# Someting this new Medic never heard of



## Macari (Feb 23, 2009)

So I’m a new Medic and I was talking to a Medic of probably 2-3 years about the code she had the day before.  
Bla bla bla... pt in PEA... bla bla bla... shocked 3 time. 
:unsure: Wait a minute now, shocking PEA?  Is this a common practice or just a foolish Medic?

Thanks
Tony


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## Hastings (Feb 23, 2009)

Macari said:


> So I’m a new Medic and I was talking to a Medic of probably 2-3 years about the code she had the day before.
> Bla bla bla... pt in PEA... bla bla bla... shocked 3 time.
> :unsure: Wait a minute now, shocking PEA?  Is this a common practice or just a foolish Medic?
> 
> ...



No. You do not shock PEA under any circumstances.

Sounds like a desperate, panic/ignorant move.


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## Aidey (Feb 23, 2009)

Per AHA ACLS guidelines PEA is a non-shockable rhythm. Maybe she was trying it as a last ditch effort before declaring the guy?


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## medic417 (Feb 23, 2009)

Aidey said:


> Per AHA ACLS guidelines PEA is a non-shockable rhythm. Maybe she was trying it as a last ditch effort before declaring the guy?



Maybe ruling out fine VF.  But if that was the case thats what she should have claimed.


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## Ridryder911 (Feb 23, 2009)

Most PEA rhythms are idioventricular in nature. If they wanted to make the rhythm into aystole, this is definitely they way to do it... but, its not the appropriate treatment. I suggest that before advising treatment; they may want to know the appropriate standard of care. 

R/r 911


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## sir.shocksalot (Feb 24, 2009)

Macari said:


> So I’m a new Medic and I was talking to a Medic of probably 2-3 years about the code she had the day before.
> Bla bla bla... pt in PEA... bla bla bla... shocked 3 time.
> :unsure: Wait a minute now, shocking PEA?  Is this a common practice or just a foolish Medic?
> 
> ...


I shock everything.





Just Kidding


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## DaMan8837 (Feb 24, 2009)

Macari said:


> So I’m a new Medic and I was talking to a Medic of probably 2-3 years about the code she had the day before.
> Bla bla bla... pt in PEA... bla bla bla... shocked 3 time.
> :unsure: Wait a minute now, shocking PEA?  Is this a common practice or just a foolish Medic?
> 
> ...



According to ACLS, if a patient is in PEA, you are to do 5 cycles of CPR (while giving Epi(/Atropine) or Vasopressin).  

After 5 cycles of CPR, you are to identify the cardiac rhythm.  If it's shockable, you ARE to shock it.


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## Macari (Feb 24, 2009)

thanks, had a feeling she was wrong.  She did transport and the hospital and on arrival they found aystole.  Go figure

Tony


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## CurbDoc70 (Mar 12, 2009)

I seem to recall some long ago deal with WITNESSING a pt go into PEA and shocking..but either way, it's obsolete now.


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## Vonny (Mar 12, 2009)

Macari said:


> thanks, had a feeling she was wrong.  She did transport and the hospital and on arrival they found aystole.  Go figure
> 
> Tony



So PEA is not shockable but she did not hurt anything by doing it.  Perhaps she was not sure and just saved herself the "what ifs" that would go through her head later on..


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## AJ Hidell (Mar 12, 2009)

Vonny said:


> So PEA is not shockable but *she did not hurt anything by doing it*.


How do you figure that?  She eradicated the rhythm, forever erasing all hope of chemically converting it.  Whether or not it would have been converted, we'll never know.  But by denying the patient that chance, I and any jury would agree that she did hurt the patients chances at life.


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## Vonny (Mar 12, 2009)

AJ Hidell said:


> How do you figure that?  She eradicated the rhythm, forever erasing all hope of chemically converting it.  Whether or not it would have been converted, we'll never know.  But by denying the patient that chance, I and any jury would agree that she did hurt the patients chances at life.



I guess I was assuming that a chemical conversion was either ruled out or was not available at the time.  Around where I live a chemical conversion is at least 40 minutes away.


