Vasopressin Vs. Epi

[Veneficus]

Rid and Veneficus-

I asked this once before and didn't get a responce, so here goes again. While paramedic education is lacking in this country, how much of ACLS being dumbed down into the crap that it is now is JCAHO responsible for? I experienced the same thing in the last class that I took that Veneficus alluded to; people who will never, EVER need the skills and knowledge taught in ACLS being REQUIRED to take the class because of JCAHO statutes. As well, many of these people don't have the background to pick up the course content in a whopping 16 hours. Have to wonder: with the course being required for so many people (that it shouldn't be required for) was the content dumbed down just to ensure a good passing rate so that it would remain the standard?

I can only answer your question with my opinion as I have no knowledge of JCAHO's inner workings or if they have any relationship to AHA, but here goes.

All providers should be trained to provide a basic response in an emergency. In most medical facilities there is equipment on hand. (code carts, manual defibs, etc) If you do not use AHA somebody has to come up with an entrely new course and go through the steps to have it nationally accedited. (You can bet anyone doing that will make money off of it, so that is a moot issue)

If you took an ACLS or similar course between 2000 and 2005 it was a change from earlier (tougher) standards. There was hope that making it less stressful and team oriented providers would have more success. That turned out to be wrong. People became too lax and were not regularly performing to standards on actual patients. The current course is set up to drill the basics into providers. Psychologists call it classical conditioning. (Pavlov would be proud) I expect in the 2010 guidlines, if not before, there will be another shift towards theory. The EP course adds a little for the people who routinely use these skills or are involved in emergency or critical care regularly. But it assumes you already know the science and medicine so you can be an active participant in the discussions.

I would guess JCAHO required AHA out of convenience. I do not think AHA "dumbed down" the course for JCAHO.

 

[TomB]

We taught one of our janitors how to diagnose STEMI on a 12 lead in a shift. How many providers think that is a complex skill and leave it to the machine to read?

Recognizing a home run STEMI is easy, and yes a child could do it.

On the other hand, identifying ST segment elevation that is not STEMI can be difficult, and that's the real issue.

So yes, 12 lead ECG interpretation is a complex skill.

 

[triemal04]

I don't know. When large numbers of people are required to take a class that they are not prepared for and will very, very likely never use, it could be argued that the content will very often change, simply because of the large numbers of people who are failing the class. I guess that's what I'm curious about; so many people I talked to in my last class were there soley because it was required by JCAHO, and those were the people that were (admittedly in several cases) way out of their depth. Not their fault; just that ACLS is something they were never exposed to. If the standards had been even what they were 6 years ago when I took my first class, there is no way they could have passed. But based on the how AHA teaches the class, their performance and knowledge was deemed acceptable. (and the most recent class I took was much, much more "team" oriented that the previous one)

Again, I don't know. But, it seems like when large numbers of people are required to do something/know something that is not applicable to their job, the way that they learn those things suffers.

 

[Ridryder911]

I understand the view but still to acclaim that Advanced Cardiac Life Support; one should understand that. It is not all psychomotor skills. True, JCAHO has recommended all nurses and code teams have knowledge in resuscitation measures. This does NOT mean that they should have watered down the curriculum.

If they were able to develop new courses, then they should have developed one for those that "might happen" upon a code. True cardiac arrest and resuscitation measures are usually a cluster in any hospital setting. Yet, to acclaim have knowledge in Advanced Cardiac Life Support; one should be knowledgeable in such.

The original ACLS was developed to ensure all were on an equal playing field. If one seen an ACLS insignia on the uniform, one could be assure they knew cardiology and definitely emergency resuscitation measures. In fact, I know of some areas automatically grandfathered one as a Paramedic when they passed the ACLS course. Of course, this was when one was expected to know oxyhemoglobin curve and how to establish a central line also.

Now, when I hear someone completing an ACLS course, it means nothing to me. As one cannot fail it only to be re-mediated basically until they pass. So how weight does it mean? This is why me and so many others are recommending the termination of requiring ACLS as a re-registry requirement.


