# ACLS and their love affair for Atropine in bradycardia.



## Aidey (Aug 25, 2011)

WTF? I'm getting ready to recert my ACLS and in the pre-test there are several scenarios involving patients with symptomatic bradycardia and 3rd degree blocks. ACLS insists that giving 0.5mg atropine is the first line of treatment.

I was under the impression that if someone was significantly symptomatic (ALOC, etc) pacing was the first line treatment, not atropine.


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## emtpche (Aug 25, 2011)

Just had a class and it is atropine for all bradycardias.  Not sure of the logic of giving atropine to a 3rd degree, wasting time I'd go straight with pacing. Can using a pressor as well


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## Chief Complaint (Aug 25, 2011)

During my ACLS course several months back we were taught that the first line treatment is pacing in the presence of a high degree block.


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## systemet (Aug 25, 2011)

* Pacing is not always immediately available in every clinical setting.

* Humane patient care often requires sedation prior to TCP, which provides a window of opportunity to trial atropine.

* There's been evidence accumulating that there's a greater vagal innervation of the ventricles than previously beleived (although I agree that atropine is unlikely to be beneficial in infranodal block).

* Junctional escape pacemakers in the AV node may be atropine-responsive.  The 3rd degree AV block secondary to AV nodal ischemia is relaitvely common in right coronary artery occlusion.


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## Aidey (Aug 25, 2011)

IV access is not always immediately available in every clinical setting. 

My issue isn't that atropine was being suggested, but that it was the first line treatment in every single scenario, including the one with the unconscious patient. If I've got a patient who is in a 3rd degree block and is unconscious with no BP they are getting paced immediately. 

Adenosine vs cardioversion is based on patient condition, why isn't atropine vs pacing? Seems a little silly.


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## Shishkabob (Aug 25, 2011)

I actually ran in to this situation a month ago.  We were called to a local clinic for an unresponsive patient in a car.  We get there to find out they took the patient inside.


I go in and the 3 nurses and doctor were running around like they lost their minds, the patient was in peri-arrest.  Unconscious, not breathing, no easily palpable pulse, nurse stated manual bp was 50/p.  I looked at the monitor they had on, saw a 3rd degree blocked and called it that.  The doc said he agreed and told a nurse to push atropine.  Atropine.  On a patient that was literally dying infront of them.   Nothing else had been done for the patient except for a 20g IV.



I slapped on combo-pads and started pacing, not wanting to wait while the doctor played around with atropine.

I don't mind trialing atropine on a conscious bradycardic patient... but in a peri-arrest situation with an obvious 3rd deg block, I'm not going to waste time.





systemet said:


> * Humane patient care often requires sedation prior to TCP, which provides a window of opportunity to trial atropine.



I don't care if you're in pain for a few minutes if I'm doing something that is actively keeping you alive.


We'll worry about the sedatives once you're stable.


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## DESERTDOC (Aug 25, 2011)

Atropine does have it's place.  But its place is not in the setting of the symptomatic patient coupled with 3rd Deg. blocks or 2nd Deg. type II, or any other truely symptomatic bradycardia .  If they are awake and mildly unstable, I might try a round of Atropine.  Other than that, they are getting paced.

If the pacer does not capture, there is Atropine, and Dopamine.

If you use Midazolam and cannot start a line, it can be given IM for sedation.


ETA:  I also think ACLS is now for the masses, and they need to teach it so that all pass.  ACLS has been dumbed down.  I still have my first ACLS book from 1993.  It is not all warm and fuzzy.  It is black printed test with black printed pictures with TONS of chemistry and biology in it, and it uses big words.  And people really failed the course.


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## ArcticKat (Aug 25, 2011)

Linuss said:


> I don't care if you're in pain for a few minutes if I'm doing something that is actively keeping you alive.
> 
> 
> We'll worry about the sedatives once you're stable.



Retrograde amnesia from Versed is a wonderful thing.


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## Aidey (Aug 25, 2011)

ArcticKat said:


> Retrograde amnesia from Versed is a wonderful thing.



That is EXACTLY what I thought, lol. I figure I've got 2-3 minutes the patient isn't going to remember that I can use to get them stable before the first Versed dose.


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## omak42 (Aug 25, 2011)

DESERTDOC said:


> Atropine does have it's place.  But its place is not in the setting of the symptomatic patient coupled with 3rd Deg. blocks or 2nd Deg. type II, or any other truely symptomatic bradycardia .  If they are awake and mildly unstable, I might try a round of Atropine.  Other than that, they are getting paced.
> 
> If the pacer does not capture, there is Atropine, and Dopamine.
> 
> ...



