# Paramedic Re-Entry Dynamic cardiology Question



## irishnyc (Oct 13, 2012)

Greetings Everyone,

I am currently in the Paramedic Re-Entry Program (been out of EMS for 3 years and realized I missed the work) This is my first posting here, so naturally I come bearing a question. I have satisfied all requirements for NREMT, with exception of the psychomotor exam. 

So here goes, in the dynamic cardiology station (ACLS has changed somewhat drastically in 3 years) lets say we have ROSC as Sinus Bradycardia (from the previous cardiac arrest simulation in which Amidorone 300mg was administered for V. Fib) for the final rhythm with VS being pulse 50 bpm & BP of 90/40..... For testing purposes... should I treat sinus brady (Post-ROSC) w/ .5-1mg Atropine or commence with rapid infusion Amiodorone (150 mg over 10 min, since the simulated Pt converted) with 1-2 L of NS and Dopamine drip 5-10 mcg/kg/min? I look forward to your guys input and thanks  



Thanks


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## Handsome Robb (Oct 13, 2012)

I'd go straight to pacing, just my opinion though. The pt is "symptomatic" (read: unconscious, hypotensive and post-arrest) and bradycardic, you could say you'd trial the atropine while setting up to pace but if you're in a ROSC scenario you're already set up to pace so.... If you can take the few seconds a 12-lead prior to pacing would be good as well. VF/VT arrest makes me think cardiac etiology, just another reason to go pacing over atropine. The literature and opinions seem to vary widely about atropine in the presence of an AMI.

Amio drip as well along with a NSS bolus and if they remain hypotensive after fluids and the pacing then jump to pressors. 

I'm sure someone with more experience and who's smarter than me will chime in and disagree with me.


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## NomadicMedic (Oct 13, 2012)

The only reason I'd disagree would be if it was an ACLS testing station. Then it would be "atropine first". (Damn AHA...)

Otherwise, I'd move right to the pacing, hypothermia, dopamine.


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## Handsome Robb (Oct 14, 2012)

n7lxi said:


> The only reason I'd disagree would be if it was an ACLS testing station. Then it would be "atropine first". (Damn AHA...)
> 
> Otherwise, I'd move right to the pacing, hypothermia, dopamine.



I thought ACLS taught to trial atropine while you setup to pace? Post-arrest I feel like you'd already be setup but I do agree, for testing purposes you should verbalize that you are considering atropine.


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## Veneficus (Oct 14, 2012)

I would not give atropine or pace a post arrest patient as part of EMS care.

If I was taking an ACLS test or a test based on those guidlines, I would make sure the airway is secured by intubation, do a 12 lead EKG, and if available start theraputic hypothermia. 

Just saying...


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## Anjel (Oct 14, 2012)

NVRob said:


> I thought ACLS taught to trial atropine while you setup to pace? Post-arrest I feel like you'd already be setup but I do agree, for testing purposes you should verbalize that you are considering atropine.



Maybe push the atropine while you are turning the monitor to pace mode and setting up your numbers?

Also.... Would you still be running amiodarone as a maintenance dose? Or is that discontinued?


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## Handsome Robb (Oct 14, 2012)

Veneficus said:


> I would not give atropine or pace a post arrest patient as part of EMS care.
> 
> If I was taking an ACLS test or a test based on those guidlines, I would make sure the airway is secured by intubation, do a 12 lead EKG, and if available start theraputic hypothermia.
> 
> Just saying...



I'm interested in your reasoning. I always learn a ton from you. Why not pace a hypotensive, bradycardic ROSC patient in the field?

The protocol monster says the hypotension must be refractory to fluid resuscitation and pacing prior to moving on to pressors. Please don't eat me for using the "P" word.

Anjel, I personally would continue the amio drip but that's just my .02


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## Veneficus (Oct 14, 2012)

NVRob said:


> I'm interested in your reasoning. I always learn a ton from you. Why not pace a hypotensive, bradycardic ROSC patient in the field?
> 
> The protocol monster says the hypotension must be refractory to fluid resuscitation and pacing prior to moving on to pressors. Please don't eat me for using the "P" word.
> 
> Anjel, I personally would continue the amio drip but that's just my .02




If the patient went into cardiac arrest, even if it is not cardiac etiology, MI, CHF, etc, the inciting event was serious enough to cause failure of compensation of the heart to supply its own demand. 

In a successful resuscitation, this scenario demonstrates return of minimal homeostasis. 

atropine and pacing will increase the HR and likely contractility. Any hibernating cells will likely be finished off and you run the risk of chemically or electrically raising performance beyond what the heart can sustain and you may have them rearrest.

I would take the conservative approach prehospital, be happy with what I had, and get them to a place that can do things like PCI, IABPs, Emergent bypass, etc.

Remember this is not a pt who presented unstable because of symptomatic brady. This is a person who had complete compensatory collapse and arrested.


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## irishnyc (Oct 14, 2012)

Hey Guys,

Thanks for the input, it is greatly appreciated  The one caveat to this particualr scenario in my head is that this would be a poss. NREMT Dynamic Cardiology scenario... with that in mind, I find myself at the mercy of current AHA guidlines, by the nature of the potential testing station in which symptomatic bradycardia and ROSC may be combined in presentation but varies in treatment, especially with regards for official testing.


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## NomadicMedic (Oct 14, 2012)

I mean, let's be honest. An arrest with ROSC doesn't typically present with sinus brady as the rhythm. Normally, there is enough epi on board that it is going to be a tachy rhythm.  

If my patient had perfusing ROSC that became bradycardia, I would feel that pacing would be an appropriate treatment to keep the patient perfusing while I beat feet to a PCI facility. 

Of course my caveat is "follow the algorithms and protocols while you're in class"


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## Veneficus (Oct 15, 2012)

irishnyc said:


> Hey Guys,
> 
> Thanks for the input, it is greatly appreciated  The one caveat to this particualr scenario in my head is that this would be a poss. NREMT Dynamic Cardiology scenario... with that in mind, I find myself at the mercy of current AHA guidlines, by the nature of the potential testing station in which symptomatic bradycardia and ROSC may be combined in presentation but varies in treatment, especially with regards for official testing.



For AHA let me set your mind at ease.

You start in a tachy/brady patient then progress to VF/VT then to asystole/PEA


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