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## CurbDoc70 (Mar 13, 2009)

Vonny said:


> So PEA is not shockable but she did not hurt anything by doing it.  Perhaps she was not sure and just saved herself the "what ifs" that would go through her head later on..



Well, actually, she did if you want to be picky. While wasting time shocking a rhythm that gets no response from defibrillation, she could have been focusing on something that might actually save the patient.

Treating possible causes and efficient CPR. Both of these are more beneficial than anything you can do, even epi and atropine. 

I know we all sometimes step out of protocol to try to save a patient, but it's a thin line between ego and negligence.


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## maxwell (Mar 16, 2009)

Shocking PEA?  Meh.  Can't kill a dead guy.  We've tried for years.  But, it's totally ACLS taboo.  Yeah, yeah, they're idioventricular excl:usually:excl  - so they //could// respond to electrical tx- but - never seen it - never documented - don't do it.


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## Vonny (Mar 16, 2009)

Macari said:


> So I’m a new Medic and I was talking to a Medic of probably 2-3 years about the code she had the day before.
> Bla bla bla... pt in PEA... bla bla bla... shocked 3 time.
> :unsure: Wait a minute now, shocking PEA?  Is this a common practice or just a foolish Medic?
> 
> ...



I would really like to know the bla bla bla parts, something must have made her take the action she took. 3 shocks sounds like a desperate effort. What ALS was available, how long to ALS.


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## ffemt8978 (Mar 16, 2009)

Macari said:


> ... I was talking to a Medic of probably 2-3 years about the code she had the day before.
> Bla bla bla... pt in PEA... bla bla bla... shocked 3 time.
> :unsure: Wait a minute now, shocking PEA?  Is this a common practice or just a foolish Medic?
> 
> ...





Vonny said:


> I would really like to know the bla bla bla parts, something must have made her take the action she took. 3 shocks sounds like a desperate effort. What ALS was available, how long to ALS.



It was ALS that did it, according to the OP, so I'd say the wait time to ALS was zero after arrival.


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## Vonny (Mar 17, 2009)

ffemt8978 said:


> It was ALS that did it, according to the OP, so I'd say the wait time to ALS was zero after arrival.



Wonder why she did it?


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## AJ Hidell (Mar 17, 2009)

Incompetence.  Besides insanity or premeditated battery, there is no other possible explanation.


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## austinmedic77 (Mar 23, 2009)

sounds like a case of shock it till you know how to work it to me, very frightening that this person is still practicing and that per the OP statements and implication of the tone of the conversation that she doesnt a) know she did anything wrong or b) doesn't care that she did something wrong.  I would hope that this was turned over to QA/QI or medical officer for review.


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## Melbourne MICA (Mar 24, 2009)

*Zapping PEA*

Sounds like a bad idea all round -  shock the pt into aystole would be the likely outcome. Fair bit of harm there. Especially if the underlying problem is at least partially correctable by other means. 

What did the operator think the rhythm was more specifically? VF/pulseless VT are usually well taught and well recognised I would have thought.

MM


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## Melbourne MICA (Mar 24, 2009)

*Blah Blah Blah*



Vonny said:


> I would really like to know the bla bla bla parts, something must have made her take the action she took. 3 shocks sounds like a desperate effort. What ALS was available, how long to ALS.



I think you're on the money. The story may well have been..... a pt who was at one point in PEA but also got DCCS x 3 whilst in VF at another point in the arrest. Chinese whispers?

MM


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## 8jimi8 (Mar 29, 2009)

my vote is that the bla bla bla is what she shocked. and _then_ the patient was in PEA..


now then I heard an ER doc say that you could make an argument that asystole is fine VF, but we _didn't_ shock that guy.


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## bonedog (Mar 29, 2009)

What if the PEA was an SVT at a rate of 220?


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## Melbourne MICA (Mar 30, 2009)

8jimi8 said:


> my vote is that the bla bla bla is what she shocked. and _then_ the patient was in PEA..
> 
> 
> now then I heard an ER doc say that you could make an argument that asystole is fine VF, but we _didn't_ shock that guy.



