Epi. in Tricyclic OD indused cardiac arrest.

[GunghoEMTP]

Does anyone know why you are not supposed to give epinepherine to a pt in cardiac arrest from tricyclic overdose? Thanks

[medic3401]

That is a very good question and I am going to show my apparent ignorance by saying that I don't remember being told that epi should not be used. That doesn't mean that I was never told. http://smilecwm.tripod.com/cwm2/cwm3.gif

I looked in a book that I have, called Pharmacology and Physiology in Anesthetic Practice, and it says this about using sympathomimetics:

"TAD, by virtue of inhibiting uptake of norepinephrine into postganglionic sympathetic nerve endings, make more neurotransmitter available to act at postsynaptic adrenergic receptors. As a result, the pressor response evoked by an indirect-acting sympathomimetic, such as EPHEDRINE, is increased two- to ten-fold in the presence of TADs. Even epinephrine present in a local anesthetic solution could evoke hypertension if administered to a patient being treated with TADs (Boakes et al, 1973)

http://smilecwm.tripod.com/cwm/killtard.gif

Now I am not able to fully understand exactly what that means, but what I gather from it is that if the small amount of epi in a local anesthetic will give someone who is being treated with TADs hypertension, then what would straight epi IV do to someone who has overdosed on TADs!!

http://smilecwm.tripod.com/cwm/eek2.gif

I hope this helps. I am still going to go to some of the ED docs and pose the question and see what they say. Again, great question. It certainly made me think.

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If a fire is an emergency to the fire dept., who do they call?

[This message has been edited by medic3401 (edited August 29, 2000).]

[medic3401]

Just a thought...maybe epi in either a smaller dose or a weaker concentration could be used. http://smilecwm.tripod.com/cwm/thinkerg.gif

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If a fire is an emergency to the fire dept., who do they call?

[pyroknight]

Greetings Wake County! If you see Mike Cooper, tell him his old roomie says "Hi!"

In a TAD OD with arrest, the cause of arrest is the TAD, not typical cardiac problems. Not only would the effect of the epi be greatly exaggerated, but the time used to administer it would be better spent administering bicarb and fixing the problem.

[Quint1Medic]

What pyro said...if you have a known cause for your arrest, then you need to correct the cause (e.g. the resultant acidosis in a TCA OD) before you mess around with standard ACLS. The fact that you may blow out some gaskets if you do is secondary.

[medic3401]

I would tend to agree with the last two posts but I will let you in on what was said in my discussions with three medics that are going to school with me. They all three felt that you should run the code like any other code and in the midst of it, treat the tricylic OD. I can't say that I disagree with them, either. Fortunately (and unfortunately in some cases) we run under protocols that dictate how we treat certain presenting problems. Most protocols are different, but I know mine make no mention of treating any contributing factor until at least the first round of Epi is in. Now the book I quoted gave a fairly convincing argument as to why we might not want to give epi during a TAD OD code (in a round-about sort of way, whether the book knows it or not!). My intention is still to talk with my medical director and some of the ER docs and see what they think. I will try to pass on the info when I get it.

Until then, take care all and stay safe!

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If a fire is an emergency to the fire dept., who do they call?

[Fedfire]

Try this link. Lots of information about TCA overdose
http://www.emedicine.com/emerg/

[Litch]

Unless you operate on a very strict protocol system, I would say that, when you know a specific cause of an arrest, such as an overdose, it is appropriate to treat the underlying cause of the arrest as part of your treatment. As you would give a diabetic arrest D50 early on in your treatment, you need to address the acidosis of the TCA overdose patient to get your code drugs to work. I am not familiar with any contraindication to giving Epi to the arrested TCA overdose. If you successfully resuscitate the patient, then the hospital may have to deal with a hypertension problem. Without the Epi there may not be a viable patient.

[Trauma_Dog]

I whole heartedly belive in treating the cause of an arrest, however you must stick to your ACLS guns while doing it.

ACLS states the most effective Tx for V-Fib other than defibrilation is EPI. Example:We don't start out working an arrest that was caused by an electrocution with Lidocaine, we start with defib then epi,same with a diabetic or hypoxia. We start out using basic ACLS and THEN start treating for possible causes.

My next point clinical pharmacology itself, which states there is no contra indication when used in the emergent setting.

Now this is just my aproach and rational to working arrest. I feel working an arrest revolves around ACLS, and if ACLS considered withholding or adding something truly benifical it would be strongly stated in training and in the book.

Just food for thought.

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Kent Simon
Paramedic Incharge
MCHD EMS,
Montgomery Co.,TX


[This message has been edited by Trauma_Dog (edited September 03, 2000).]

[GunghoEMTP]

I believe in treating a patient according to ACLS in an arrest, but we do have to remember that ACLS is just a basic guideline in which to follow.
If I remember right the discussion was that if you do give EPI in a TOD arrest there is a 0% chance of resuscitating the patient. What I am looking for is the reasoning behind that.

[pyroknight]

Even here in the land of restrictive protocols (Denver Metro) our medical advisors have an out called a variance form. TAD overdose is not a common occurrence and is not something they are going to write into the protocols. If you treat a TAD overdose according to ACLS protocols you'll cover your ass and be the kind of mediocre paramedic that I can't stand. If, on the other hand, you take a little knowledge away from this discussion, you will know that varying from ACLS protocols is in the best interest of this patient. Your best insurance is to never stop learning and to maintain a good relationship with your physician advisor. Do no harm. Epi in a TAD OD is doing harm. Period.

[This message has been edited by pyroknight (edited September 04, 2000).]

