A 69 year old male with an implantable defibrillator calls EMS because it shocked him. A medic who was on the call with me was assuming that the defibrillator was malfunctioning. That is usually not the case. In fact, I cannot think of a single time when an implantable defibrillator shocked a patient unnecessarily. This patient told me that he got lightheaded at about the same time as he was shocked, so I was running off the assumption that the patient had been in Ventricular Tachycardia, and the ICD shocked him. We put the patient on the monitor, and the patient was in a first degree AV block with frequent (15 per minute or so) PVCs.
The best treatment for PVCs is oxygen, so we started the patient on 4 liters, and obtained IV access. By this time, the patient was in ventricular trigeminy, and it wasn’t long before we started seeing couplets. Vitals: HR 88, BP 152/88, RR 18, SaO2 100%, EtCO2 34, and he weighs 193 pounds. Of the five of us on scene, there were three medics, and the other two medics wanted to give him a cordarone drip.
I told them to give 100mg of lidocaine, and follow that with a maintenance drip of 2mg/ minute. The PVCs were almost completely resolved (less than 4 per minute) within 3 minutes, and we took our ride to the hospital.
When we returned to quarters, we had a discussion on the benefits of lidocaine versus cordarone, and turned it into a training session. I must admit that other medics may have different feelings on this, but here are the reasons why I prefer lidocaine over amiodarone for conscious patients:
1. Amiodarone causes too much hypotension for my comfort
2. Amiodarone frequently causes bradycardia
3. Amiodarone has a long half-life, so in the event that 1 or 2 occurs, the patient is going to be screwed for a long time
4. Although lidocaine toxicity is theoretically a worry, I have never seen it on any of my patients.
So that is why I go with lidocaine. Any other readers have different opinions? If so, why?