My understanding of PEA is it describes a rhythm that should produce mechanical action and output but shows no signs of doing so (that you can  discern on examination). 

This may include rhythms like junctional, idioventricular (IVR a common one) or bradycardias. Suffice it to say a ventricular complex has been generated indicating there should be some calcium channel action (phase 3 of the action potential??) to contract the myocardium and produce even a small but discernible output you may not even feel pulses but hear heart sounds on auscultation.

It is also my understanding when you throw 360Joules at the myocardium it will either go into VF (which it was in previously) or asystole  or if you're very lucky and you had a good rhythm to begin with it may bounce back (not likley -maybe with some CPR of a pt with a pulse but not with electricity). 

Ambos (not just ER docs) will also twist the truth a little by looking at an asystole and calling it (very) fine VF and thus giving them an excuse to shock it in a vain hope that an output will result from a rhythm that will produce one.

It still all depends on looking at a (less than optimal) screen or a printout. There may be a fairly substantial fudge factor involved.

My guess is still that the story has gotten a bit distorted along the way. Otherwise, as some of the guys have quite rightly pointed out and assuming the story is accurate, the operator has shocked a non shockable rhythm. Very naughty for a qualified ambo.

Lets not forget a lot of dogs (and pigs I think) gave their lives to testing the original Defib machines.  We owe it to them (and our patients of course) to defib appropriate rhythms.

MM


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## Melbourne MICA (Mar 30, 2009)

bonedog said:


> What if the PEA was an SVT at a rate of 220?



That would still produce some sort of output wouldn't it? Haven't seen many pulseless SVT's. Low BP's, unconscious, poorly perfused etc for sure but not pulseless. Not sayng it can't happen or course.

MM


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## bonedog (Mar 30, 2009)

But would you not cardiovert ?


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## Ridryder911 (Mar 30, 2009)

PEA or EMD (electrical mechanical disassociation) is nothing more than electrical conditions not able to match with the mechanical or muscle fibers .. in other words the battery is firing but the engine is not turning over. 

Realistically, most clinicians will tell you the only true PEA rhythm is an idioventriular and if there is anything else it will not be long until it becomes one. 

There is no reason to "convert or defib" such rhythms since it is not the "firing" mechanism that is damaged; alike placing a pacemaker.... again it is not the battery that is broke it is between the battery and the engine. 

R/ r911


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## bonedog (Mar 30, 2009)

True Rid, iatrogenic medicine is defibrillation an idio ventricular rhythm.

I would hope though that you would be treating the fast non perfusing rhythm.


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## Melbourne MICA (Apr 1, 2009)

bonedog said:


> But would you not cardiovert ?



Absolutely - either as a PEA pt (because even an SVT should produce an output though the pt may present pulseless) or in the post arrest pt who has an extremely poor perfusion state.

The idea being to produce the best electrical circumstances to produce an  output most conducive to good tiisue and myocardial perfusion (which is of course ideally sinus rhythm). 

In the meantime other issues affecting output need addressing. So whether its inotropy or other means to improve contractility or BP you have to address these as well. 

The issue is multi-factorial and rarely ever straightforward. 

MM


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## Melbourne MICA (Apr 1, 2009)

Ridryder911 said:


> PEA or EMD (electrical mechanical disassociation) is nothing more than electrical conditions not able to match with the mechanical or muscle fibers .. in other words the battery is firing but the engine is not turning over.
> 
> Realistically, most clinicians will tell you the only true PEA rhythm is an idioventriular and if there is anything else it will not be long until it becomes one.
> 
> ...



I like the metaphor but structural events can produce this state like a cardiac tampanade, the hyper- inflated asthmatic or other conditions that compromise pre-load/afterload. So whilst oxygenation of functional pacemaker tissues continues they will fire even if no output occurs - (which of course is a downward spiral to arrest anyway).

The severe asthmatic may well present with sinus tach or (more likely) a sinus or other brady (pre-arrest) as they become profoundly hypoxic. This qualifies as a PEA. The presenting problem is just returning enough blood to the heart during diasystole. For all intents and purposes there is nothing wrong with their heart it's just constricted by the hyperinflation. So they go into a PEA then full arrest, then die.