[medic3401]

Just to let you know, I did talk with one of our ER docs (who also happens to be our assistant Medical Director and former state Medical Director) and he said until AHA changes its guidelines, a v-fib code should be run as a v-fib code. He did say that sodium bicarb should be given early in the resuscitation but epi is still indicated. I trust his judgement and am going to continue to treat v-fib as I have been. I hope this helps some.

Matt

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If a fire is an emergency to the fire dept., who do they call?

[pyroknight]

Unfortunately they don't teach common sense in medical school. Easier to receive forgiveness than to ask permission. I'll continue to do what's in the best interest of each patient and justify myself later if I have to.

[Trauma_Dog]

If things first, I am Not a mediocore medic. Second, I be be sold on the Idea, however you have given No prof, No text on the issues or were is it written, all I have heard is word of mouth and I cannot treat a pt based on that. To do that would negligent.

I have looked in the Brady paramedic book,ACLS and even the PDR neither does not mention any data on this issue.

I take offence of your view of me as a medicore medic, since you don't know me or how I preform in the job setting. I would not judge you w/o knowing you first. My stats are the highs in the service for the last two years running and I do credit that to ACLS, which is THE single most accepted and informative source and cardic emergent care for the pre-hospital provider.

My intention of my post was not to ruffel your feathers, I DO respect your opinion, which has promped me to do some research on the issue. I only ask that you debate with issues and data rather than an attack on my ability.

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Kent Simon
Paramedic Incharge
MCHD EMS,
Montgomery Co.,TX

[pyroknight]

My apologies, in reviewing my post, my tone was much more harsh than I intended. I should appreciate that you at least know ACLS protocols. That alone puts you ahead of most of the competition. Please accept my sincere apology. You apparently share my passion for excellence in patient care and I'm afraid this time I was just a little too passionate.

I'll try to be a little more civil.

On a different note, apologies in advance to the overly suicidal sensitive among you, we, as responders, didn't cause this problem. The patient (read psycho) OD'd and if ACLS kills them, they shoulda thoughta that aheada time.

[This message has been edited by pyroknight (edited September 08, 2000).]

[spunk639]

How many pure TAD overdoses are there ? By pure I mean solely TCA on board, no ETOH or various recreational drugs on board. What effects do those have. A VF arrest should be worked as a VF arrest but add in the other factors. Recently I had an OD arrest Pt took TAD, Crack, Heroin, Pot, Etoh, Birthcontrol, clindamyacin and Tylenol. Pt presented to BLS as a VF arrest on our arrival we learned nature and cause of arrest, we got pulses and a BP with some resp. effort later on. However pt 20 hours later went into Resp Distress syndrome, later died. Begin with protocols as guidelines and adapt your knowledge to the situation to provide best for the Pt.

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REST IN PEACE
NEW YORK CITY EMERGENCY MEDICAL SERVICE

1869 - 1996

[jedge168]

I tend to agree with most of the posts previously made. A v-fib arrest should be run by ACLS. However if you know the cause of the arrest, in this case TCA, treat it (within your protocol of course). Just remember that epi and bicarb in the same IV don't mix. FLUSH FLUSH FLUSH. This is a "common sense" answer on my part. I don't recall in either my paramedic classes or my degree classes, or anytime in the last 10 years that I've been a medic this ever being touched on.

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Jim Edge, Paramedic/Firefighter
Fayetteville NC
jedge168@firehousemail.com

[Weruj1]

bump

[azemsdiva]

Thats very interesting...... I never heard anything about TCA vs EPI...but just a thought....if they are in cardiac arrest....does it really matter? i mean lets be realistic....how many cardiac arrest victims actully make it? and if they do they usualy die in a day or so anyway.....so i think that u run the code like every other code....and if its a known TCA OD then yeah treat it as such... but lets face it u cant kill them anymore then they already are.... Correct???...just a thought....;)

[RoryEl]

If not in cardiopulmonary arrest and with wide QT then definitely bolus with bicarb. If decompensating, treat their symptoms and the underlying problem. They're gonna need a bicarb drip at the hospital that's titrated to pH derived from ABG's. Flood them with sodium so to speak since TCA are competitive sodium blockers (blocks - slows - the fast sodium channels of ventricular depolarizations amoung other things). If already arrested, bolus with bicarb while treating per ACLS. See Fedfire's post. He pointed you in the right direction

[Ridryder911]

I can not find any literature suggesting not to use epinepherine in TAD. There are several of course indicating use of NaHC03, & use for Q-T indicators. Some highly suggest Levophed as well.

here is alink with some results of Tricyclic O.D.

http://emj.bmjjournals.com/cgi/content/full/18/4/236

Would like some literature regarding contraindications, other than just talk.

Be safe,
Ridryder 911

[FireHAZMEDIC]

Tricyclics will cause acidosis as documented above. Bicarb and ensure a patent airway and hyperventilate to blow off CO2. I don't have my tox texts with me, but as I recall the action potential is messed up by inhibiting movement of Na and K. The EKG changes (assuming they didn't take anything else) QTc prolongation (>0.43), bradycardia with PVCs, widening QRS, followed by torsades or VFib.
We are fortunate to carry Vasopressin. Amiodarone would further block Na and K, making a bad situation worse.

If you are only carrying Epi. Wow. ACLS and SOPs are only guidelines but deviating from the standard......... Call med control. Follow orders. Best patient care is always the bottom line. But, a good medic is no good to anyone after they pull the certification due to practicing without a license.

[opdistance01]

I think most of you are right in the fact that a TCA code should still be run like any other code. In fact, that, in my book, is exactly how it should be done. ACLS, in its algorhythms mentions to look and treat for the possible causes of the arrest(5 H's, 5 T's) anyone remember these. In an emergent situation there is no contraindication to Epi, I have yet to hear anything about no using Epi on a TCA code and until I hear otherwise, if i run into a TCA code, I'm gonna treat it like any other that I've run.