Funny that you mention this as there has been talks of having an "Advanced ACLS" course for those healthcare providers that need to know more than just your basics.  Not sure if this is an AHA thing or just the training centers that I am affiliated with.....


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## triemal04 (Aug 26, 2011)

DESERTDOC said:


> ETA:  I also think ACLS is now for the masses, and they need to teach it so that all pass.  ACLS has been dumbed down.  I still have my first ACLS book from 1993.  It is not all warm and fuzzy.  It is black printed test with black printed pictures with TONS of chemistry and biology in it, and it uses big words.  And people really failed the course.


ACLS is extraordinarily dumbed down compared to what it used to be, for many reasons, but largely (based on my own experience, whatever that's worth, and a guess) due to the number of people that are required to hold and maintain that cert, and the horrible way that AHA wants it to be taught.

Several years back I went through the full course instead of a refresher to see what new things I could learn.  I literally walked away from that class wanting to vomit (due in part to a hangover but that's another story).  After talking with the instructor I was told that AHA has the course set up so that the "instructor's" major role is to push play and let a video run, along with a couple parts where they will actually lead the class in a pseudo-mega code and Q/A session...that's it.  Granted, this will vary if you can find a good class, but for one filled with people who have never practised that type of medicine, and likely never will beyond an assisting role (physical therapist, pharmacist, couple scrub nurses and the like) but are taking it because they are required...unfortunately makes sence.  It really is a merit badge now, and, if you can't find a class where you've vetted the instructor beforehand, not worth taking.


omak42 said:


> Funny that you mention this as there has been talks of having an "Advanced ACLS" course for those healthcare providers that need to know more than just your basics.  Not sure if this is an AHA thing or just the training centers that I am affiliated with.....


It's called ACLS for Experienced Providers (ACLS EP)...from what I've heard it's kind of the same as the above; find a good class and it's very much worth it...find a not so good one and it's a merit badge.


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## Shishkabob (Aug 26, 2011)

triemal04 said:


> due to the number of people that are required to hold and maintain that cert



This is what annoys me.  Most of the people taught ACLS don't need ACLS, as they won't be running arrests... ever.  Physicians, Paramedics, NPs/PAs and critical care nurses really are the only ones that will ever be running an arrest or peri-arrest.



EMTs don't need ACLS, so I don't understand why your average RN/RT/Rad tech/etc need it.  They will never be in the decision making position running a code.  


On my average arrest, it's me as the lone Paramedic, my EMT, and then a bunch of first responders.  We do just fine having a single ACLS provider on scene.


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## triemal04 (Aug 26, 2011)

Linuss said:


> This is what annoys me.  Most of the people taught ACLS don't need ACLS, as they won't be running arrests... ever.  Physicians, Paramedics, NPs/PAs and critical care nurses really are the only ones that will ever be running an arrest or peri-arrest.
> 
> EMTs don't need ACLS, so I don't understand why your average RN/RT/Rad tech/etc need it.  They will never be in the decision making position running a code.
> 
> On my average arrest, it's me as the lone Paramedic, my EMT, and then a bunch of first responders.  We do just fine having a single ACLS provider on scene.


This is hearsay, so take it with a grain of salt, but what a couple of the people in that particular class said was they needed it because: A)JCAHO required it (maybe I suppose though I don't fully buy that depending on the position), B)their employer required it to decrease liability, C) it would make them more appealing to potential employers.  Either way, what happens is the same thing that has/is happening to paramedic classes; more people want the cert than actually need it and are willing to pay, so someone steps in to provide it for them, which eventually leads to a dumbing down of the content, and you get left with a cert that is, unfortunately, meaningless.


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## systemet (Aug 26, 2011)

Aidey said:


> IV access is not always immediately available in every clinical setting.
> 
> My issue isn't that atropine was being suggested, but that it was the first line treatment in every single scenario, including the one with the unconscious patient. If I've got a patient who is in a 3rd degree block and is unconscious with no BP they are getting paced immediately.
> 
> Adenosine vs cardioversion is based on patient condition, why isn't atropine vs pacing? Seems a little silly.



Yeah, I guess the point I was trying to make was that if you're going to sedate prior to initiating TCP that giving atropine is probably reasonable.  Perhaps it was unnecessary to state that.

I haven't recerted to the new guidelines.  If they're saying atropine before pacing in the critically unstable patient, I'm suprised.  Are they then recommending that you defer pacing until after IV placement?  Or is this just in the situation where you already have a patent IV?