IVR as an "escape" rhythm like junctional is often generated when the optimal pacemaker site is non-functional (for whatever reason) so an alternative pathway is needed to generate a QRS and hopefully LV contraction and output. It all depends on both functional pacemaker tissue and perfusion with oxgenated blood of pacemaker tissue. It also depnds upon a myocardium that is still able to mechanically produce and ouput. LVF is a good one for cardiac related PEA's. Stuffed myocardium (Starlings stuff), but working pacemaker sites>>>>>PEA.  

At least that's my understanding. 

MM


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## Melbourne MICA (Apr 1, 2009)

*Correction*

I was reading what I have written and I'm not advocating syncing/defibbing a pulselss pt - it's VF or VT according to the guidelines. You would be using CPR and inotropes to improve/produce venous return and output as astarting pt. 

A pt who becomes completely pulsless will not likely be in SVT to begin with. Confusing the issue sorry but its complicated to begin with I guess. Any wonder the ILCOR guidelines have changed so much over the years.

In a pt who has an SVT I would be suspecting an output is there to begin with suffice it to say.

MM


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## bonedog (Apr 1, 2009)

A PEA with a rate greater than 160 should be defibrillated-immediately.

If you were dealing with a low out put SVT or one with ischemic chest pain , associated pulmonary edema and or decreased LOC you would cardiovert. 

This is why the narrow complex PEA with a dangerously high rate should have an attempt at cardioversion, in this case un-synchronized.

Rid do you have any anecdotal evidence when using vasopressin with PEA?

I entered many patient's into the TPA in PEA study, got perfusing rhythms back on three, none survived to discharge.


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## 8jimi8 (Apr 1, 2009)

bonedog said:


> A PEA with a rate greater than 160 should be defibrillated-immediately.
> 
> If you were dealing with a low out put SVT or one with ischemic chest pain , associated pulmonary edema and or decreased LOC you would cardiovert.
> 
> ...



Sorry what does TPA stand for in this instance?


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## Melbourne MICA (Apr 1, 2009)

bonedog said:


> A PEA with a rate greater than 160 should be defibrillated-immediately.
> 
> If you were dealing with a low out put SVT or one with ischemic chest pain , associated pulmonary edema and or decreased LOC you would cardiovert.
> 
> ...



We have a guideline for accelerated idioventricular rate >100 which is of course to treat it as VT so no worries with defib. We also have a PEA gudeline which is to bsacially treat it as an non VF/VT arrest using CPR/drugs only. 

Do your guidelines allow defib of any PEA with a monitored rate above 160/min?

MM


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## bonedog (Apr 1, 2009)

TPA-Tissue Plasminogen activator... an older lysis drug. The hypothesis of the study was that if the PEA was caused by thrombosis (either coronary/ischemic or large PE, lysis would treat the cause)

MM, protocols do allow defibrillation of PEA's 160 or greater. Of course as you noted in a previous posting,it is most appropriate to treat the cause. IF it is a sinus rhythm, defibrillation would be iatrogenic, however if you suspect cardiac/primary arrythmia, then treat as such.


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## daughertyemta (Apr 5, 2009)

I seen ER docs do it as a last ditch effort, even on asystole.  Does it work..Ive never seen it...But a medic I know swears he shocked asystole one time as a last ditch and it worked~!  So who knows...Stick to what you know and have learned.  Otherwise you look like a fool!


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## Melbourne MICA (Apr 5, 2009)

*What works and doesn't work*

I think the changes to the ILCOR guidelines reflect a serious amount of detailed analysis and our approach is now getting very specific so the empahsis on reperfusion strategies with boxed defibs attempts has proven to be key. 

Whilst the myocardium still has little life left in it our steps have the best chance of success. So its not the end of the story but rather a waypoint in the process.

Asystole in a pt on the other hand is generally and more often than not, an end point rather than an early acute step in the process. This is well understood in studies going back many decades. A completely depolarised myocardium showing asystole (in at least 3 leads) will not respond to Defib - so says the evidence. So we keep the ACLS/CPR going.