R/r 911

 

[VentMedic]

so many people I talked to in my last class were there soley because it was required by JCAHO, and those were the people that were (admittedly in several cases) way out of their depth.

JCAHO does not specifically require ACLS but does require training appropriate for the work area. If the people in your class had a work place requirement to require ACLS, JCAHO is looking at how well they adhere to their own standards. They could also write for the specific training without the ACLS card requirement.

Many code and rapid response teams teach resuscitation with the AHA guidelines but with their own information and equipment specific to the hospital's needs.

The same goes for PALS. There is nothing worst then having experience PICU staff members attempt to sit through the PALS course unless it is taught onsite by people who know the needs of the team and make an effort to teach the guidelines without it sounding like a bedtime story meant for children.

 

[MedicReneeInstructor]

My squad doesn't carry vasopressin for a few reasons, the cost and it's a quick and easy dose. From dr's that I have talked with, in our setting which is a rural setting, the vasopressin won't help much because by the time we are called the patient is usually out of v-fib. If it's a witnessed arrest the vasopressin might be a better choice in place of the first two rounds of Epi. In that respect I can see why city or big city ambulances might carry it.

 

[Sasha]

My squad doesn't carry vasopressin for a few reasons, the cost and it's a quick and easy dose. From dr's that I have talked with, in our setting which is a rural setting, the vasopressin won't help much because by the time we are called the patient is usually out of v-fib. If it's a witnessed arrest the vasopressin might be a better choice in place of the first two rounds of Epi. In that respect I can see why city or big city ambulances might carry it.

Vasopressin is only for vfib?

 

[MedicReneeInstructor]

Vasopressin is only for vfib?

I'm sorry no. My mind was centered on just v-fib for some odd reason. LOL =) Vasopressin is also used for V-tach. =) It has also been used to stop GI bleeds and in Diabetes Insipidus but for the Medic it's used in a cardiac incident which involves v-tach or v-fib. =)

 

[Sasha]

I'm sorry no. My mind was centered on just v-fib for some odd reason. LOL =) Vasopressin is also used for V-tach. =) It has also been used to stop GI bleeds and in Diabetes Insipidus but for the Medic it's used in a cardiac incident which involves v-tach or v-fib. =)

I was under the impression that anytime soemone was in cardiac arrest. Asystole and the like, that you could use Vasopressin instead of the first dose of epi.

 

[medic417]

I was under the impression that anytime soemone was in cardiac arrest. Asystole and the like, that you could use Vasopressin instead of the first dose of epi.

It can replace either the first or second dose of Epi. You give 40 U one time then return to Epi 1mg next time around.

 

[triemal04]

I was under the impression that anytime soemone was in cardiac arrest. Asystole and the like, that you could use Vasopressin instead of the first dose of epi.

You do, although it has more uses than just that. A couple of studies have shown that it's actually more effective in asystole/PEA than in vfib/vtach as well though I believe most areas that have it use it for all codes. As well, AHA has changed it's stance on vasopressin to treating it the same as epi; use one or the other, instead of always vasopressin first.

 

[MedicReneeInstructor]

I was under the impression that anytime soemone was in cardiac arrest. Asystole and the like, that you could use Vasopressin instead of the first dose of epi.

Yes, you can replace for any pulseless rhythm the first two doses of Epi (1mg) with 40u Vasopressin.

 

[medic5740]

If not ACLS, then what?

Okay, so the treatment protocols are not the best in AHA ACLS. Let's say that is true to consider the alternative. Where is the alternative? Where is the alternative to AHA PALS? Where is the alternative to ITLS, PHTLS, PEEP, and a myriad of other programs. It's fine to tear them apart, degrade them, and belittle those certified in providing care based upon those programs. BUT what do you have to offer in place of those? They are the programs that are available nationally. Where are the national organizations to design better programs? Why are we educating healthcare providers with the "wrong" treatment protocols, and where are the programs with the "right" treatment protocols?

