# Another ACLS Question



## truetiger (Jul 17, 2010)

I've heard two different things about checking a rhythm. Here's the scenario, after defibrillating vfib/tach do you check the rhythm after? I've had one ACLS instructor tell us to do a quick look right after, and another say immediately start CPR after defibrillating without checking a rhythm. What would you do?


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## ExpatMedic0 (Jul 17, 2010)

I believe its old standards vs new standards? Its been a while I have to recert on ACLS soon. If I remember correctly you do CPR for 1 minute then check the rhythm. Anyone else?
Shock, resume CPR for 1 minute then check rhythm I THINK... anyone else?


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## ExpatMedic0 (Jul 17, 2010)

I am not sure about this website.... but it was updated in 2009.

http://enotes.tripod.com/vfib.htm


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## MrBrown (Jul 17, 2010)

No rhythm check is to be performed after defibrillation according to our clinical guidelines.

The appropriate time to perform a rhythm check is at each two minute interval (each 200 compressions).

200 compressions
Rhythm check - shock if indicated
200 compressions
Rhythm check - shock if indicated
Adrenaline 1mg 
Repeat

Oh, and a rhythm check is *one* Ambulance Officer looking at the monitor and deciding to shock or not, none of this bloody "oh lets all stop what we are doing, hands off and gorp at the monitor"!


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## lightsandsirens5 (Jul 17, 2010)

schulz said:


> I believe its old standards vs new standards? Its been a while I have to recert on ACLS soon. If I remember correctly you do CPR for 1 minute then check the rhythm. Anyone else?
> Shock, resume CPR for 1 minute then check rhythm I THINK... anyone else?



I believe it is two minutes after a shock. Before you check anything. Pulse, rhythm......not 100% sure on that one, bit for some reason one minute don't sound right and two minutes is coming to mind. 

I'll have to go look to be sure.


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## truetiger (Jul 17, 2010)

I've been going by extended/unknown downtime 2 mins cpr then rhythm check, defib if needed. Witnessed/ known short downtime, rhythm check/defib then cpr. Checking rhythm only at 2 min rhythm checks, and immediately resuming cpr after defib.


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## CAOX3 (Jul 17, 2010)

Defib followed by five cycles of compressions then re check rhythm.


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## citizensoldierny (Jul 17, 2010)

Just did ACLS about a month and a half ago. Immediately resuming CPR is what the standard is. Rationale bieng even if the heart converted to a perfusing rhythm it will need help at this point.


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## wyoskibum (Jul 17, 2010)

*Gotta keep the pump primed*



truetiger said:


> I've heard two different things about checking a rhythm. Here's the scenario, after defibrillating vfib/tach do you check the rhythm after? I've had one ACLS instructor tell us to do a quick look right after, and another say immediately start CPR after defibrillating without checking a rhythm. What would you do?



The 2005 guidelines advocate 2 mins of CPR after defibrillation, then check for pulse, repeat shock if indicated.


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## AnthonyM83 (Jul 17, 2010)

Definitely resume compressions IMMEDIATELY after CPR. 

Some providers can't help it and want to do a quick check. But there's no point. It's delaying the constant compressions which is the thing we need to improve on the most to help survival. Regardless of the rhythm you're going to do compressions anyway, so why look? It just delays.


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## 8jimi8 (Jul 17, 2010)

i didnt realize there was so much confusion about this.


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## ExpatMedic0 (Jul 17, 2010)

There shouldn't be lol. I am due for ACLS recert and haven't worked a code in over a year. :blush:

Well back to Rapid CE with me for remedial training!


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## AnthonyM83 (Jul 17, 2010)

This "new" standard has been the standard for 5ish years....there shouldn't be any confusion to this. Maybe drug dosages yes, because local protocols vary, but confusion about what to do after a shock!?!?!?

Only two people answered incorrectly, but even the ones who got it right didn't seem that confident.



THE MORE RARELY WE USE A SKILL, THE MORE WE SHOULD PRACTICE IT. I'm sure there's some skills I'm guilty of not practicing enough, too...



Compressions until last minute possible (including during charging unless it's a rapid charge unit...and even then you can still do it), shock, continue CPR immediately. The interruption in compressions should be MINIMAL. 

I try to train myself that the phrases "no pulse" "charging" and "shock delivered" should always be followed with "continue CPR" (or a variation of it). So the phrases roll off your tongue as one sentence to minimize delays in resuming compressions.


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## Outbac1 (Jul 19, 2010)

After shock delivered resume CPR. I have to agree with Mr Brown on this.

  Anyone heard rumors on the new guidelines due this fall? So far I've heard continuous compressions for 6 minutes including thru shock delivery. No attempt at airway control or "breaths" for 6 mins.  Basically continuous compressions, shock prn and IV access during the first 6 mins.

 Our MD wants to do inservices within a month of the new guidelines being published so we can do them right away. Apparently most places do not adopt them for up to two years after they are published. 

 Your thoughts?


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## EMS_Junkie (Jul 19, 2010)

The American Heart Association says after defibrillating VF/pulseless VT, to immediately start CPR for 2 minutes and then do another rhythm check.  If you think about it, if you save a "dead heart" its not going to work correct right away, so doing CPR for that 2 minutes even if they are in a rhythm other than VF/VT will help nourish the heart and perfuse remaining tissues.


