Question: This question may be a very rare situation but I have not been able to get an answer from any paramedics I have asked. As per the "Patching" section in the introduction of the ALS PCS the literature states "BHP cannot be reached despite reasonable attempts by the paramedic to establish contact, a paramedic may initiate the required treatment without the requisite online authorization if the patient is in severe distress and, in the paramedics opinion, the medical directive would otherwise apply". In a situation where a cardioversion is required and the unstable patient is still conscious, it is fairly common practice to ask for sedation and pain control (i.e. Morphine/Midazolam) along with orders for cardioversion. If multiple BH patches cannot be completed and in the paramedics opinion cardioversion is required for the unstable but conscious patient, are we able to administer sedation and pain control? I ask this because there is not a directive that directly deals with pain and sedation prior to delivering the cardioversion, but is common to ask for such direction.
Thanks for this question. There is no definite criteria that would constitute a patch failure. This is an instance in which paramedic judgment must come into play. If two or three unsuccessful patch attempts have been made, and in your judgment the patient is at risk for serious harm with further delay in care, then you would be right in carrying out a treatment (cardioversion for unstable tachycardia in this case).
This scenario in particular, however, can be problematic. Additional agents that may be used for analgesia and sedation can result in hypotension and respiratory depression as common side effects. The purpose behind using your judgment in order to carry out a treatment prior to completion of a BHP patch is to prevent serious deterioration or harm to a patient as a result of a time-sensitive medical issue. Administering analgesia and sedation doesnt necessarily fall into the same category as time-sensitive. The administration of those medications may help with comfort but in an already unstable patient might actually cause further harm.
In the unlikely event that you have a patch failure with a patient who needs cardioversion who is unstable, paramedic judgement is required. If the patient requires medication for sedation due to maintained level of consciousness, this most likely reflects adequate perfusion to allow time for either successful patch connection with the BHP or transport if transport times are relatively short. If the paramedic judges that the patient does not require analgesia or sedation due to altered LOC, this most likely represents poor perfusion and cardioversion would be appropriate and a patch to a BHP as soon as possible.
The Regional Base Hospital would not routinely support sedation and or analgesia without a patch prior to cardioversion. However every call is different and these scenarios can be dynamic. If the patch attempt fails and the paramedic judges the patient is too unstable to wait for transport or a successful patch AND requires some analgesia /sedation prior to cardioversion AND will tolerate the adverse effects of sedation / analgesia the paramedic may proceed with sedation / analgesia and subsequent cardioversion. The situation should be well documented on the ACR and BHP contact should be made as soon as possible. Again the call you describe would be a very unlikely situation.