Occult VF with the appearance of asystole is also well understood but I guess its still up to the operator to identify it. I seriously doubt the algorhythm in an AED for instance, would be sensitive enough to pick it but a keen eye may well do so.

There is also a bit of a fudge factor involved I suspect and in the absence of much hope the view arises "to give things a go anyway - the pt can't get any worse" - in other words the old "last ditch effort".

In PEA there is clearly a little life left in the myocardium - A waypoint. So there are far more alternatives to be indulged like syncing and also a larger window of opportunity ( - but not much larger!!!). 

Thats the way I look at it. 

MM


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## bonedog (Apr 5, 2009)

MM are you guys doing any post resuscitation hypothermia Tx?


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## Ridryder911 (Apr 5, 2009)

Remember, PEA is a condition *NOT* a rhythm. One should emphasizing the cause of why the patient is presenting this. Aystole is a terminal rhythm and more and more research is beginning to demonstrate there is poor outcomes hence the reasoning of stopping resuscitation measures, when verified. 

I am hopeful for hypothermic resuscitation as an old provider realizing the differences in cellular metabolism in death of hypothermic and normal temperature. The problem I foresee is the continuation of this within the hospital setting. Yes, most have coolant pads and other such equipment, but since this is so new and in comparison the research is still out on how successful it is; I doubt we see a 100% change for some time. 

R/r 911


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## reaper (Apr 5, 2009)

Rid,

We are starting our post ROSC ICE program next month. We were to start it a few months back, but it has taken longer to get the major hospitals on board. They now have all the equipment and are already using it in house. We also have the flight service gearing up for it, so they can transport pt's that have had cooling started on them.

Our biggest hurdle was training. We had to make sure that everone in the service recieved the education on it. This was everyone from "B's" to medics.

I will let you know how it does, after a few months of doing it.


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## Melbourne MICA (Apr 5, 2009)

*Rich*



bonedog said:


> MM are you guys doing any post resuscitation hypothermia Tx?



Yes we are and have been doing so for some time. The programme started out as a trial a couple of years ago and continues now as part of our resus protocol.

In an nutshell it involves cooling to 33deg C with cold Nacl, sedation with Midaz and paralysis with Panc. There is also a big emphasis on post ROSC pefusion management - in fact we are getting a new expanded guideline soon entirely dedicated to this aspect of arrests. 

We're getting very good resus numbers - don't quote me but if I remember correctly our survival to hospital numbers for arrest pts are now 31%. New ILCOR plus aggressive post ROSC Mx and maybe cooling is producing good outcomes.

MM


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## Melbourne MICA (Apr 5, 2009)

Ridryder911 said:


> Remember, PEA is a condition *NOT* a rhythm. One should emphasizing the cause of why the patient is presenting this. Aystole is a terminal rhythm and more and more research is beginning to demonstrate there is poor outcomes hence the reasoning of stopping resuscitation measures, when verified.
> 
> I am hopeful for hypothermic resuscitation as an old provider realizing the differences in cellular metabolism in death of hypothermic and normal temperature. The problem I foresee is the continuation of this within the hospital setting. Yes, most have coolant pads and other such equipment, but since this is so new and in comparison the research is still out on how successful it is; I doubt we see a 100% change for some time.
> 
> R/r 911



Its a good point about the hospital side Ryders. 

Our "RICH"  - (rapid infusion of cold Hartmanns) trial was botched by the hospitals who often failed or forgot to continue the cooling process for the required period. 

As far as the EMS part went our numbers were spot on and the pt %'s looked good. So now the hospitals have had to start their own part of the trial again. Our cooling as I said to Bonedog is now part of the guideline.

I guess we'll see whether the combined programmes (as it should have been originally) will produce real improvements in neuro scores for the pts.

Lets face it - looking at the way EMS is portryaed by some doctors and politicians- "the great EMS swindle" as it was called by one doc, and the way our own services are now perceiving it we need all the specific points scoring EMS/ALS/ stuff we can get. 

Though we do other great stuff, being able to tell people their family member actually has a fair chance of surviving an arrest and coming out the other end with their marbles is a huge PR bonus for us.

MM


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