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## 82-Alpha599 (Jul 20, 2010)

rhythm check before med push or defib, not after


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## AnthonyM83 (Jul 21, 2010)

82-Alpha599 said:


> rhythm check before med push or defib, not after


Cite your source?
Rhythm check, shock, cpr, push drug, rhythm check, shock/noshock, cpr, med, rhythm check

It's unrealistic that you'll be able to load and push a drug right after the rhythm check, yet before the delivery of the shock, especially on a rapid charging defibrillator. 

Thoughts?


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## MrBrown (Jul 21, 2010)

No point checking the rhythm after you give adrenaline, we've known for thirty years that drugs in cardiac arrest have proven ineffective.


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## tylerp1 (Aug 8, 2010)

Well, when you defib a pt with vtach or vfib, the defibrillator is going to make the rhythm asystole because it's restarting the heart, so if you dont go right into compressions, youll see asystole, so give good, high-quality CPR.


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## firecoins (Aug 8, 2010)

You shock, do 2 minutes of CPR, THAN check rhythm.


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## jjesusfreak01 (Aug 8, 2010)

Somewhat related question. In my county, they practice hard and fast CPR, which is proving to give patients great circulation to the point that some wake up during CPR, some make purposeful movements, and often they will breathe after being completely apneic during cardiac arrest. This happens despite the fact that they remain in a deadly rhythm (read asystole, vtach, vfib, etc).

My question is this. If you (a paramedic) were off duty and came upon an arrest and started CPR, and the patient responded with breathing or better, which stopped when CPR was stopped, would you consider giving a good ol' thump if you knew you weren't going to have a defibrillator anytime soon?


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## Jay (Aug 9, 2010)

truetiger said:


> I've heard two different things about checking a rhythm. Here's the scenario, after defibrillating vfib/tach do you check the rhythm after? I've had one ACLS instructor tell us to do a quick look right after, and another say immediately start CPR after defibrillating without checking a rhythm. What would you do?



Check out the attached Pulseless Arrest scenario from the ACLS megacodes. 

I made it a PDF for you so you can easily download and print it for your review.

You will see in Box 4 for VT/VF to shock and then *Resume CPR immediately* where it then says to do 5 cycles which should roughly equate to 2 minutes worth of CPR. 

Hope this helps... Good luck!!!


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## Hockey (Aug 9, 2010)

Outbac1 said:


> After shock delivered resume CPR. I have to agree with Mr Brown on this.
> 
> Anyone heard rumors on the new guidelines due this fall? So far I've heard continuous compressions for 6 minutes including thru shock delivery. No attempt at airway control or "breaths" for 6 mins.  Basically continuous compressions, shock prn and IV access during the first 6 mins.
> 
> ...



My thoughts? Well...sure good, but I surely won't be doing compressions when we shock.  Letting go for ~3 seconds isn't going to make someone anymore deader


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## Fox800 (Aug 9, 2010)

jjesusfreak01 said:


> Somewhat related question. In my county, they practice hard and fast CPR, which is proving to give patients great circulation to the point that some wake up during CPR, some make purposeful movements, and often they will breathe after being completely apneic during cardiac arrest. This happens despite the fact that they remain in a deadly rhythm (read asystole, vtach, vfib, etc).
> 
> My question is this. If you (a paramedic) were off duty and came upon an arrest and started CPR, and the patient responded with breathing or better, which stopped when CPR was stopped, would you consider giving a good ol' thump if you knew you weren't going to have a defibrillator anytime soon?



Nope. I'd continue CPR, since the pt. is continuing to be pulseless and apneic.


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## zzyzx (Aug 10, 2010)

@Anthony: are you sure you don't want to do a rhythm check before giving a medication? Do you really want to slam 1 mg of epi into someone who has just returned to a perfusing rhythm after a defib, or slamming 300 mg of amiodarone into someone who has convereted into a normal sinus rhythm with a pulse?

Guys, for EMT's using AED's, they should immediately go back to CPR w/o checking pulses after they have shocked. But for us medics, there really is no reason not to check what's on the monitor after you shock. That just seems like common sense to me. No, I don't advocate doing a pulse check after a defib, unless you see an organized rhythm.


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## Fox800 (Aug 10, 2010)

zzyzx said:


> @Anthony: are you sure you don't want to do a rhythm check before giving a medication? Do you really want to slam 1 mg of epi into someone who has just returned to a perfusing rhythm after a defib, or slamming 300 mg of amiodarone into someone who has convereted into a normal sinus rhythm with a pulse?
> 
> Guys, for EMT's using AED's, they should immediately go back to CPR w/o checking pulses after they have shocked. But for us medics, there really is no reason not to check what's on the monitor after you shock. That just seems like common sense to me. No, I don't advocate doing a pulse check after a defib, unless you see an organized rhythm.



The research has shown that patients will not jump into a perfusing rhythm immediately after defibrillation. That is why we do another 2:00 of CPR following defibrillation, and wait to do a pulse check until that cycle is done. You should wait for that 2:00 rhythm check before you decide which meds to push.


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