I rank Amiodarone 11 out of the 33 drugs we carry.
I know the literature for Amiodarone is almost as weak as the literature for Lidocaine. I will leave the recommendations up to the AHA (currently they recommend amio for VT with pulses while leaving you the option of lidocaine or amio for VFIB/VT without pulses — that may all change in October with the new recommendations scheduled to come out). I have chosen Amio over Lidocaine as my antiarrythmic of choice based largely on personal, unscientific anecdote.
The years have given me a certain hard-won calmness on the job, but there are a few calls out there that get me a little uptight amomng them — bad respiratory distress and symptomatic VT in a patient who is still talking to me.
I read a cardiology book once where a wise old doctor sighted his preference for medication over electricity by saying that electricity always (at least briefly) produces asystole. Asystole is death and death isn’t a good thing, so you want to avoid asystole if you can. I like that man’s thinking.
Our dose for VT with pulses is to draw up 150 mg of Amiodarone, mix it in a 100 ml bag of fluid and run it in over 10 minutes. If I am only carrying 250 bags, I will spike the bag, pull out the spike, squirt out 150, then put the spike back in. In the story below I posted back in 2006, we had just gotten Amiodarone, and instead of mixing the Amio, I gave it as a bolus like we do in cardiac arrest. I could argue that since I was uncertain how unstable the patient was I gave the VT with pulses dose at the VT without pulses rate. In truth, I just wanted to get the drug in her and did the simplest quickest thing I could. I have noticed as a clinical coordinator, that this is the most common medication error. Likely a combination of ignorance, panic and unwillingness to risk waiting 10 minutes to give the whole dose, medics slam it in. That can lead to hypotension. I know better now. I also have a little more confidence the Amiodarone will work. Here’s the story:
“Woman not acting right according to her husband. History of lupus,” the dispatcher tells us.
It is a nice house in a residential neighborhood in the north section of town. We back in the drive, and then wheel the stretcher in through the open garage door.
“You don’t need that. She can walk out,” an officer says, as he comes out of the door leading into the house.
So we leave the stretcher in the garage and walk into the sparely furnished spacious house. Inside we find a woman in her thirties sitting in a chair with a faraway look in her eyes. “She’s not acting right,” her husband, a large muscular man in a orange shirt that is the color of a prison jumpsuit, says. “It is not her at all. This been going on all day.”
I approach her and have her squeeze my hands. She has equal grips. I raise my arms and she keeps holding my hands. “Let’s go and keep your hands up.” She lets go and keeps her arms up. While they appear a little unsteady, there is no drift. Her pupils are equal but not reactive at all to my penlight. “Are you in any pain?”
She shakes her head.
I ask the husband what hospital he wants us to take her too. He tells us. I ask if he knows her meds.
“I have them right here,” he says. He is holding her pocket book.
“Any drugs or alcohol?” I ask.
“No,” he says, sounding close to being offended.
It is genneraly my style to do as much as I can while transporting. If the patient doesn’t appear critical or to need an immediate intervention, I tend to always do my workup in the back of the ambulance on the way to the hospital. We are about twenty minutes from the hospital. I expect to have a complete assement, history, and basic ALS done along with my runform written by the time we hit the hospital. I help her up and we walk out to the garage where my partner has set up the stretcher. The woman appears slightly unsteady, so I hold her left arm as we walk.
The husband steps up into the back of the ambulance with us. “No, you have to sit in the front,” I say. For a moment I think why not let him sit there. I can the history I need from him without having to schooch up to the front to talk to him, but I have another partner in the back with me and I am going to do an ALS workup, so I guess I’d rather not have him back there.
My partners are fairly new to EMS. Driving for the first time is the young man I wrote about in the story Compressions. In the back with me is another new EMT, who is very eager, but still needs more seasoning. My partner takes her blood pressure while I strap a tourniquet on her arm. He gets 160/100. That’s certainly noteworthy.
She is watching me as I look for a vein. She seems almost like someone who is high. I’m wondering if she is seeing tracks when I move my hand in front of her eyes. It is very strange.
I get a flash on the IV, and withdraw the needle, and start drawing blood. I have about half a tube, but it is drawing so slowly, I decide to just attach the saline lock. I detach the vacutainer, and while I am clamping down on the vein with my left hand, suddenly the patient starts to shake. She isn’t just shaking, she is seizing violently.
“What’s going on back there? What’s going on?” the husband demands.
“She’s having a seizure,” I say. “It’s okay; I have medicine to stop it.”
“What’s going on? What’s going on! Is she all right?”
I am holding on to her arm, clamping the vein off for dear life. She is having a gran mal seizure. I can’t reach my narcs, which are locked up in a cabinet behind the captain’s chair. I’m not panicked because I’m thinking maybe she had a seizure earlier and was acting so weird because she was postictal. Besides, most seizures stop after a couple minutes anyway. I have to believe hers will stop, or hope so at least. I’m going to give her a minute or two to find out. While she is still flailing I manage to get the saline lock attacked to the catheter and taped down.
