Rhythm and Resuscitation

[shelvpower]

Hi guys I have a question for all the Paramedics around here, Im still In school (last year) and have only done a level 3 first aid course. Ive been a ride along with our local ambulance service for a short while now(over weekends).

I have been learned that if a patient has no pulse that I should start CPR but what heart rhytms will lead to a pt not having a pulse? Ive performed CPR on a hit and run case and according to the paramedic the pt was in ventricular fibrillation. About 2 weeks ago we were also dispatched to a motorcycle vs tree.
We arrived on the scene to find the pt prone (face down?) We held c-spine and turned him around, the paramedic connected the ECG and it showed a rhytm (wasnt asystole) but he told me to start chest compressions while he started an IV and the emt-B bagged.
What possible rhythm could he have been in?
To cut a long story short, we managed to get a pulse and transported him to a nearby hospital where he is currently in a stable condition. On that scene I realised that I want to become a paramedic.I am planning to go and study a 4 year Emergency Medical Care (4 year full time) course next year.

 

[DesertMedic66]

Ventricular fibrillation, ventricular tachycardia, pulseless electrical activity, and asystole are the main rhythms that may present without a pulse.

 

[Brandon O]

Ventricular fibrillation, ventricular tachycardia, pulseless electrical activity, and asystole are the main rhythms that may present without a pulse.

To elaborate a bit more, ventricular fibrillation never has a pulse (it's a totally disorganized rhythm); asystole never has a pulse (the heart's doing nothing); ventricular tachycardia may or may not have a pulse, depending on how fast it is and other factors; and pulseless electrical activity is defined as ANY rhythm (even a totally healthy-looking one) which is nevertheless failing to produce a palpable pulse, usually due to problems with the heart or circulatory system.

 

[JPINFV]

As mentioned earlier, pretty much any rhythm can not have a pulse. If it looks like (or similar to) a normal rhythm, then something is preventing the heart from pumping blood. For example, if the sac around the heart (pericardium) is filled with blood, then it's possible that the pressure is preventing enough blood from entering the heart to produce a pulse. This is in addition to asystole (flat line), ventricular fibrillation (little scribble) or ventricular fibrillation (big scribbles).

 

[shelvpower]

As mentioned earlier, pretty much any rhythm can not have a pulse. If it looks like (or similar to) a normal rhythm, then something is preventing the heart from pumping blood. For example, if the sac around the heart (pericardium) is filled with blood, then it's possible that the pressure is preventing enough blood from entering the heart to produce a pulse. This is in addition to asystole (flat line), ventricular fibrillation (little scribble) or ventricular fibrillation (big scribbles).

So just for interest sake, is there a way for a paramedic to positively identify a pericardium filled with blood and if so, what procedures can the Paramedic take to treat it?

 

[Carlos Danger]

So just for interest sake, is there a way for a paramedic to positively identify a pericardium filled with blood and if so, what procedures can the Paramedic take to treat it?

Purely as a temporizing measure, you can treat it pharmacologically by using fluid loading and inotropes to increase the force of myocardial contraction. This can work well for a while in mild cases of tamponade.

If it's a more severe case, a needle can be inserted into the pericardium and fluid withdrawn. This technique is rarely successful when performed in the field, however.

 

[mycrofft]

Tamponade at an ECG website (who knew?)

AND I QUOTE:

Tamponade

Electrical alternans on the ECG
In case of tamponade, fluid collects in the pericardium. Because the pericardium is stiff, the heart is compressed, resulting in filling difficulties. This is a potentially life-threatening situation and should be treated with pericardiocentesis, drainage of the fluid. Tamponade can be the result of pericarditis or myocarditis. After a myocardial infarction a tamponade can also develop; this is called Dresslers' Syndrome. In case of cancer,increased pericardial fluid may develop. This is usually caused by pericarditis carcinomatosis, meaning that the cancer has spread to the pericardium

The ECG shows:

Sinus tachycardia
Low-voltage QRS complexes microvoltages
Alternation of the QRS complexes, usually in a 2:1 ratio. Electrical alternans can also be seen in myocardial ischemia, acute pulmonary embolism, and tachyarrhythmias
PR segment depression (this can also be observed in an atrial infarction).

http://en.ecgpedia.org/wiki/Clinical_Disorders

 

[Brandon O]

Identification is classically muffled heart sounds (good luck), JVD, and hypotension. Maybe pulsus paradoxus or mechanical/electrical alternans.

 

[mycrofft]

PEA, formerly known as Electro-Mechanical Disassociation ( EMD), will give yo a variety of EKG activity including sometimes a good looking QRS, but no actual pulse is being generated in the circulatory system. (Personally, I feel EMD is one variety of PEA because of the many etiologies for "PEA"; wait for the film at eleven).

http://en.wikipedia.org/wiki/Pulseless_electrical_activity

WIKIPEDIA's article on PEA includes etiologies, the six T's and six H's (one of them TWICE):
These possible causes are remembered as the 6 Hs and the 6 Ts.[2][3][4]

Hypovolemia
Hypoxia
Hydrogen ions (Acidosis)
Hyperkalemia or Hypokalemia
Hypoglycemia
Hypothermia
Tablets or Toxins (Drug overdose)
Cardiac Tamponade
Tension pneumothorax
Thrombosis (Myocardial infarction)(Pulmonary embolism)
Tachycardia
Trauma (Hypovolemia from blood loss)
=================================
There are conditions where some but not all pulses are palpable so the pulse can palpate (and auscultate) as irregularly-irregular, or regular with pauses, or regular with an irregular strength (mixed weak and strong pulses).

Atrial fib, my pet diagnosis, will do that, no problem. Superimposed signals for ventricular contraction will give you a "pause-THUMP" effect felt by the patient as well as the tech; the ectopic impulses will feel weak and irregular; the underlying regular rhythm will occasionally superimpose on an ectopic (see above) or just be stronger pulses felt amid the clutter.


Isn't V-Tach probably the most common?
And I'm glad someone is talking about the difference between placatory pulselessness and electrocardiographic pulselessness.

 

[Brandon O]

Isn't V-Tach probably the most common?

By the literal definition, both pulseless VT and VF would be "pulseless electrical activity," but we put them in their own category since we never expected them to have a pulse anyway.

 

[mycrofft]

Isn't V-Tach probably the most common?
And I'm glad someone is talking about the difference between placatory pulselessness and electrocardiographic pulselessness.

"Placatory"? Someone take my Spellcheck….please.
Make that "palpatory"...

(Without the elipsis, it makes it into "placatory" anyway!)