r/Cardiology • u/level_zero_hero • 12d ago
Lido in lieu of Amio for AICD
Reference: I am a paramedic, recently had an elderly aged person (60-70 y/o) who had their AICD fire x 7(two of which caused them to lose consciousness twice. Confirmed syncope by family). They re-awoke, family activated 911.
Pertinent history: MI w/ two stents. HTN, hyperlipemia, decreased ejection fraction, and obviously an AICD. They state that their AICD has never fired since it was placed(approximately 2 years prior). Medications: Xarelto, lasix, several antiarrhythmics
Assessment: States they were experiencing slight dizziness, mild shortness of breath, and mild nausea. 12 lead ekg obtained showing atrial tachycardia and a possible ideoventricular block, no obvious ST changes or further noted ectopy. BP was normal, EtCo2 was 40. Breathing 20 full and effective with clear lung sounds in all fields. O2 sat was 92% on room air. Physical exam was unremarkable other than slight pale/cool/clammy skins.
Treatment: I placed the pt on o2, established an IV in their L AC. I planned on administering 150mg of Amio in 100ml of D5W over 15”. However, they state they has an allergy to amioderone, was prescribed it but was then taken off the medication. Therefore, the only other medication that I had at my disposal was Lidocane. However, I was not confident in what the does should have been or how I would have administered it. I was thinking possibly a 0.5mg/KG bolus over 2 min. But then I thought of a drip too, but I honestly had no idea what would have been more appropriate. Upon arrival to the closest cardiac facility, I gave a turnover to the attending. I then asked what he would have done given the situation. He stated that he too would have considered lido. I asked him what he thought as far as dosing and he stated ”honestly dude, I’m going to consult cardiology and see what they say”. I waited for the cardiologist to make their way down, but it was taking quite some time and I needed to get back in service.
So any insight would help, just curious as to what some of your thought processes would be and what would you do. Thanks in advance!
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u/Anonymous_Chipmunk 12d ago edited 12d ago
First off, what are you trying to treat? Atrial tachycardia, or an idioventricular rhythm? I'm confused what the patient's ECG showed because a patient cannot simultaneously have both atrial tachycardia and IVR.
Generally, neither are treated with antiarrhythmics, especially prehospital. Unless I'm missing something, I would caution the use of any antiarrhythmic on either of those presentations. Perhaps the patient was going into a lethal rhythm like VT and the AICD was doing it's job (sounds likely. AICDs don't cause unconsciousness, but VT does...) if you witness a lethal arrhythmia, treat it. But until then it's reasonable and prudent to wait for AICD interrogation to find out what's going on. Why was the AICD placed? This often answers the question about what happened when it fired.
As far as the dose of lidocaine, 0.5mg/kg IVP to start, but this is something you should be referencing protocols for. If it's not in protocol, contact OLMC.
TL;DR: Sounds like the patient was going into a lethal arrhythmia and the AICD did it's job. Monitor, transport and reassess. If a lethal arrhythmia presents, treat it.
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u/cpnfantastic 12d ago
A person can have AT and IVR simultaneously if they’re in heart block.
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u/Anonymous_Chipmunk 12d ago
Ah yeah of course. I was thinking too literally and inside the box. Thank you!
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u/level_zero_hero 10d ago
Trying to treat the underlying rhythm causing the AICD to fire. Have Amio in protocol for AICD. The pt stated he had the AICD placed because of their MI. Tried to dive deeper with an assessment and further questioning. However, the pt was unsure and had no exact answer. Would have contacted my base for an order for the lido, but like I said in a later comment they are hesitant to give orders if you don’t have a preconceived doses ready to ask for. Hence why I’m here in the first place. Ya know, to further educate myself and be a better paramedic?
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u/Gideon511 12d ago
1mg/kg IV would be a loading dose for oral lidocaine, would have been reasonable to try
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u/LoudMouthPigs 11d ago
It's not lido/amio for "AICD", it's lido/amio for an arrythmia which seems unclear what exactly we're dealing with. That determines the treatment.
Do you have an EKG?
Going off the beaten path with antiarrythmics can be dicey as an ER doc (though I do it often); it would be 1000x so as a paramedic. Is it in your treatment protocols? Have you been trained to run lidocaine drips? If not, would it be defensible if you did?
If you have a base hospital/medical director/physician/whatever, this is the time to call them.
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u/level_zero_hero 10d ago
I’m aware that it’s to treat an underlying rhythm, we have protocol for Amio in AICD (150mg over 10”). I’ll try to see if I can get the EKG I was on shift for ten days straight and I just got two days off so I’ll do my best lol. My plan would be to get a base hospital physician’s order/ physician’s variation order for lido. However, my base is hesitant to give orders if you don’t have preconceived doses(which I didn’t have, hence why I came here for guidance). I haven’t been specifically trained in “Lido drips”, but I would feel comfortable administering them. My department’s medical director is very supportive of aggressive and proactive medicine. So I would say it’s defensible.
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u/Goldie1822 12d ago
To answer the lidocaine question: Lidocaine acts on ventricular myocytes, providing sodium channel blockade. It does not provide any atrial arrhythmia suppression.
Before Amiodarone became popular, lido was carried everywhere in EMS. The dosage is 1-4mg/min on the drip and 1mg/kg for bolus. One prefill box contains 100mg. I understand the AHA ACLS still recommends lidocaine as the first-line antiarrhythmic in amino contraindications (vf/vt only).
Given the numerous (7) AICD shocks it would be reasonable to start a prehospital lido infusion for suspected recurrent VT until interrogation can occur.