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## Aidey (Aug 26, 2011)

I haven't actually taken the class yet, I was just doing the pre-test. In every single question about bradycardia treatment the correct answer was atropine, no matter how unstable the patient in the scenario was.


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## MrBrown (Aug 26, 2011)

Atropine in 0.6mg doses prn if effective with no maximum dose

If unresponsive to atropine, adrenaline drip

If unresponsive to adrenaline drip, give morphine+low dose ketamine and pace


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## LondonMedic (Aug 26, 2011)

Linuss said:


> This is what annoys me.  Most of the people taught ACLS don't need ACLS, as they won't be running arrests... ever.  Physicians, Paramedics, NPs/PAs and critical care nurses really are the only ones that will ever be running an arrest or peri-arrest.
> 
> 
> 
> ...


The ALS qualification in the UK and Europe is similar, it's a broad course of first principles designed for anyone from junior doctors to consultants and nurses to ODPs. It covers the algorithms well but fails to get into the details and doesn't answer the difficult questions.

The idea, apparently, is that everyone who might be involved in an ALS arrest should know the playbook and have an idea of what's coming next and what might be needed.

The problem of course is that the people who will be running these arrests - the middle grade doctors and paramedics (although they usually do their own in-house training) - need to know and understand a lot more than just the algorithms. But there's no training except experience for that.


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## ekgpress (Aug 31, 2011)

*Atropine for 3rd Degree AV Block (KG)*



Aidey said:


> WTF? I'm getting ready to recert my ACLS and in the pre-test there are several scenarios involving patients with symptomatic bradycardia and 3rd degree blocks. ACLS insists that giving 0.5mg atropine is the first line of treatment.
> 
> I was under the impression that if someone was significantly symptomatic (ALOC, etc) pacing was the first line treatment, not atropine.


-----------------------
"As with everything - there needs to be clinical correlation to answer this. The thought on Atropine as "1st line treatment" is that it is usually pretty easy to give quickly - therefore still to be considered first.  That said - atropine has its best chance to work if the block is at the AV nodal level (narrow QRS) - and is much less likely to work for lower level block.  3rd degree AV block may EITHER be at the level of the AV node (narrow QRS) or below (wide QRS). I'd clearly be in favor of trying atropine if the patient was not in extremis, needed treatment and had a narrow QRS form of 3rd degree block. I'd be less inclined to try it if the block was truly complete with a wide (ventricular escape) QRS. The other part of the question relates to availability of pacing in the situation at hand - IF immediately available, then clearly it would seem to be preferred for complete AV block with a wide QRS that is in need of treatment.  Hope that helps - Ken Grauer, MD


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## systemet (Aug 31, 2011)

ekgpress said:


> Hope that helps - Ken Grauer, MD



I'm assuming this is the same Ken Grauer who wrote "The ECG Pocket Brain"?

I've just got to say that I bought a copy, and thought it was really well designed and presented.  Thanks!

http://www.amazon.com/ECG-Pocket-Ex...MSOU/ref=sr_1_3?ie=UTF8&qid=1314792585&sr=8-3


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## ekgpress (Aug 31, 2011)

Yes - This is me.  THANK YOU for your kind words - Ken Grauer, MD


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## ekgpress (Aug 31, 2011)

LondonMedic said:


> The ALS qualification in the UK and Europe is similar, it's a broad course of first principles designed for anyone from junior doctors to consultants and nurses to ODPs. It covers the algorithms well but fails to get into the details and doesn't answer the difficult questions.
> 
> The idea, apparently, is that everyone who might be involved in an ALS arrest should know the playbook and have an idea of what's coming next and what might be needed.
> 
> The problem of course is that the people who will be running these arrests - the middle grade doctors and paramedics (although they usually do their own in-house training) - need to know and understand a lot more than just the algorithms. But there's no training except experience for that.


---------------------------------------------------------
I believe that the more you know - the better you are in your particular role (even if it is not a "decision-making role" at the scene). As stated - you get a much better idea of what is needed and what may be coming next - AND you may HELP whoever the decision-maker is by presenting suggestions (of course requires receptivity to your input by the "decision-maker").  Running a code is a team effort - and the more educated you become, the better a team member you will be - Ken Grauer, MD


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## LondonMedic (Aug 31, 2011)

ekgpress said:


> ---------------------------------------------------------
> I believe that the more you know - the better you are in your particular role (even if it is not a "decision-making role" at the scene). As stated - you get a much better idea of what is needed and what may be coming next - AND you may HELP whoever the decision-maker is by presenting suggestions (of course requires receptivity to your input by the "decision-maker").  Running a code is a team effort - and the more educated you become, the better a team member you will be - Ken Grauer, MD (ekgpress@mac.com)


I see no problem with anyone who can understand the content doing the course, the issue I see is that there is no Advanced advanced course for those who need to push a bit further.