Then she stops seizing. She sits there now, looking off to the left. She is awfully still. I don’t think she is breathing. I look at her closely, but I can’t see any movement. I do a sternal rub. No response. I don’t feel a pulse, but we are bumping down the road so I can’t be certain.
The man in front is flipping out. “Shouldn’t we be going faster? Shouldn’t you have the lights on? Is she all right?”
“Get out my airway kit,” I say to my partner, while I quickly put her on the monitor. I need to see what is going on. I’m hoping for a nice sinus tack.
Here’s what I see:
I cut off her shirt and slap the pads on.
“Step it up to a three,” I say to the driver.
I am tempted to shock her, but I flash back to calls I have had in the past where a patient suddenly went into v-tack and I shocked them — few with a good outcome. I shock them, they die. First shock doesn’t do anything, second shock kills them. Not everytime for sure, but several memmorable times. I had patients who were talking to me. I’d shock them, and they would say — they both in fact said the same words. “You’re killing me.” I’d apologize, hit them again, and they would die. In ACLS they teach you to jump to electricity if the patient is unstable. I remember one teacher saying “Go ahead and jolt em!” But I don’t think she has seen what I have. I don’t like electricity on a live person. But on the other hand — not only is she not talking, she might not even be breathing. I can’t readily tell. She is having a period of post-seizure apnea or she is breathing mightly lightly. I do have an IV. My med kit is on the bench next to me. There is that line in the ACLS books about giving a brief trail of meds if there is time. She is going to need me to breathe for her in a minute, but she should still have some good oxygenated blood in her. I unzip the med kit and pull out a vial of amiodarone. I draw up 150 mg and push it in into the lock. I look at the monitor.
EMS is all about the action, but sometimes itís about waiting.
What happened? I’m thinking. Did she seize because she was in v-tach or did she go into v-tack because of the seizure? It was a true gran mal seizure, not a hypoxic seizure. People stop breathing after a seizure sometimes, but then start up again. But she’s in v-tack. What the ? What do I do?
“What’s going on?” the husband is shouting. The driver has one hand on the wheel and the other trying to hold the man into his seat.
Should I shock her? If I do, the next minute I know I’m going to be doing CPR. But soon I am going to have to do something more. I can’t wait too long.
Should I have the driver pull over and grab a board out of the outside compartment so we can lay her down on it and verifying that she is pulseless start CPR? How is the husband going to act?
I look back at the monitor.
Whew! She is out of v-tack. Thank the Lord. The amio worked. I’m not certain if itís a sinus tack or a rapid afib. The rate runs from 140 to 170.
I have the ambu-bag in my hand, but now I tell my partner to get a nonrebreather out of the cabinet.
I have a pulse. There’s some small chest rise. I get a blood pressure 170/120. She still doesn’t respond to a sternal rub. We check her blood sugar. HI, which means itís over 600.
I try to patch to the hospital, but all I can hear on the radio is a high-pitched whine.
“What’s going on? What’s going on back there?” the husband demands.
The whining stops on the radio and when I ask if the hospital is on, the operator tells me they are off now, but he will try to get them back on. They come back on, I give my patch, but get no acknowledgement.
I put in another IV and start running fluid in. She is still unresponsive. Her rhythm is looking better.
I think about tubing her, but she is satting at 98%, so I just watch her airway.
We park at the hospital, and the husband, comes around to the back and when we open the doors, he sees her laying there, her breasts hanging out in the open. I quickly grab a sheet and cover her up.
The husband wants to know what’s going on. I tell him I’m not really certain. She had a lethal heart rhythm, but she’s out of it now. Her sugar is high. He confirms she is not a diabetic and has never had seizures before.
We wheel her in. They never got our patch so they are not expecting us. They quickly get us a room. She is responding to the sternal rub now, and mutters a few words. I give my report while they get the rest of her clothes off.
When her lab results come back, her sugar is 1200, and most of her electrolytes are way out of whack.
The nurse tells me her husband kept saying how slow we drove to the hospital.
Hereís what her final rhythm looked like when we turned her over.
I’m been doing nothing but nursing home, doctor’s offices, visiting nurse, and minor MVA calls. I knew I was due.
Maybe if I shocked her, she would have converted and been okay. Maybe not. I’m glad it worked out the way it did. I wish I had her on the monitor before she seized, curious what her original rythmn was. If she had seized a few minutes later I would have had her on there. I’m glad I already had the IV in.
“Woman not acting right according to her husband. History of lupus,” the dispatcher tells us.
You never know in this job.
Action: Reduces myocardial cell membrane excitability by increasing the
effective refractory period
Inhibits alpha and beta adrenergic stimulation, causing peripheral
vasodilation and decreased heart rate
Indication: Cardiac arrest — ventricular fibrillation
Wide Complex Tachycardia w/pulse>150 bpm
Contraindication: none for cardiac arrest, contraindicated for wide complex tachycardia
with hypotension (synchronized shock indicated). Bradycardia.
Dose: Cardiac arrest Ė 300 mg IV; May repeat at 150 mg
Wide Complex Tachycardia w/pulse>150 bpm Ė 150mg IV over 10
Drip Ė 1mg/min
Side Effects: Hypotension, bradycardia, headache, dizziness, nausea, vomiting