ACLS and their love affair for Atropine in bradycardia.

Aidey

Aidey

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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.
 
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
 
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.
 
* 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.
 
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.
 
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.
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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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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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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.
Click to expand...

Retrograde amnesia from Versed is a wonderful thing.
 
ArcticKat said:
Retrograde amnesia from Versed is a wonderful thing.
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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.
 
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.

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.
Click to expand...

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.....
 
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.
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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.....
Click to expand...
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.
 
triemal04 said:
due to the number of people that are required to hold and maintain that cert
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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.
 
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.
Click to expand...
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.
 
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.
Click to expand...

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?
 
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.
 
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
 
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.
Click to expand...
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.
 
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.
Click to expand...
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"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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Yes - This is me. THANK YOU for your kind words - Ken Grauer, MD
 
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