Acls algorithm question
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Anjel
Forum Angel
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I would. He is pulse less and has electrical activity.
And there isn't too much you would do about the heart block If he did have a pulse. Except treat if He was bradycardic.
Anjel
Forum Angel
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If you were to work the arrest and he ROSC. Then I would be watching that block very closely. Because it could lead to worse.
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Yes, this is treated as PEA. 2 minute cycles of CPR with 1 mg epi 1:10,000 every 3-5 minutes while working through H's and T's.
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Since I feel like beating a dead horse...
Definitely PEA. Like Anjel said, the patient is pulseless and has an organized rhythm.
Definitely PEA. Like Anjel said, the patient is pulseless and has an organized rhythm.
sirengirl
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:deadhorse:
and don't forget your airway. hypoxia is an easily correctable one of the H's and T's...
Merck
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I'd say that the short answer of yep, PEA, is the way to go for the quiz.
However, I have to say that I would find this rhythm odd for a pre-hospital cardiac arrest. Knowing the rate would be a great help (I know it's just a quiz but just for argument sake). While you probably would do well treating this as the PEA I think consideration should be given to this being a rhythm that could support a low-output state which should be investigated. I would take more than a cursory listen for HS. If this was the case perhaps TCP would be as much, if not more, effective that typical ACLS stuff. The rate would help. 20 vs 60 is a big difference. And past hx on the patient is huge as well - cardiomyopathy, dyskinesis for whatever reason (aneurysm), whatever might play a role in supporting a low output state.
That said epi will probably have an effect, we just don't want to harm either.
Granted it's all academic. So short answer yes with a but, long answer no with a maybe.
However, I have to say that I would find this rhythm odd for a pre-hospital cardiac arrest. Knowing the rate would be a great help (I know it's just a quiz but just for argument sake). While you probably would do well treating this as the PEA I think consideration should be given to this being a rhythm that could support a low-output state which should be investigated. I would take more than a cursory listen for HS. If this was the case perhaps TCP would be as much, if not more, effective that typical ACLS stuff. The rate would help. 20 vs 60 is a big difference. And past hx on the patient is huge as well - cardiomyopathy, dyskinesis for whatever reason (aneurysm), whatever might play a role in supporting a low output state.
That said epi will probably have an effect, we just don't want to harm either.
Granted it's all academic. So short answer yes with a but, long answer no with a maybe.
Just a couple of thoughts.
Rate may or may not matter.
I have seen right sided infarcts paced to death by people trying to raise rates without concern for underlying cause.
PEA means there is not a palpable pulse, which is different from no cardiac output.
While low percent ejection fractions are particularly appealing, 20% is still better than 0%. You may actually want to accept Loss of consciousness or really bad looking vital signs in the short term opposed to starting CPR. (probably one of those times when a manual BP will be more diagnostic than automated)
Playing the odds.
Since PEA is technically an arrest, and your service hasn't sprung for a pocket ultrasound to look for cardiac wall motion
the most common cause of cardiac arrest is MI. (many authorities quote 70%) you maybe looking at the best rhythm the diseased heart is capable of producing.
Perhaps it is time for protocols or med command to recognize termination of efforts out of hospital in a PEA arrest?
From the textbook stand point, any rhythm without a pulse is PEA and would be treated as such.
Yes I would fail a student in ACLS class for treated a second degree heartblock on the PEA part of the exam. The testing criteria spell out what is acceptable or not right on the exam paper. Treating low output failure is not part of the ACLS megacode.
Like I tell students. I don't believe ACLS is the tool of resuscitation experts. But, while you are here it is like church. I recite my part of the prayer and you recite yours. We all go home happy. What you do at home is your business. What you do here is mine. I suggest the path of least resistance. Say what I need to hear to check the box.
Rate may or may not matter.
I have seen right sided infarcts paced to death by people trying to raise rates without concern for underlying cause.
PEA means there is not a palpable pulse, which is different from no cardiac output.
While low percent ejection fractions are particularly appealing, 20% is still better than 0%. You may actually want to accept Loss of consciousness or really bad looking vital signs in the short term opposed to starting CPR. (probably one of those times when a manual BP will be more diagnostic than automated)
Playing the odds.
Since PEA is technically an arrest, and your service hasn't sprung for a pocket ultrasound to look for cardiac wall motion
the most common cause of cardiac arrest is MI. (many authorities quote 70%) you maybe looking at the best rhythm the diseased heart is capable of producing. Perhaps it is time for protocols or med command to recognize termination of efforts out of hospital in a PEA arrest?
From the textbook stand point, any rhythm without a pulse is PEA and would be treated as such.
Yes I would fail a student in ACLS class for treated a second degree heartblock on the PEA part of the exam. The testing criteria spell out what is acceptable or not right on the exam paper. Treating low output failure is not part of the ACLS megacode.
Like I tell students. I don't believe ACLS is the tool of resuscitation experts. But, while you are here it is like church. I recite my part of the prayer and you recite yours. We all go home happy. What you do at home is your business. What you do here is mine. I suggest the path of least resistance. Say what I need to hear to check the box.