 

[VentMedic]

Okay, so the treatment protocols are not the best in AHA ACLS. Let's say that is true to consider the alternative. Where is the alternative? Where is the alternative to AHA PALS? Where is the alternative to ITLS, PHTLS, PEEP, and a myriad of other programs. It's fine to tear them apart, degrade them, and belittle those certified in providing care based upon those programs. BUT what do you have to offer in place of those? They are the programs that are available nationally. Where are the national organizations to design better programs? Why are we educating healthcare providers with the "wrong" treatment protocols, and where are the programs with the "right" treatment protocols?

Many hospitals and specialty teams do have their own protocols and guidelines written by their medical director for specific types of patients. Examples: Vasopressin and use in children with specific diseases and transplants or both adults and children with LVADs or congenital defects

Both vasopressin and epinephrine have multiple applications in various protocols for different patients.

Blanket recipes do not always fit every patient. For prehospital, you may have to use the accepted guidelines because you are dealing with the unknown patient most of the time.

AHA ACLS just does the research for what might be the broadest and easiest guidelines with the data available. The facilities that are active in the research may have moved on to other drugs and protocols that may become the future of the next ACLS set of guidelines.

There are many national organizations that are involved with the AHA and are not always in agreement with the published guidelines particularly in the area of pediatrics. Thus, you get NRP and STABLE as additional algorithms from the other associations for more specific treatment.

Then you also have the European Cardiology Societies as well as the NZ/Australia associations which do their own research. Some are in agreement with the U.S. and some vary. Other examples can be some of the dissimilarities between the Canadian, European and NZ/Australian Societies for Pulmonary medicine. Often the differences will lie in the drug therapy and technology since other countries have access to meds and advanced equipment long before the U.S.

Just more reasons why I encourage people to read the medical journals and not only JEMS. You might be the first to know in your neighborhood what the future will hold for the next set of guidelines and protocols.

 

[Veneficus]

Okay, so the treatment protocols are not the best in AHA ACLS. Let's say that is true to consider the alternative. Where is the alternative? Where is the alternative to AHA PALS? Where is the alternative to ITLS, PHTLS, PEEP, and a myriad of other programs. It's fine to tear them apart, degrade them, and belittle those certified in providing care based upon those programs. BUT what do you have to offer in place of those? They are the programs that are available nationally. Where are the national organizations to design better programs? Why are we educating healthcare providers with the "wrong" treatment protocols, and where are the programs with the "right" treatment protocols?

I think ACLS and the some other similar courses are good for what they are designed for. We must understand that it is not meant to be a substitute or replacement for a deeper understanding of the material or the ability to know when/how to deviate from the guidlines.

If I didn't think they had value I wouldn't be an instructor. (which is why I don't teach ITLS or PHTLS. Anyone capable of sitting in one of those classes can sit in ATLS) Some will flip out and complain how they don't know how or are not permitted to read x-rays, but how many providers who take ACLS or PALS are not permitted to intubate? We managed to address that quite well.

 

[TomB]

In the November 2008 EMCast at EMedHome.com, Amal Mattu M.D. makes the case that cardiac arrest patients receive no benefit from Vasopressin and may have worse neurological outcomes when compared with Epinephrine (regardless of rhythm).

 

[CurbDoc70]

Yep, the biggest advantage to Vaso I know of is the 10 minutes it buys you to get your *** to the truck.

 

[jason152318]

The good thing about epi is it will hopefully increase the chances of producing a shockable rhythm. Along with its other actions. vasopressin has been studied by the AHA and has shown to have strong effects. It depends on the problem that is causing the crdiac arrest.

 

[8jimi8]

One ACLS instructor that I spoke with preferred vasopressin first because of its peripheral effects. He explained that a heart in AMI is already oxygen starved and that epinephrine only made it work harder. Seems logical to me.

 

[Ridryder911]

I was informed that Vasopressin has had some remarkable outcomes in pediatric arrest and to look for some changes in the new PALS. As well, Amiodarone has had some very disappointing outcomes and to look at it as the new Bretylium.

R/r 911