CORRESPONDENCE

GFTuohy,MD Departmentof Anesthesiology University of Missouri KansasCity Philip yon tier Heydt, IVIEd,RRT JRCEMTP Euless, Texas In Reply: I appreciate the interest in our paper. ) agree, intuitively, that the more exposure paramedics receive to various endotracheal intubation practice medalities, the more optimal will be their training in the procedure. I strongly suggest that endotracheal intubation practice on live people who are under general anesthesia is merely another model for intubation training. In no way does the controlled operating room environment and anesthetized patient mimic the emotional content or physical feel of an actual field emergency intubation. In our community, it is generally considered unethical for paramedics to practice endotracheal intubation on individuals undergoing general anesthesia without the individual's prior informed consent. This need for consent, as well as a potential for litigation, has seriously limited the ability to obtain operating room experience for our paramedics. Because of this, fresh human cadavers have been used for intubation training. Realistically, supervised endotracheal intubation instruction with a fresh human cadaver is little different from instruction using a freshly arfesthetized patient. During our mannequin practice sessions, each student received 2(} minutes of supervised, individual instruction while other students observed and participated. These practice sessions included teaching distracters to simulate the actual field setting leg, poor lighting, vomiting, trauma). One important point is that our paper addresses adult intubation and should not be considered when evaluatingpediatric intubation. Without any implicatons, our study supports the concept of using only mannequins and didactic sessions

SEPTEMBER 1992

21:9

for teaching the skill of adult endotracheal intubation to paramedics.

SamuelJ Stratton, MD, FACEP LosAngeles CountyDepartmentof Health Services EmergencyMedical ServicesAgency Paramedic TrainingInstitute Torrance, California

Augmented Carotid Massage To the Editor. Each time I read an article on a new pharmacologic method for treatment of paroxysmal supraventricular tachycardia {PSVT), I do so with chagrin. The editorial "Calcium Pretreatment to Prevent VerapamilInduced Hypotension in Patients With SW" [January 1992;21:68] left me disappointed. Although it is primarily a review of the literature on the subject and focuses on the correct dosage and preparation of calcium, its tone seems to lend credence to the idea of using a second drug to prevent a potential adverse effect of a first drug in the treatment of PSVT. Nonpharmacologic means often can be used to terminate the majority of cases of PSVT.1,2 Although the above statement may appear fatuous, the fact is that the use of carotid massage for the termination of PSVT has become a lost art, particularly since the introduction of verapamil,3 the modernist's panacea for PSVT. Carotid massage was described as a technique for use in paroxysmal tachycardia early in the 20th century, ~ but in modern textbooks seems to get relegated to the category of "honorable mention." In 1980, Waxman et aH studied patients with known PSVT and the effects of respiration and body position on termination of induced episodes of PSVT. They found that such episodes were more likely to be terminated if the patient was in a head-down (Trendelenburg) position and also in the deep inspiration portion of the respiratory cyc)e. Concurrently, the same lead author (with others) reported on the use of "vagal techniques" for the termina-

ANNALS OF EMERGENCY MEDiCiNE

tion of PSVT.2There was no report, however, on the use of such measures in combination. Prior to the Waxman studies, I was an advocate of carotid massage and had experienced fair success with it for termination of PSVT. After the publication of the Waxman articles, however, I expanded my method as follows: I. After examination, including auscultation of the carotid arteries, carotid pressure is applied (while observing the cardiac monitor) first on one side, and then, if not successful, on the other side. The patient should be flat in the supine position; usually no more than five seconds of pressure is applied at one time. 2. If the above does not terminate the episode, the patient is placed in a Trendelenburg position of about -10 ° and instructed to take a full inspiration, full expiration, and again full inspiration that is held briefly. This in itself will convert some patients to normal sinus rhythm. 3. If not effective, then carotid massage is carried out in the Trendelenburg position after the respiratory maneuvers described above have been completed. 4. If not effective, then pharmacologic methods are used. I have been using the above technique, which I term augmented carotid massage, regularly since 1981, and have used it in 100 to 200 patients with excellent results. There have been no instances of ensuing dysrhythmia (beyond the few seconds of transient bradycardia that may be seen with all modalities) or hypotensien. Importantly, there have been no instances of cerebral ischemia, transient or otherwise. Also, there have been no instances of recurrence, as is common with adenosine. Although I have not collected the data, I believe that at least 60% of all patients with PSVT have converted to normal sinus rhythm with the above-described, nonpharmacoiogic method. I have used it successfully in pregnant individuals in whom the administration of any drug might be potentially harmful to the developing fetus. A

fringe benefit of such use is that a certain percentage of patients thought to have PSVT instead have atrial flutter with 2:1 atrioventricula block but the P waves are not easily visible due to the rapid ventricular rate (usually about 150}. The use of carotid massage increases the atrioventricular block and allows the P waves to be seen, the correct diagnosis to be made, and a course of inappropriate therapy to be avoided. ) have always prided myself in being a clinician, and have tried to adhere to the doctrine of primum non nocere. I believe the conversion of PSVT is clearly an area where no drug is frequently better than one or two drugs, and where something new is not necessarily something better.

Paul R Pomeroy,MD, FACEP EmergencyDepartment St Mary Hospital Livonia, Michigan 1. Waxman MB, et al: Effects of respiraton and posture on paroxysmal sapraventricular tachycardia. Circulation 1980;62:1011-1020. 2. Waxman MB, et al: Vagal techniques for termination of paroxysmal supraventricular tachycardia. Am J Cardiol 1980;46:655-664. 3. Sung R J, Etser B, McAUister RG:

Intravenous verapamil for termination of re-entrant supraventricular tachycardias. Ann Intern Med 1980;93:682-689. 4. Cohn AE, Fraser RF: Paroxysmal tachycardia and the effect of stimulation of the vagus nerves by pressure. Heart 1913-14;5:93-108.

In Reply: I appreciate Dr Pomeroy's insightful response to the editorial authored by Dr Hargarten and myself. The point of the editorial, however, was not to discuss management options for PSVT, but to discuss the use of calcium once the decision to use verapamil is made. It is assumed that before the use of pharmacologic management, all other conservative means have been exhausted (eg, Valsatva, carotid massage, or even cold water immersion of the face if one is so bold). Few physicians, I'm afraid, are as aggressive as Dr Pomeroy with the

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Augmented carotid massage.

CORRESPONDENCE GFTuohy,MD Departmentof Anesthesiology University of Missouri KansasCity Philip yon tier Heydt, IVIEd,RRT JRCEMTP Euless, Texas In Rep...
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