I know that jet or mil touched on this a while back, but there are some fairly subtle changes in the new ACLS guidelines. One question I have is re: monophasic vs. biphasic defib. Ive never used a biphasic, I dont think, and the algorithm we all learned was 200/300/360. Did this apply to biphasic defibs in general or was this the monophasic algorithm. Now all monophasic shocks are 360 (which I think is smart) and I just wonder if that was the way it always was. Also the breathing thing that was touched on and the increased attentiveness to not pausing CPR during drug delivery, etc.

There was a Circulation paper from 1998 about this that has settings of 150-150-150. That's what all of the biphasic defibrillators in my hospital are set to.

http://circ.ahajournals.org/cgi/content/full/97/16/1654

My question is this: apparently, the whole "shock to 200/300/360" is no longer valid, and that is for the monophasic defib that is in most hospitals? When I did ACLS two years ago, thats what we learned. Has this changed since?

Escalating stacked shocks used to be done because it was thought to reduce transthoracic impedence and improve delivery of energy to the muscle. Subsequent shocks were done at the previous effective joules, or 360J if ineffective. The biphasic shocks were also stacked (3 in a row) and escalating but I can't recall the recommended joules (I want to say 100-120-150). Our biphasic defibrillators would print out the exact joules delivered, which changed based on thoracic impedence. There was great lab and anecdotal experience supporting biphasic (and internal defibs use it) but the evidence in the real world doesn't show superiority. Does that answer the question?

I've always started at 360 joules with the monophasic....that was my practice pattern since 1998....escalating energy levels never made sense to me....the guys dead already for christ sake....turn the knob all the way clockwise...don't waste time.

I've always started at 360 joules with the monophasic....that was my practice pattern since 1998....escalating energy levels never made sense to me....the guys dead already for christ sake....turn the knob all the way clockwise...don't waste time.
When I first started as a paramedic about 30 years ago, we had defibs that would go to 500J.

When I first started as a paramedic about 30 years ago, we had defibs that would go to 500J.

Thats the most shocking piece of info I've heard all day!!! :eek:







Sorry, couldn't resist.

Speaking of ACLS, I just came from my testing for certification. I thought I knew what to do given the algorithms for the megacodes but then the medic started throwing different scenarios at me and to be honest, with some of them I just had no idea/blanked on. It kind of freaks me out knowing that I'm off to hospital in the fall. I had walked through those algorithms several times and thought I had them down...

There is variability among the biphasic units...I believe the new ACLS recommendation is to follow manufacturer instructions in determining what energy level to select.
The new ACLS monophasic algorithm is 360J for first and all subsequent shocks.
The other interesting change is that you don't shock first. CPR for approx 90 seconds, then interpret the rhythm and shock if necessary.

I've always started at 360 joules with the monophasic....that was my practice pattern since 1998....escalating energy levels never made sense to me....the guys dead already for christ sake....turn the knob all the way clockwise...don't waste time.


LOL, old school.

BTW, i've enjoyed your posts on the military M,md. Thanks I'm staying away from there for now because of them.

There is variability among the biphasic units...I believe the new ACLS recommendation is to follow manufacturer instructions in determining what energy level to select.
The new ACLS monophasic algorithm is 360J for first and all subsequent shocks.
The other interesting change is that you don't shock first. CPR for approx 90 seconds, then interpret the rhythm and shock if necessary.


that's only if they've been down 4-5 minutes prior to resuscitation (ie no CPR for 4-5 minutes).

Then you'd do 5 cycles or 2 minutes of 30:2 compressions:ventilations and then shock.

If you witness it or you're in the hospital and they've had immediate care its shock immediately.

later

There is variability among the biphasic units...I believe the new ACLS recommendation is to follow manufacturer instructions in determining what energy level to select.
The new ACLS monophasic algorithm is 360J for first and all subsequent shocks.
The other interesting change is that you don't shock first. CPR for approx 90 seconds, then interpret the rhythm and shock if necessary.

360 J for monophasic
150-200 J for biphasic truncated exponential waveforms
120J for biphasic rectilinear
200 if not sure of type of biphasic

now if someone could please give me a breif interpretation of what a biphasic truncated exponential waveform or rectilinear I would be all set. I'm thinking if it is biphasic I am going for the 200J.