ACLS and their love affair for Atropine in bradycardia.

[ekgpress]

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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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

 

[LondonMedic]

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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.

 

[PFD2171]

Atropine

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

 

[ekgpress]

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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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

 

[mtngael]

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.

 

[WTEngel]

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...

 

[ekgpress]

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.

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 ....

 

[DV_EMT]

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)

 

[WTEngel]

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

 

[Aidey]

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.

 

[Handsome Robb]

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

 

[ekgpress]

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).

 

[DV_EMT]

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?

 

[ekgpress]

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.

 

[fast65]

* 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: