underlying factors to consider, as you should know, and there are a reason hospitals, medical units and such carry leather restraints and other such devices including police handcuffs with an officer accompanying you in the truck.

There is no requirement for leather restraints on my ambulance, but my state medical director has written protocols with a variety of options for sedation for excited delirium.

By Chemically Restraining a patient you open yourself and your EMS/Fire Department to lawsuits and losing your license.

By protecting my patient, I am protecting everyone else, too.

Please explain the justification for the legal advice that you are giving. Did you stay at a Holiday Inn Express last night?

You should be a patient advocate,

I am being a patient advocate.

You are advocating putting the employer and the medic first, because of some imaginary legal risk.

this does not mean “knocking them out” to better control them. Unknown medical history, allergies, head trauma… all these contribute and should be considered. By doing so could result in a medic induced code due to your actions to use drugs to control a patient.

We do not need to knock the patient out, but we do need to knock them down – we need to sedate excited delirium patients.

I provided a link to the ACEP White Paper. You should have used that opportunity to learn about excited delirium syndrome. Rather than learn, you decided to be an evangelist of ignorance. You wag your finger at me based on what?

You mention Unknown medical history, allergies, head trauma…. How would we make any of these better by increasing metabolic stress?

Fighting against restraints will only make the metabolic stress worse.

What do the experts state in that White Paper?

The majority of lethal ExDS patients die shortly after a violent struggle. Severe acidosis appears to play a prominent role in lethal ExDS-associated cardiovascular collapse.[1]

ExDS is Excited Delirium Syndrome.

Acidosis is not going to get better with continued struggling, but sedation can stop the struggling. Leather restraints do not stop the struggling. Leather restraints do protect others, when secured correctly, but leather restraints also increase the danger to the patient.

ExDS subjects are known to be irrational, often violent and relatively impervious to pain.[1]

An irrational struggling acidotic patient is going to become less acidotic because . . . ?

An irrational struggling tachycardic patient is going to become less tachycardic because . . . ?

An irrational struggling hypertensive patient is going to become less hypertensive because . . . ?

An irrational struggling hyperthermic patient is going to become less hyperthermic because . . . ?

An irrational struggling hypoxic patient is going to become less hypoxic because . . . ?

Sedation decreases the struggling and decreases the cycle of worsening metabolism that the patient exacerbates by fighting against restraints.

Most authorities, including this Task Force, posit the beneficial use of aggressive chemical sedation as first line intervention. As with any critically ill patient, treatment should proceed concurrently with evaluation for precipitating causes or additional pathology.[1]

The experts do not agree with Shane’s fear of over-sedation.

The experts do not agree that the rest of the patient’s history is more important than sedation.

The experts appear to want to protect the patients with head injuries by sedating the patient.

The experts have thoroughly investigated the condition of excited delirium (something police, EMS, and emergency department staff are familiar with) and decided that use of aggressive chemical sedation as first line intervention is the right thing to do.

I think a little more thought should go into your blogs.



[1] White Paper Report on Excited Delirium Syndrome
ACEP Excited Delirium Task Force
Vilke GM, Debard ML, Chan TC, Ho JD, Dawes DM, Hall C, Curtis MD, Costello MW, Mash DC, Coffman SR, McMullen MJ, Metzger JC, Roberts JR, Sztajnkrcer MD, Henderson SO, Adler J, Czarnecki F, Heck J, Bozeman WP.
September 10, 2009
Free Full Text PDF

Updated link to PDF 7/23/2018.


‘Hog-tying’ death report faults Fla. medics

An internal investigation by Broward County’s Fire Rescue division concluded that errors by emergency personnel may have caused the death of a Lauderhill man who suffocated after being “hog-tied” by Broward Sheriff’s Office deputies and county paramedics.[1]

This death is from October 15, 2001, so it has been over a decade and everyone in EMS should be refusing to allow patients to be placed in the prone position following restraint. Hog tying should never even be considered.

The responsible way to manage someone who is combative is to chemically restrain the patient. Physical restraint is for the purpose of being able to inject the patient with the chemical restraint.

Should the medics have known better? Yes, but it was a decade ago and there are still EMS agencies that are not aggressive with chemical restraints.

This is the responsibility of the medical director. We are supposed to be trained and equipped to not make things worse. Clearly, we can make things much worse, if we do not have the right education and medication and protocols.

We should not be treating our excited delirium patients like animals in a rodeo. As medical people, we are supposed to be smarter than the patient with the malfunctioning brain.

Diabetes, head injury, stroke, hypoxia, hyperthermia, drugs, psych, et cetera. There are many possible reasons for this behavior. Our job is to sedate the patient with the least harm to everyone involved, including the patient.

Image credit.

Tasers protect everyone, including the patient,[2] so it is safer for everyone if police use a Taser and then EMS sedates the patient. This is not likely to be effective unless aggressive doses of sedative are given.

Given the irrational and potentially violent, dangerous, and lethal behavior of an ExDS subject, any LEO interaction with a person in this situation risks significant injury or death to either the LEO or the ExDS subject who has a potentially lethal medical syndrome.[3]

They point out that a perfect outcome is expected every time.

A perfect outcome is not possible every time.

One of the problems in dealing with excited delirium is that it looks easy, but only when it is done right.

Making the treatment of unstable patients look no more eventful than the treatment of stable patients is what good EMS is all about.

When we make it look easy, some people will claim that we over-reacted. We cannot go back and handle things differently, but we should not want to. Some conditions need to be approached as if they arfe life-threatening. Excited delirium is one of them.


