Thursday, September 29, 2011
To shock or not to shock, that is the question?
This is is the ECG strip from one of my patients last week. Heres the dilema, he was a 45 year old male weighing about 400 pounds and recently loosing 200 pounds. He was at the gym working out when BAM! he collapses. We get on scene and he is talking to us but dripping in sweat. When we hook him up on the monitor we only saw the rhythm for about 5 seconds and one of the stickers came off because of the sweat. Looking at it for only 5 seconds was more than enough to get our hearts racing. We needed to get him out of there immediately! This is a lethal rhythm that can lead to a very not so "and they lived happily ever after" moment. So heres the question? He is fully alert, talking to us, blood pressure is normal, and mentation is A0X4. However, he is cool, pale, and diaphoretic. Do we shock him or do we administer Amiodarone? I would have synchronized shocked him (200J *he's a big guy), however we decided to take the less risky route. Reason being his blood pressure was stable. I still wished we would have shocked him, a bit of an ornery man he was. He did not want to go to the hospital and he was swearing at us and being super combative. He even refused treatment from me because of the way my perfume smelled. Seriously? This went on for about 5 minutes until we told him, "sir if you do not come with us, you will die." Straight to the point, words no one wants to hear, but they sure do make one think twice. He finally was sane and came with us. His fussing stopped after that and was super cooperative. Knowing i was gonna die i would too. We ran him in "hot" and administered 150mg of Amiodarone over 10 minutes. Being in the Paramedic program we were programed more like branded into our heads to automatically set this up as an IV drip set, however my preceptor showed me a great tip. If we dont have the time to set of an IV drip, you can draw up your 150 mg of Amiodarone which is 3ml and add to 7ml of Normal Saline (NS) in a Syringe. This makes it into a diluted solution that can be monitored closely and administered at 1ml of fluid per minute to a total of 10 minutes, which is the rate you want it at.
So we did this and it did not work, he was still in V-tach. I was very impressed with the patient's vital signs, other than the heart rhythm all other signs were stable. When we got to the hospital the nursing staff was freaking out and one doctor was happy that we didn't shock him and the other was mad at us that we didn't. We ended up shocking him (200J *like i said, big guy) with out any sedation (ouch!) and his heart finally converted to a normal sinus rhythm. He was rushed to the Cath lab and we found out that his heart's refractory period was about 15% (its bad). This means his heart is using minimal force to beat, he could die of a weak heart. Poor guy, i never knew the out come, but i hope his heart fought to live. He was on the right path to becoming healthier, but i guess it was a bit too late. So what would you have done? To shock or not to shock?
Posted by Paola Cooper at 9:43 PM