# ACLS questions



## ethomas4 (Jan 24, 2012)

Sorry if I repeat questions, excuse the ignorance etc.

International EMT I here about to take ACLS in the states.

my question is..After achieving ROSC on a VF/pulseless VT patient we are to optimize oxygenation, ventilation and treat hypotension etc

do we treat hypotension with EPI, Dopamine AND norepinephrine?? or do we only use nor epi if the pt is refractory to epi and dopamine and/or with a SBP of <70mm Hg?


Thanks, I will probably have a few more questions, thanks for sharing your knowledge!!


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## STXmedic (Jan 24, 2012)

Typically Epi is intra-arrest as a bolus. If the patient remains hypotensive once ROSC is achieved, and assuming the patient doesn't have an immediately correctable issue of hypovolemia, Dopamine is usually the preferred agent, primarily for the benefit of increased cardiac output via B stimulation.


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## sweetpete (Jan 24, 2012)

Also, I seem to recall treating hypotension after ROSC if the systolic is less than 90, not 70. Just something to add.

Take care


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## ethomas4 (Jan 24, 2012)

sweeetpete,

 I asked about the SBP of 70 because in the AHA ACLS book is just says that norepinephrine "may be effective for management of patients with severe hypotension i e ,70 and a low total peripheral resistance who fail to respond to less potent adrenergic drugs such as dopamine, phenylephrine, or methoxamine."

but it alos says treat hypotension with epi, dopamine and norepi..so I am a bit confused

Is that just like an FYI thing or a protocol? thats what i was trying to ask.

THANKS!!


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## STXmedic (Jan 24, 2012)

It's going to be protocol based, and dependent on what your service carries. For example, I do not personally know of any ground service that carries phenylephrine (though I'm sure a few are out there). 

In regards to norepi over dopamine: Norepi is a more selective and potent A stimulator. So yes, when dopamine is not working 2/2 a failure to increase systemic vascular resistance, norepi is more likely to benefit.


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## 46Young (Jan 24, 2012)

ethomas4 said:


> Sorry if I repeat questions, excuse the ignorance etc.
> 
> International EMT I here about to take ACLS in the states.
> 
> ...



First thing after achieving ROSC would be to ask for the various vitals, run a 12 lead, verbalize txp to a STEMI/PCI center, and also to admin 1-2 liters of chilled (4 degrees Celsius) saline plus other cooling techniques. If hypotensive after that bolus, then go into other hypotensive interventions. The fluid bolus is indicated first in ACLS, then pressors.


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## DPM (Jan 24, 2012)

46Young said:


> ...admin 1-2 liters of chilled (4 degrees Celsius) saline plus other cooling techniques. If hypotensive after that bolus, then go into other hypotensive interventions. The fluid bolus is indicated first in ACLS, then pressors.



We don't have chilled Saline but we go fluid challenge first, then if PT is still Hypotensive use Dopamine / Epi. Atropine only for symptomatic Bradycardia.


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## MSDeltaFlt (Jan 24, 2012)

If your pt is hypotensive after ROSC, you generally give these in this order

Fluid bolus, then dopamine, then norepinephrine, then epinephrine.

As far as chilled saline goes, you start that if and only if the receiving they are able to continue therapeutic hypothermia. Otherwise it will offer no benefit at all.


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## WTEngel (Jan 24, 2012)

In my experience, we go with dopamine, epi, then norepi.

When you start moving from one vasopressor to the next, you typically end up stacking them. Once you max out dopamine, start epi on top, once you max out epi, then start norepi.

Levophed (norepi) is rough stuff. It is a last ditch vasopressor typically, causing such profound vasoconstriction that it can sometimes turn the tips of the fingers and toes dark blue and black due to the ischemia.

Anyone ever heard the saying "Levophed leaves 'em dead..."

I would always be prepared to start a vasopressor drip post ROSC, even if you are giving a fluid challenge. The heart is weakened, and most liklely has suffered an ischemic event, likely leading to some degree of heart failure. I think the important thing to understand is that the hypotension control recommendations (AHA) are a process, not a set in stone "give this medication for this specific number."

This is just my experience. It is protocol specific, of course.


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## 46Young (Jan 25, 2012)

DPM said:


> We don't have chilled Saline but we go fluid challenge first, then if PT is still Hypotensive use Dopamine / Epi. Atropine only for symptomatic Bradycardia.



Copy that, but I believe the OP stated that they were testing for ACLS. My advice was for passing the megacode.

MSDeltaFlt, same thing.


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## DPM (Jan 25, 2012)

Quite right, I didn't read that!

Chilled saline all the way for ROSC according to the AHA.


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## Handsome Robb (Jan 25, 2012)

Dopamine is the first line pressor in ACLS after a fluid challenge. I just redid ACLS for medic school 2 months ago.

I doubt any ACLS megacode will involve stacking pressors although the proctor may ask you for other options besides the dopamine.


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## MSDeltaFlt (Jan 25, 2012)

NVRob said:


> Dopamine is the first line pressor in ACLS after a fluid challenge. I just redid ACLS for medic school 2 months ago.
> 
> I doubt any ACLS megacode will involve stacking pressors although the proctor may ask you for other options besides the dopamine.



You definitely stack them if the pt is still hypotensive. You don't swap. Swapping doesn't do anything. When you Max one out add another on top of it.


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## systemet (Jan 25, 2012)

This also depends on what you're trying to do.  In the field it's hard to differentiate the cause of the hypotension.

Dopamine's a great inotrope, but it also increases the HR, both of which increase myocardial oxygen demand.  It has pressor effects at higher doses, but you have to eat a lot of myocardial oxygen demand to get there, and the maximal effects are weaker than norepi.

Norepinephrine is more of a pure pressor, although it has some inotropic effects.  In some situations, particularly where SVR is an issue, it might be a better agent, e.g. some septic shock.

Neither will work well if the patient is volume-depleted.

Most of the time EMS ends up using dopamine, because this is all that's available.  Norepinephrine has a bad reputation in EMS, but it's still used quitely widely in ICU care.

http://emergency-medicine.jwatch.org/cgi/content/full/2010/303/1
http://www.medscape.com/viewarticle/738317
http://www.ncbi.nlm.nih.gov/pubmed/19412154
http://www.minervamedica.it/en/getf...M4OZ9SB5tqM%2FSTSg%3D%3D/R02Y2009N05A0333.pdf


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## WTEngel (Jan 25, 2012)

Well if you are purely trying to pass an ACLS evaluation and don't care to reconcile it with any practical application (not to say the algorithms are not practical, but the comments some people adding are), then:

If patient has SBP lower then 90 mmHg, shows altered LOC, or other signs of poor perfusion, administer a 1-2L NS bolus. If ineffective, Dopamine, epi, and norepi are all considered equivalent per the algorithm, based on patient presentation. 

2 things to note are:

The dose of dopamine for treatment of symptomatic bradycardia is different than the dose for hypotension post ROSC, at 2-10 mcg/kg/min or 5-10 mcg/kg/min respectively. Check your algorithms, you will see what I am talking about.

The dose for dopamine and epi are not the same in either the bradycardia or post ROSC algorithms:

Dopamine is 2-10 or 5-10 mcg/kg/min (brady vs. ROSC) 
This *IS* weight dependent.

Epi is 2-10 mcg/min (bradycardia) 
This *IS NOT* weight dependent. 

Epi is 0.1-0.5 mcg/kg/min (post ROSC) 
This *IS* weight dependent.

I commonly see students in ACLS making the mistake of saying the same dose for both meds, or getting the dose for brady vs. ROSC confused. It is easy to do with so many similar numbers floating around, and few people  (instructors included) take the time to read the little grey box to the side...


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## WTEngel (Jan 25, 2012)

systemet said:


> Norepinephrine has a bad reputation in EMS, but it's still used quitely widely in ICU care.



I completely agree. Norepi absolutely has its place, especially for sepsis and other distributive forms of shock. You are correct, it is used often in the ICU and other critical care environments, for a number of patients who do not end up dying. 

I think the reason it has a bad rap in EMS is that a lot of providers do not have experience with it, and tend to see the negative effects due to poor/inappropriate use, as opposed to the ICU where we have much closer monitoring of the patients, and the negative effects can be diminished as much as possible because the providers have a much higher degree of competence with the drug. 

I suppose I should have been more measured in my criticism of it, however I still cringe at the thought of medics who hardly ever use the drug jumping to it as a first line intervention for hypotension that is most likely cardiogenic in nature.


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## Veneficus (Jan 25, 2012)

*the voice of reason*

I hate to be the bearer of bad news, but let's face it, if you are following ACLS algorythms without actually knowing "why", it's probably best you just stick to CPR and defib until somebody who actually knows what they are doing shows up.

It takes far more knowledge and experience to be good at resuscitation than a 16 hour class that often falls short of even that.

