Question

[medic7873]

Had a megacode after an interview last week. Pt was pulseless, and once I got to it I pushed Lido. Down the road I got a pulse back, 3rd degree block so I paced 'em. Heres the question. Lidocaine is contraindicated for high degree heart blocks, but if the patient is paced isn't it now a paced rhythm, not a block? I mentioned that during the megacode, but they stood there stone faced waiting to see whether I would hang the drip or not. I mentioned that I was taught conflicting things on the subject, and I would call for orders to see what the Med director wanted. I'm curious to see what you all think. I couldn't have done that badly because they called me back after all was said and done. Gotta pass a background/employment/medical check and I'm good to go!

[prncssmdc]

What was the original rhythm?

[itzajimmithing]

Hence the problem with the megacode. A totally unlikey scenario that you will likely never encounter in real life. But you did the one thing that can never hurt you in an interview. If you are not sure, contact MC and ask. No reasonable interviewer would ever give you a hard time for calling the doc, that's what they are there for.

[medic7873]

What was the original rhythm?
Started off normal sinus. Pt had CP, went to V-Fib, then the block once I got a pulse back. Like I said I couldn't have done that badly, they did call me back, so we'll see. It's a pretty busy department down here, I'm really hoping to get on. They already ran my driving record before I got there (which going back 7 years is pathetic, 2 tickets last 5 years, ALOT if you go back 7!!!).

[kjrff23]

Did you push anything else besides/before the lido? To answer your drip question you could have considered using dopamine, if it's in your protocol, for a 3*AVB pt. It might not do much but it can help what the pt already has for activity and maybe speed it up a little and make the contractility more efficient. Like prncssmdc said too, I would like to see the monitor to see what the pt. was doing. You were right to say you would contact medical control, no one could fault you for that.

[prncssmdc]

Hence the problem with the megacode. A totally unlikey scenario that you will likely never encounter in real life. But you did the one thing that can never hurt you in an interview. If you are not sure, contact MC and ask. No reasonable interviewer would ever give you a hard time for calling the doc, that's what they are there for.

AMEN to that. In real life you would probably have a tremendous amount around you to give you clues as to what is going on -- family, meds, a REAL history. I hate these scenarios - why would he go from NSR to 3rd deg block after v-fib? Overdose? Med reaction? The list goes on forever. I understand why you hung the lido - to prevent the v-fib from coming back I'm assuming, and ultimately it's not a bad choice in my humble opinion. The v-fib will kill him - so make sure it doesn't return, and, you can always do with 3rd deg what you did...pace. (I'm a fan of amiodarone myself - maybe one of these days I'll actually have someone recently dead enough to push it - but have seen it work wonders in the ER and on post-resus).

itzajimmithing has a good point - you can never go wrong by calling MC - atleast in real life you can't. Unfortunately in the fairytale land of megacodes (especially if they are run by jack-offs) they usually don't give you that option - or worse yet, fail you for it.

Best of luck with the rest of the process, I hope you make it. Try not to sweat it and let us know how you do...good or bad.

[kjrff23]

(I'm a fan of amiodarone myself - maybe one of these days I'll actually have someone recently dead enough to push it - but have seen it work wonders in the ER and on post-resus).

Ok, I have heard a rumor that we are going to be getting this sometime in the future in my state protocol, I don't know if all ALS will get it or just the medics. I know what the pill form does for people prone to v-tach but what are the indications for the IV form, I am assuming it's still an anti-arrythmic?

We used to carry bretylium several years ago for use after or for an allergy to lido, but they took it off since no one ever used it and didn't give us anything in it's place.

[ghettoredneck4205]

We carry Amiodarone at both of my jobs. At one job you have the choice of using it or lidocaine. At my FD job though, lidocaine has been pulled completely off the truck. Any protocol that used to use lidocaine is now using amidodarone. In pulseless VF/VT you use a loading bolus off 300mg and then an additional 150mg if a second dose is needed. For maintenence drip and any other arrhythmia protocol that you would have used lidocaine for you simply mix 150mg of amiodarone in a 100ml bag of NS and drip at a rate that would infuse over 10 min. It actually works great.

[kjrff23]

We carry Amiodarone at both of my jobs. At one job you have the choice of using it or lidocaine. At my FD job though, lidocaine has been pulled completely off the truck. Any protocol that used to use lidocaine is now using amidodarone. In pulseless VF/VT you use a loading bolus off 300mg and then an additional 150mg if a second dose is needed. For maintenence drip and any other arrhythmia protocol that you would have used lidocaine for you simply mix 150mg of amiodarone in a 100ml bag of NS and drip at a rate that would infuse over 10 min. It actually works great.

Thanks for the info, it sounds like it works well. It will be interesting to see if we get it. It does sound like that would be the drug of choice for the megacode scenario rather than the lido, especially if the pt. ventricular rate in the 3* block was in the toilet.

[Lord_Balsac]

amiodarone > lidocaine