In message <000201be88ef$e771aaa0$6aeeabc3@default>, Simon Carley
<[log in to unmask]> writes
Re. to pulse check or not?
We had this discussion at a recent ACLS.
The wording of the ACLS manual is clear enough, but in practice, we
would challenge most people to be SURE (in less than 10 seconds) that
the morphology / rate of the VT had not changed on a defib screen after
cardioversion. So why not check a pulse as well while pondering the
monitor? As Andy Lockey wrote: IF IN DOUBT, CHECK A PULSE!
>By co-incidence we had a male >70 with VT & chest pain
>Apparently cardioversion on induction happens but I am not sure how often,
Presumably vagal stimulation (due to sux and tickling his oropharynx)?
But then this should only work with broad complex tachycardias arising
from a supraventricular focus with aberrant conduction (ventricles have
few Acetyl Choline receptors). Did your man have BBB on his post-
induction 12-lead?
>For cardioversion in these patients (in hospital) I prefer an RSI as opposed
>to sedation (with midazolam) as it appears to be quicker in onset and
>offset. Do others agree or is sedation still the norm?
For the CVS-compromised, but still conscious (just), wouldn't a full RSI
be more of a risk than a sniff of midazolam and get on with it? In VT
with adverse signs, midazolam (in small quantities) seems to be a
reasonable compromise between safety and humanitarianism. Assuming the
shock succeeds and they restore good perfusion, the low doses of
midazolam required to sedate the CVS-challenged seem to rapidly wash out
allowing speedy recovery of CVS and RS function.
We recently saw a chap with very compromising VT (barely palpable
brachial, GCS=13), who responded to a 50J shock after a few mgs of
midazolam. Yes, he felt the shock, yes we warned him he would feel it
and yes he even remembered it. But he felt bloody awful (like he was
dying) just before it and pretty fine after it, so he was quite happy.
Dr G Ray
Staff Grade
A&E
Sussex
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