Lest we forget, they are also consensus guidlines, put together by the high priests over at AHA, who don't always have best patient care in mind.

Sometimes a guidline is based on ease of usage or recolection goals for people who may never see a code in their career.

I think it would be much more effective if it were broken into a category for experts and one for non-experts.

Sadly the advanced provider course doesn't exactly meet the goal.

Call me old school, but remember when an ACLS card actually meant you knew something?


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## WTEngel (Jan 25, 2012)

Oh Vene...you know you have no problem being the bearer of bad news! 

I couldn't agree more. ACLS has gotten easier, and more "friendly". Some of the changes are great, some are quite obviously done because the majority of people need an "ease of learning" accommodation. 

I would have to say that my biggest disappointment with ALCS has to be from the instructor side, not the student side. All too often I see instructors being lax on standards that are already lax to begin with. Not holding people accountable on the exam, doing a piss poor job of actually teaching the course, blatantly giving false information...I wish the instructors were vetted more. I know where I teach it actually means something to be an ACLS instructor, as opposed to other places, where it means you got your ACLS provider last week.

The scariest part of the whole situation is that even with the simplified algorithms, reduced emphasis on rhythm recognition, and reduction in initial medications listed (on the algorithm at least) people still manage to fail the written and practical!

I pride myself in working for an organization that only takes great ACLS instructors, and only passes competent ACLS providers. Unfortunately this is the exception, not the rule.

BTW, taking my MCAT in may, looking at applying Early Decision by August 1st. I know you aren't in the US, but may want to pick your brain about the med school experience sometime...


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## Veneficus (Jan 25, 2012)

WTEngel said:


> Oh Vene...you know you have no problem being the bearer of bad news!



True, but I at least like to sound sorry about it sometimes.





WTEngel said:


> I would have to say that my biggest disappointment with ALCS has to be from the instructor side, not the student side. All too often I see instructors being lax on standards that are already lax to begin with. Not holding people accountable on the exam, doing a piss poor job of actually teaching the course, blatantly giving false information...I wish the instructors were vetted more.



To solve this problem where I teach at, a couple of years ago, the training center decided to institute the idea of TCFs whose responsibility became to set the example and police instructors. Instructors now refer all questions to the TCFs and only a TCF can teach without direct oversight of one.

It has worked better than any had hoped. While it did cull the instructor herd considerably, it helped to centralize courses, which we were able to make draconian (lets say the rules are followed without exception and without emotion, you pass or fail by the numbers.) with the support of various dept heads. 

For a while we were known as the place not to go for any reason, but after a course of about 3 years became known as the place to send your people to really learn.

I strongly support and recommend such a system.



WTEngel said:


> The scariest part of the whole situation is that even with the simplified algorithms, reduced emphasis on rhythm recognition, and reduction in initial medications listed (on the algorithm at least) people still manage to fail the written and practical!.



Where I am at, they are only permitted 1 retest of the megacode on test day, if they fail that or the written they take 48 hours off and try again. Should they fail that, they get to repeat the course in its entirety. If it means they cannot work (which is an institutional policy) then so be it. We have full support of the organizational authorites and usually call a department head to report a failure right away.



WTEngel said:


> I pride myself in working for an organization that only takes great ACLS instructors, and only passes competent ACLS providers. Unfortunately this is the exception, not the rule.



seconded




WTEngel said:


> BTW, taking my MCAT in may, looking at applying Early Decision by August 1st. I know you aren't in the US, but may want to pick your brain about the med school experience sometime...



If I can help, I am at your service.


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## MSDeltaFlt (Jan 25, 2012)

I misposted earlier by just giving out a blanket statement like that.  It's a bit more complicated. Our protocols go by AHA guidelines. And for our hypotensive pts that have a pump problem, if the BP is 70-90 WITH S/Sx of shock we start Dopamine. If BP is <60 with S/Sx shock start norepi. If BP 70-90 WITHOUT S/Sx shock we give dobutamine.  I personally like those options available to me.


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## Handsome Robb (Jan 31, 2012)

MSDeltaFlt said:


> You definitely stack them if the pt is still hypotensive. You don't swap. Swapping doesn't do anything. When you Max one out add another on top of it.



In actual practice absolutely! In an ACLS scenario during class I highly doubt any proctor will ask you to go further than dopamine. 

Well that's going to depend on the class and your instructors but I'd say having a scenario requiring you to stack pressors would be the minority


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