Because it is life-threatening.

Our job is to try to prevent death, not to cause death. If we do not protect our excited delirium patients by aggressively sedating them, we will kill some of our patients.


[1] ‘Hog-tying’ death report faults Fla. medics
Report cites 9 ‘failures’ that it says cumulatively may have led to man’s death
By Elgin Jones
South Florida Times
April 19, 2012
Article Reprinted at EMS1.com

[2] Joe Lex: Electrical Misadventures – Microwaves, Cords, Plugs, TASERs, and Lightning
Published: August 30, 2010
Free Emergency Medicine Talks
Page with mp3 link to download

Dr. Joe Lex is one of the most sought after emergency medicine lecturers in the world. Listen to this and to the rest of his talks that are at Free Emergency Medicine Talks.

[3] White Paper Report on Excited Delirium Syndrome
ACEP Excited Delirium Task Force
Vilke GM, Debard ML, Chan TC, Ho JD, Dawes DM, Hall C, Curtis MD, Costello MW, Mash DC, Coffman SR, McMullen MJ, Metzger JC, Roberts JR, Sztajnkrcer MD, Henderson SO, Adler J, Czarnecki F, Heck J, Bozeman WP.
September 10, 2009
Free Full Text PDF

Updated link to PDF 7/23/2018.


Comments on Cardioversion – 2010 ACLS – Part II

In response to Cardioversion – 2010 ACLS – Part II, there are some new comments. Chris from Sweden, had written –

What meds do you use in the hypotensive, but still conscious patient for sedation? Could ketamine and low dose of midazolam be of use here?

Gerardo Gastélum comments –

Not Ketamine for cardioversion. Ketamine rises heart rate and coronary O2 requirements.

Benzos like Midazolam or Diazepam + Opiates such as Fentanyl or Morphine can do the works. AHA also recomends etomidate, thiopental and propofol, but out of these I chose etomidate due to it´s cardiovascular stability.

I disagree.

There may be more of a desire to avoid sedatives that vasodilate and depress cardiac activity. This is one of the reasons that etomidate is recommended. I think that either effect is going to be short-term – if the cardioversion, or series of cardioversions, works.

Some people discourage sedation. One of the things that they do not appear to consider is the possibility of needing to cardiovert more than once.

I can get away with shocking her without sedation, justify it as saving her life, and sedate her afterward to deal with the side effects of such brutal treatment, but the idea of appropriate sedation prior to cardioversion almost scares me into an unstable tachycardia.

Fortunately, nobody here is recommending that we not sedate for cardioversion.

With comments on this topic, I tend to wonder, Has this been covered in an EMCrit podcast? What would Dr. Scott Weingart do? Maybe he can make up some EMCrit screensavers with the slogan WWWD? (What Would Weingart Do?). Dr. Weingart is trying to smooth the transition from treatment in the ED (Emergency Department) to treatment in the ICU (Intensive Care Unit) and possibly take over the world of emergency education.

I think the clever something to give is probably a low dose of etomidate, maybe 5 or 7 mg of etomidate. They’re not going to be fully unconscious, like when we gave the 10 or 15 mg, but it’ll take the edge off.

They’re getting no pain control whatsoever from that, so if you were really a smart guy, give a little etomidate with some ketamine, or even just ketamine alone.[1]

Listen to the whole podcast – all 9 minutes of it. I just copied a few sentences, but this very short podcast covers a lot of material that is very important to understand before dealing with the unstable tachyarrhythmia patient.

Image credit.

In the second comment, Gerardo Gastélum provides a quote from the 2010 ACLS guidelines that is important for the understanding of the difference between unstable and just symptomatic.[2]

Thank you for the great description from ACLS.


[1] EMCrit Podcast 20 – The Crashing Atrial Fibrillation Patient
by EMCRIT on FEBRUARY 12, 2010
Podcast page

[2] Management of Symptomatic Bradycardia and Tachycardia
2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science
Part 8: Adult Advanced Cardiovascular Life Support
Part 8.3: Management of Symptomatic Bradycardia and Tachycardia
Free Full Text from Circulation

Unstable and symptomatic are terms typically used to describe the condition of patients with arrhythmias. Generally, unstable refers to a condition in which vital organ function is acutely impaired or cardiac arrest is ongoing or imminent. When an arrhythmia causes a patient to be unstable, immediate intervention is indicated. Symptomatic implies that an arrhythmia is causing symptoms, such as palpitations, lightheadedness, or dyspnea, but the patient is stable and not in imminent danger. In such cases more time is available to decide on the most appropriate intervention. In both unstable and symptomatic cases the provider must make an assessment as to whether it is the arrhythmia that is causing the patient to be unstable or symptomatic. For example, a patient in septic shock with sinus tachycardia of 140 beats per minute is unstable; however, the arrhythmia is a physiologic compensation rather than the cause of instability. Therefore, electric cardioversion will not improve this patient’s condition. Additionally, if a patient with respiratory failure and severe hypoxemia becomes hypotensive and develops a bradycardia, the bradycardia is not the primary cause of instability. Treating the bradycardia without treating the hypoxemia is unlikely to improve the patient’s condition. It is critically important to determine the cause of the patient’s instability in order to properly direct treatment. In general, sinus tachycardia is a response to other factors and, thus, it rarely (if ever) is the cause of instability in and of itself.

One of my earliest posts was a variation on the distinction between unstable and symptomatic –

Cardioversion – I’m not doing that, you do it!