VAQ 8 Answer

Here’s the answer to VAQ 8.  It’s a bit of tricky one, and there’s bound to be some controversy over what the actual rhythm is, and what sequence one should do things in the management.  NB I didn’t mention DCR as part of the management, as the rhythm is unclear.  I don’t think you’d fail if you DCR’d this guy for a possible SVT, but given that you’d be giving sedatives to do it, you’d probably want to do it afer you’d thrombolysed, started inotropes and intubated him.  Anyway hope you find this useful, and feel free to leave a comment!

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5 Responses to VAQ 8 Answer

  1. majedzei@gmail.com July 27, 2012 at 11:57 am #

    Thank you for your great efforts in providing SAQ/VAQ and the answers as well. I really find the white board seasons very very helpful, thank you so much.
    In regards to SAQ 8, I have one question. The patient had unstable narrow complex tachycardia and clinically peri arrested. Why you did not choose to shock with synch DC? Would this have made the patient more stable and would improve the delivery of the thrombolytic agent subsequently?
    Would the exam answer defer?

    I would love to hear from you.

    Cheers
    Maj

  2. Andy B July 27, 2012 at 12:26 pm #

    Good question regarding DCR Maj. This is one of those cases where what you do in theory and what you do in practice clash.
    On paper, the dogmatic teaching would be to DCR this patient first, however….
    Whilst seriously unwell and hypotensive, this patient was alert, sitting upright, tolerating a CPAP mask. To administer a DCR shock would have required some sort of sedation/IV analgesia.
    Some would argue then that you should intubate him first, but again, the risk of unrecoverable hypotension is huge from RSI in this setting.
    I think those of us in the room were very reluctant to give any sort of drug which may either reduce his respiratory effort or lower his blood pressure further.
    Also, one of the risks of DCR is turning a perfusing rhythm into a non-perfusing rhythm, which people argue is not a problem, as you can just “zap them again”, however your risk of having an unrecoverable arrhythmia (eg asystole) is extremely high in someone having an LAD/LMCA infarct, which then makes your well intentioned DCR a retrospectively very bad idea.
    We were lucky enough to have a cardiologist put an echo on while were resuscitating this patient, and he had no LV wall motion, which is a scary sight, and I think that made us reluctant to stun an already non-functional stunned myocardium.
    So in summary, yes, the dogma states that DCR is the treatment for a shocked arrhythmia, however in practice it’s not always right. I think if the arrhythmia is the primary problem, (ie in a non-infarct setting) then yes, DCR immediately as there is no other problem to fix.
    In the setting of a very large, unstable AMI, it becomes a risk-benefit situation, with the priorities being re-perfusion, blood pressure support, maximising oxygenation and if safe, arrhythmia control.

    Anyway I hope that helps explain my answer, I think in reality in the exam you should mention DCR, but in practice it’s a much trickier situation!

  3. majedzei@gmail.com July 29, 2012 at 11:27 am #

    Thanks Andy for your comment.. you made my exam answer more acceptable now..
    Please we do need more VAQ/SAQ, and perhaps more frequent-weekly/fortnightly, with similar answer style.. it is really helpful Andy.
    Cheers
    Maj
    Majed

  4. rajeshmalik August 1, 2012 at 10:55 pm #

    Hi Andy,
    Thanks for discussing VAQ 8. Once again a great discussion. I was wondering could Ketamine be used as the Induction agent in this particular case ?
    Cheers,
    Rajesh

  5. Andy B August 2, 2012 at 12:05 am #

    Hi Raj
    Ketamine would be a reasonable choice in this patient. In fact, I had it drawn up, however after a collegiate discussion with ICU we decided to use fentanyl. The theoretical advantages of ketamine are lack of hypotensive effect, depending on dose you may preserve airway reflexes (which there are arguments for and against). The argument against it as voiced by ICU in this case was that the patient was already getting a bit agitated, and ketamine sometimes doesn’t go so well in people who are confused/agitated (although Minh Le Cong from the PHARM site would argue against that in the acute psychiatric retrieval population!). So in summary, yes I think ketamine is a reasonable choice. I’d be interested to hear others opinions if you agree or disagree.

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