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I completely agree with the sentiments you are expressing regarding low output rhythms, and want to echo what vene has said.
ACLS and PALS are useful for pre-hospital providers and in hospital providers for maybe the first 5-10 minutes of a code. After that, the provider (as in physician, PA, NP, etc.) gets to decide where they go. If I was the provider in this case, I would certainly explore a low output rhythm scenario while trying to increase perfusion and MOST IMPORTANTLY expediting consultation by interventional cardiology (as this is most likely a MI.)
By the time the patient has reached this point, the myocardium is likely 25-50% larger than normal, engorged, swollen, and very labile. Forcing contraction with the use of pressors or pacing on this patient needs to be weighed against what further damage you are causing compared to CPR (completely situation dependent.) The primary goal for treatment on this patient is reperfusion therapy and minimizing reperfusion injury in the short term through thoughtful use of best-practice therapies.
Alternatively, if you are a student, or for the majority of paramedics in the back of an ambulance, you provide excellent CPR and push epi every 3-5 minutes, plain and simple.
I can not think of a service out there that is going to let a field medic begin to explore low output scenarios and trouble shoot this situation (I am sure they exist somewhere, but it is such a rare occurrence). Additionally, if you think you will have time to get secondary access that is adequate for pressor and inotropes, hang and calculate you dopamine or epi drip, start it and monitor for effect without effecting the quality of basic interventions, I think you may be overstating your abilities. I have seen well trained ICU staff who do this kind of stuff day in and day out have difficulty keeping this type of situation organized, and they have quite a few more resources available.
Just a few thoughts to consider.
ACLS and PALS are useful for pre-hospital providers and in hospital providers for maybe the first 5-10 minutes of a code. After that, the provider (as in physician, PA, NP, etc.) gets to decide where they go. If I was the provider in this case, I would certainly explore a low output rhythm scenario while trying to increase perfusion and MOST IMPORTANTLY expediting consultation by interventional cardiology (as this is most likely a MI.)
By the time the patient has reached this point, the myocardium is likely 25-50% larger than normal, engorged, swollen, and very labile. Forcing contraction with the use of pressors or pacing on this patient needs to be weighed against what further damage you are causing compared to CPR (completely situation dependent.) The primary goal for treatment on this patient is reperfusion therapy and minimizing reperfusion injury in the short term through thoughtful use of best-practice therapies.
Alternatively, if you are a student, or for the majority of paramedics in the back of an ambulance, you provide excellent CPR and push epi every 3-5 minutes, plain and simple.
I can not think of a service out there that is going to let a field medic begin to explore low output scenarios and trouble shoot this situation (I am sure they exist somewhere, but it is such a rare occurrence). Additionally, if you think you will have time to get secondary access that is adequate for pressor and inotropes, hang and calculate you dopamine or epi drip, start it and monitor for effect without effecting the quality of basic interventions, I think you may be overstating your abilities. I have seen well trained ICU staff who do this kind of stuff day in and day out have difficulty keeping this type of situation organized, and they have quite a few more resources available.
Just a few thoughts to consider.
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How often do you actually get that!?! 
How often do you actually get that!?!
That is why I have to teach my people myself.
QC.
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If you want something done right, sometimes you just have to do it yourself!
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No autopulse but we do have the ALS care vent. Works great on patients in arrest but we need a different option for vented transports. Keep in mind we are primarily 911 but do IFTs for the snfs in the area since we have the monopoly on ambulance transport in the county.
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NomadicMedic
I know a guy who knows a guy.
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LUCAS device and a vent FTW.
Christopher
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A pulseless Wenckebach!? Awesome case, probably not one you'd be likely to see. If I did come across that rhythm, dollars to doughnuts they've got a good EtCO2 and you just can't feel a palpable pulse.
Given this rhythm generally supports life and rarely requires any pharmacologic intervention, my assumption is going to be that the Tank is Low and I am working a hypovolemic arrest.
I'm going to look for potential signs of internal bleeding, get some big fluid boluses on board, and check their EtCO2 early...
I'm going to go out on a limb here and say in this case...
...wait for it...
...CPR and 1mg Epi may not be helpful! (BURN THE HERETIC WITCH)
If their tank is empty, you're not pushing anything around. Rapid bolus of 1L saline, atropine in case we're working with vagotonic effects, and work to consider our many causes of that style of heart block.
Fluid, atropine (holding off on the 1mg Epi), and pacing until I can get that liter of fluid in and I can start a dopamine or epi drip.
OD? Calcium seems high on my list.
MI? Fluid to reverse cardiogenic shock, but come on... 2nd Degree AVB Type I is not a cardiogenic shock rhythm...
All in all I would place great doubts on that rhythm being a true pulseless rhythm, but worth thinking about.
Anjel
Forum Angel
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But.... What about the protocols!? They don't say all that.
I'll kidding Aside thank you for this post a lot of things "clicked".