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## PFD2171 (Aug 31, 2011)

*Atropine*

Please don't forget that ACLS and PALS are not written for pre hospital providers only.


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## ekgpress (Aug 31, 2011)

LondonMedic said:


> I see no problem with anyone who can understand the content doing the course, the issue I see is that there is no Advanced advanced course for those who need to push a bit further.



---------------------------------------------------
At the risk of mentioning my own material - I believe it is an answer "for those who need (want) to push a bit further" - ACLS-2011-PB - ACLS: Practice Code Scenarios - ECG-2011-PB - Ken Grauer, MD


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## mtngael (Oct 27, 2011)

I know this is an old thread, but thought it was worth reviving. 

There used to be talk of developing an ACLS (though not necessarily by that name) specifically for EMS. I'm not sure if that's still being discussed on any fronts.

From my perspective, as both a provider and an instructor/training coordinator, I have a real problem with the continued mandate of a class that has essentially become a glorified CPR class. This is especially difficult to swallow as the cost of the program climbs inversely to the amount of actual knowledge or skills delivered. 

I think it's time for an alternative.


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## WTEngel (Oct 27, 2011)

I know this is an old thread, but since I saw it, and nobody seemed to address the issue directly, here is the quoted text from Circulation regarding atropine use in high degree heart blocks:

"Avoid relying on atropine in type II second-degree or third- degree AV block or in patients with third-degree AV block with a new wide-QRS complex where the location of block is likely to be in non-nodal tissue (such as in the bundle of His or more distal conduction system). These bradyarrhythmias are not likely to be responsive to reversal of cholinergic effects by atropine and are preferably treated with TCP or -adrenergic support as temporizing measures while the patient is prepared for trans- venous pacing."

The issue is that very few people seem to be able to accurately identify high degree heart blocks on a consistent basis. So for ease of teaching and for ease of practical application on the part of the provider, the current algorithm lists that once atropine has been trialed and no rise in rate is noted, the provider should move immediately to TCP, Dopamine, or Epi, whichever they have most ready access to and prefer. 

It also states that providers in the course should be warned of the likelihood that atropine may be ineffective in high degree heart blocks or instances where cardiac transplantation has been performed, and should preferably rely upon TCP or beta adrenergic support while TVP is being organized for implementation.

So the bottom line is that instructors are expected to inform students that atropine will most likely be ineffective in these cases, however it is up to the provider to recognize the specific instances in question, and use the ACLS guidelines appropriately. Due to the large number of people who will likely miss a high degree heart block on initial analysis, AHA places a one time trial of atropine in the algorithm, with the next step being to initiate TCP or b-adrenergic support should the atropine be ineffective. 

I will also mention that AHA mentions that atropine should not delay TCP in the patient in-extremis, or severely symptomatic. I find it interesting that they mention this in about two sentences in passing in the journal, but have no mention of it anywhere in the curriculum. 

Let's be honest, how many instructors actually read the journal? The pros do, the amateurs do not...


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## ekgpress (Oct 27, 2011)

mtngael said:


> I know this is an old thread, but thought it was worth reviving.
> 
> There used to be talk of developing an ACLS (though not necessarily by that name) specifically for EMS. I'm not sure if that's still being discussed on any fronts.
> 
> ...


Unfortunately - ACLS has become a big (money-making) business - ergo mandating use of expensive course materials regardless of the quality and experience of those who are putting on the course. In the "old days" - we were able to tailor our courses for the needs of participants (ie, special attention given to certain topics for our physician residents taking the course .... ). I don't know an answer to your concern - other than suggesting perhaps you might give a supplemental class that goes beyond the AHA core ....


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## DV_EMT (Oct 28, 2011)

Atropine is what we always give for symptomatic bradycardia here at the hospital. But otherwise, we just usually go check and see how the patient is doing (usually their sleeping)


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## WTEngel (Oct 28, 2011)

Symptomatic bradycardia combined with poor perfusion I should say...


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## Aidey (Oct 28, 2011)

WT, you touch on my issue with the test/program. On every test question or scenario the correct answer is atropine first, even if the pt is in extremis.


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## Handsome Robb (Oct 28, 2011)

Aidey I had the same question when I took the new guidelines. Te questions specify having an IV established. That's the reasoning behind trialing the atropine. It's stupidly worded questions. 

