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Know your toolbox

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?

One reply on “Know your toolbox”

I agree. About a year ago we had a patient who's AICD was going off almost continuously. My partner and I counted 13 shocks in about 10 minutes after we made contact.

The monitor showed a sustained wide complex rhythm, but the patient was so uncomfortable and thrashing about that the baseline was too muddy to tell much more.

We gave him Versed to calm him down, 100mg of Lidocaine IV, and a 2mg/minute Lidocaine infusion.

A few days later we got a note from one of our doctors who wanted to know why we gave Lidocaine in preference to Amiodarone.

My reply was as follows,

1) It is faster to administer than Amiodarone because I don't have to draw it up.

2) It worked.

3) As the lawyers say, "Race Ipsa Loquitur". Which means, "The facts speak for themselves.

While the AHA and some doctors seem enamored of Amiodarone, no one can quite say what advantage it has.

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