risnwb

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I've got a quick question about when to use the bradycardia vs. pea ACLS algorithms:

If you have a patient who becomes unresponsive, and your unsure if a faint pulse is present (we can say that there's no pulse), and your monitor shows sinus bradycardia or third degree block, do you follow the bradycardia algorithm and begin transcutaneous pacing immediately to correct the symptomatic bradycardia, or do you begin the PEA algorithm and initiate CPR?

Thanks!
 

risnwb

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so even if you think the bradycardia is causing the hypotension and resulting in lack of palpable pulse, you still do CPR rather than pace the patient to correct what you think is the underlying problem?
ok. thanks!
 

AegriSomnia

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I worked as a paramedic for quite sometime and am not an anesthesiologist so I may not have the perfect treatment plan. IMHO I was thinking that if you have no detectable pulse you should begin CPR and, thus, you would assume the patient to be in a PEA. You would also be giving atropine, as well as epi, as part of the treatment plan so if it is a severe bradycardia there is a good chance that it may respond to the pharmacological treatment and raise the HR and BP. If you witness this incident you may be more or less sure that the patient is in a severe bradycardia so you may be better off pacing than immediately starting CPR. You could also use U/S to check for cardiac movement for definitive proof, but you should be prepared for cardiac arrest.
 
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monchi

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If the contractions cannot generate a palpable pulse, then chest compressions. There is no circulation. Speeding up the rate of these contractions is just stepping on the gas without changing gears.
 

pgg

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More than once I've seen code-runners delay starting compressions because they weren't sure if there was a pulse or not. I've done it myself, albeit long ago pre-medschool - unresponsive apneic patient, thought he had a pulse, did rescue breathing but no compressions, ambulance arrived and they quickly determined that he was in vfib. He was almost certainly pulseless all along and I was getting my lips dirty for nothing.

IMO the risk of inappropriately delaying CPR is far higher than the risk of a cracked rib or two from compressions that might not be necessary. Symptomatic bradycardia with a questionable pulse should be treated as PEA.
 

AegriSomnia

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PEA is Pulseless Electrical Activity - a rhythm, but no cardiac output. PEA is a type of cardiac arrest, but all cardiac arrests are not PEA.
In this specific instance where there is a rhythm on the monitor and the patient is pulseless means the patient is in PEA. By using using the sentence above I wasn't implying that all cardiac arrests are PEA. So, yes, all PEAs are cardiac arrests but not all cardiac arrests are PEAs.
 

fakin' the funk

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so even if you think the bradycardia is causing the hypotension and resulting in lack of palpable pulse, you still do CPR rather than pace the patient to correct what you think is the underlying problem?
I think this was addressed, but just to be clear:

No pulse -> chest compressions, no questions asked. Time is brain and myocardium. This'll buy you 3-6 minutes to think about what's going on with the patient. Hopefully by that time you've got a monitor/defibrillator on the patient, and are oxygenating as well.

If, for example, at the next pulse check, they have a weak pulse and are bradycardic on the monitor, time to pace. But at least for the last 3-6 minutes you've been getting blood to brain at a MAP of ~60-80.
 

gasaddict54

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i think this was addressed, but just to be clear:

No pulse -> chest compressions, no questions asked. time is brain and myocardium. This'll buy you 3-6 minutes to think about what's going on with the patient. Hopefully by that time you've got a monitor/defibrillator on the patient, and are oxygenating as well.

if, for example, at the next pulse check, they have a weak pulse and are bradycardic on the monitor, time to pace. But at least for the last 3-6 minutes you've been getting blood to brain at a map of ~60-80.
this^^^^^^
 

Planktonmd

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ACLS protocols are not specifically designed for patients who are already connected to a monitor and under the immediate care of an anesthesiologist.
In the OP's example it seems he is referring to a severe bradycardia in a monitored patient where the pulse could not be felt.
In this situation you need to support the cardiac output as soon as possible which means you should star CPR while you are planning a course of action in your head to treat the bradycardia if you think that it is the cause of the problem.
Bradycardia could be a symptom of another problem like severe hypoxia, hypothermia,tension pneumothorax... that also needs to be addressed simultaneously.
It is OK to change the sequence of steps you normally do and for example: start CPR, give Atropine then go straight to pacing if you think that Bradycardia secondary to a third degree block for example is the main problem.
When you don't know what the next step should be just stick with the ACLS guidelines.
 

Idiopathic

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If the contractions cannot generate a palpable pulse, then chest compressions. There is no circulation. Speeding up the rate of these contractions is just stepping on the gas without changing gears.
not necessarily true, if you can get atrial activity out of it you can augment SV - just like pacing a post-bypass patient with a sagging pressure. can you palpate a radial pulse with a SBP of 60? doesnt mean there isnt one there that could be augmented.

hopefully there is more than one person and you can do CPR, give atropine/epi and get pads, the right answer is CPR first though