The algorithms say for symptomatic bradycardia with hypotension go straight to paing


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## ekgpress (Oct 28, 2011)

DV_EMT said:


> Atropine is what we always give for symptomatic bradycardia here at the hospital. But otherwise, we just usually go check and see how the patient is doing (usually their sleeping)



Atropine is the drug indicated for "symptomatic bradycardia". That said - it is important to be aware of when atropine is or is not likely to work.  It works best in cases of excess parasympathetic tone (ie, during the early hours of acute inferior MI).  It works best for narrow QRS rhythms (conduction defect at level of AV node). It is far less likely to work with Mobitz II and/or wide QRS rhythms (conduction defect likely to be below the AV node). Atropine shouldn't be used if the patient doesn't have true "symptomatic bradycardia" (will often not be needed for that patient who slows down during sleep . . . . for whom evaluation for possible sleep apnea may need to be considered).


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## DV_EMT (Oct 28, 2011)

ekgpress said:


> Atropine is the drug indicated for "symptomatic bradycardia". That said - it is important to be aware of when atropine is or is not likely to work.  It works best in cases of excess parasympathetic tone (ie, during the early hours of acute inferior MI).  It works best for narrow QRS rhythms (conduction defect at level of AV node). It is far less likely to work with Mobitz II and/or wide QRS rhythms (conduction defect likely to be below the AV node). Atropine shouldn't be used if the patient doesn't have true "symptomatic bradycardia" (will often not be needed for that patient who slows down during sleep . . . . for whom evaluation for possible sleep apnea may need to be considered).



Agreed! Usually Pt's who are BBB patients or Pt who are entering IVR (idioventricular) have the prolonged QRS with interupted SA-AV nodal conduction. 

..But what about patients with AICD Pacemakers whos lower limit is not regulated? technically they also have a widened QRS complex due to their pacemakers. Also what about Bi-Ventricular Pacers/Dual Chamber pacers? What if the patients underlying rhythm is Slow AFIB?


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## ekgpress (Oct 28, 2011)

DV_EMT said:


> Agreed! Usually Pt's who are BBB patients or Pt who are entering IVR (idioventricular) have the prolonged QRS with interupted SA-AV nodal conduction.
> 
> ..But what about patients with AICD Pacemakers whos lower limit is not regulated? technically they also have a widened QRS complex due to their pacemakers. Also what about Bi-Ventricular Pacers/Dual Chamber pacers? What if the patients underlying rhythm is Slow AFIB?



IF the patient has a pacemaker - then no need for Atropine. On the other hand, an AICD without lower rate regulation won't be protected. The "concept" that I would use remains the same - namely that Atropine is the drug to consider first for symptomatic bradycardia. Whether or not the QRS is wide simply gives us a clue as to the likelihood that Atropine will work - with the point being that if the level of the conduction defect is at the AV node, the chance that Atropine will work is much greater than if it is below the level of the AV node. That said - it is possible for a patient with for example a Mobitz I 2nd degree AV block (that is typically block at the AV nodal level) to have a wide QRS because in addition the patient has a bundle branch block .... in which case, even though the QRS is wide - the Atropine is more likely to work. Similarly - it is possible for the QRS to be narrow on rare occasion with a Mobitz II block - in which case the Atropine will be less likely to work. IF a patient has slow A Fib (even with a wide QRS) - then the level of conduction system disease is still likely to be high (either at the sinus node from sick sinus syndrome - or the AV node) - in which case Atropine may be effective to temporarily increase the ventricular response (though the response to Atropine is far from guaranteed if the reason for slowing is sick sinus). Ultimately - a permanent pacer may be needed.  BOTTOM LINE: There is NO simple answer that I know of, and "no one size fits all". Even if Atropine is less likely to work - it is often reasonable to try it if the patient has symptomatic bradycardia since it is usually easy to administer, and may "buy time" while other measures (pacing; catechol infusion) are contemplated. But Atropine is NOT benign (may cause unchecked tachycardia with consequences of its own) - so it should not be used in the patient who is tolerating the slow rhythm without significant symptoms.  Hope the above is helpful.


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## fast65 (Oct 28, 2011)

systemet said:


> * Humane patient care often requires sedation prior to TCP, which provides a window of opportunity to trial atropine.



I just wanted to address this real quick. While I agree that sedation is definitely nice if you have time, if the situation is severe enough to where I'm going straight to pacing, then I'm not going to delay my treatment a couple of minutes to provide sedation. Of course I'll consider sedation after I have everything setup, but my first priority is to stabilize the patient.

 I believe Kelly Grayson actually tested out the pacers from Zoll and Lifepack on himself and found that it's pretty tolerable, not comfortable, but not excruciating. But I could be wrong. h34r:


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