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Post by jpollock on Jul 16, 2015 8:33:39 GMT -5
torsades.pdf (889.79 KB)
this 80M wrecked his car and was found pulseless on scene. Multiple Epi and shocks given. At outlying ER this continued and just before they called it they got pulses back. Attached is the rhythm strip (flight gave mag when they got there). He was transferred to us (trauma accepted). on arrival he is intubated and has stable vital signs and minimal signs of trauma. The EKG at TTH had some ST depressions and borderline inferior elevations, but cardiology didn't want to cath right away and wanted to see what type of neuro function he had (had got roccuronium at outlying at some point and he was not moving) Labs were a mess and he had what was probably a liver infarct on CT and some rib fractures.
Besides showing the cool rhythm strip, I wanted to remind everyone that sometimes "traumatic arrests" are really just arrests that end in trauma. Also I wanted to ask for thoughts about giving magnesium in refractory pulseless V-tach or V-fib? (maybe they would have got a pulse quicker and gotten a better outcome?) |
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Post by erwoody on Jul 16, 2015 14:24:55 GMT -5
great case..have had multiple similar arrests either "from" or "on the way" to dialysis who present in asystole who do very well with insulin and calcium. Just tapped a fresh keg of Illusive Traveler
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Post by pbruss on Jul 16, 2015 18:34:05 GMT -5
From what I have read, the conversion rate for vtach-vfib with amnio, mag, lidocaine all are about 20-30% but procainimide is around 80%. Now I can not honestly say those numbers are accurate for both pulsless v tach but they are for v tach with a pulse. I'll read up.
My personal opinion for any pulsless rythm is drugs are almost useless. You need good hard uninterrupted chest compressions and identify and fix the reason for the rythm.
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Post by erwoody on Jul 17, 2015 12:12:54 GMT -5
who's ever heard me talk about procainamide? best one ever
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Post by pbruss on Jul 18, 2015 5:21:37 GMT -5
in memergent cases like this how do you dose it?
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Post by kemple on Jul 18, 2015 14:51:55 GMT -5
good question, I feel like we fall back on the stuff that's easy to dose.
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Post by slevittMD on Jul 18, 2015 16:59:13 GMT -5
I've honestly never given procainamide (although I intend to sometime in the not-too-distant future), so can't speak from experience with dosing. Looking at PressorDex, seems like the 100mg/dose over 2 min q5 min would be the easiest to do in code situation. Other option is 20-50mg/min drip. Max dose is 17mg/kg or 1000mg (probably 1000mg for us since anything >60kg would hit that), or until rhythm controlled, QT prolongs, or hypotension.
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Post by kemple on Jul 19, 2015 15:13:50 GMT -5
Yeah but if you're in a code without a pulse I don't think I would want someone spending 2 minutes pushing procainamide. Hands could be better utilized with other things in a smaller ED setting.
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Post by slevittMD on Jul 19, 2015 15:59:49 GMT -5
Has anyone used it in a code? Like I said, I've never used it and want to try it, but I don't think in a code will be the first time. Amiodarone is just too quick and easy to dose. I see it more for stable patients or maybe borderline unstable that I don't want to shock just yet.
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Post by jpollock on Jul 20, 2015 16:57:51 GMT -5
Did a quick search on PubMed...all small studies. To summarize: Mag works decently for torsades. It does have some action when used for refractory monomorphic V tach (like Bruss said about 1/4 may terminate after a couple grams). For V fib it may help increase the chances of ROSC 18.5-> 25.5% (p=.38), but not survival to hospital discharge.
Herz. 1997 Jun;22 Suppl 1:51-5.
Effect of magnesium on sustained ventricular tachycardia
Manz M1, Jung W, Lüderitz B.
Resuscitation. 2001 Jun;49(3):245-9.
Magnesium sulfate in the treatment of refractory ventricular fibrillation in the prehospital setting.
Allegra J1, Lavery R, Cody R, Birnbaum G, Brennan J, Hartman A, Horowitz M, Nashed A, Yablonski M.
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Post by pbruss on Jul 24, 2015 15:20:09 GMT -5
durring a code i give the procanimide as apush over about 1 minute. there is usually a gram vial in the code cart. see below,
Rev Esp Anestesiol Reanim. 2009 Oct;56(8):511-4.
[Efficacy of procainamide in the treatment of refractory ventricular fibrillation: report of 4 cases and a review of the literature].
[Article in Spanish]
Contreras ZE1, Ximena ZS.
Author information
Abstract
Ventricular fibrillation is the most common malignant arrhythmia, found in up to 55% of patients who go on to experience cardiac arrest. Only monophasic or biphasic defibrillation has been shown to be effective. The efficacy of antiarrhythmic drugs is much lower and depends on how much time has elapsed since the onset of symptoms. In patients with persistent ventricular fibrillation refractory to shocks, treatment options are limited. We report 4 cases in which procainamide was administered at a dosage of 17 mg/kg in 1 minute. Heart rhythm was restored and pulse rate recovered in less than 3 minutes in all cases.
there are other papers out there but i have to go intubate someone |
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