ACLS question

[confusedmedstudent22]

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Not sure if right forum to post in, please move if incorrect.

Question about ACLS regarding Vfib/pulseless Vtach algorithm. I know shocks most important. But I get confused regarding the diagrams with the medications getting thrown in. I know epinephrine comes first. But usually in many diagrams it says to then use amiodarone if refractory. What does this mean exactly? Does this mean I use amiodarone in place of a second dose of epinephrine and just alternate epi and amio? Or do I just continue to throw epi and add amio as well whenever I feel X amount of epi hasn't done anything? This part was never well explained to me and I feel like I understood the rest of it.

 

[jdh71]

CPR is the MOST important. Just something to keep in mind. It's the high quality CPR that will save people. Until you get a perfusing rhythm you give epi every two minutes if you cannot get the heart back with a shock. You can ALSO give an antiarthythmic like amiodarone at that time.

In a real code stuff just kind of happens at approximate times. When I have to deal with vfib or vtach arrest I simply tell the pharmacist to get an amio bolus prepared and I just give it when it's ready regardless of the timing.

CPR until they have a rhythm or you are shocking them. Epi every two minutes. The rest of the stuff we do is largely horse**** but we do it anyway because: dying person.

 

[confusedmedstudent22]

CPR is the MOST important. Just something to keep in mind. It's the high quality CPR that will save people. Until you get a perfusing rhythm you give epi every two minutes if you cannot get the heart back with a shock. You can ALSO give an antiarthythmic like amiodarone at that time.

In a real code stuff just kind of happens at approximate times. When I have to deal with vfib or vtach arrest I simply tell the pharmacist to get an amio bolus prepared and I just give it when it's ready regardless of the timing.

CPR until they have a rhythm or you are shocking them. Epi every two minutes. The rest of the stuff we do is largely horse**** but we do it anyway because: dying person.

Oh, they definitely emphasized CPR no doubt whenever we had ACLS class. I was just confused because on the diagram it kind of implies alternating epi/amio for drugs but everyone I've seen has just repeated epi several times before amio. Thanks for the clarification!

 

[joeDO2]

this is common point of confusion. epi is given every 3-5 minutes independent of other drugs. any other drugs you add in such as amio you do without consideration for epi timing. but, as was said above, none of the drugs actually do anything. cpr, defib, and treating the cause are the only useful tools you have.

 

[zany_brainy]

.

 

[WTEngel]

Alright, I know you're probably clear on a lot of the things I'm going to say, but just hear with me for a minute...the better you organize the code at the beginning, the less trouble you will have keeping track of where you are at.

First, ensure that CPR is occurring and that it is effective.

Second, make sure that you have the monitor attached with leads and defib pads. Once this is done, clear and analyze the rhythm.

From this point on I find the following cadence to be most useful in making sure you don't forget anything: Compressions, Monitor Medication, in that order always...

So, for example, if the rhythm is VF/Pulseless VT, i would generally say something like this:

(Look at compressors) Resume compressions
(Look at monitor person) charge the monitor to 200 J, clear and defibrillate when you are ready
(Look at medication person) prepare 1 mg of epinephrine 1:10 and administer it immediately after the defibrillation.

Once I've given these orders, I'm basically free for the next two minutes while they perform high quality CPR.

After 2 minutes if they still present with VF/VT (this is what the manual classifies as refractory), I essentially repeat the process with the exact same orders, except instead of epi, I order 300 mg of amiodarone.

resume compressions, charge to 200 and shock when you're ready, prepare 300 mg amiodarone and administer it immediately after the shock.

And this repeats every two minutes, and all I have to do is keep track of what I gave last and what the rhythm is on analysis. If I follow this cadence, it spaces my epi administration at about every 4 minutes (exactly between 3 and 5) and it spaces my antidysrhythmic at about 4 minutes.

Also, remember, in the shockable VF/VT scenario, you are always alternating between a vasopressor and an antidysrhythmic. So the med cycle goes: 1 mg epi, 300 mg amiodarone, 1 mg epi, 150 mg amiodarone, 1 mg epi, (antidysrhythmic of your choice), 1 mg epi, (antidysrhythmic of your choice), and so on until there is a status change or I terminate. Remember, there is 2 minutes of high quality CPR and a defibrillation if appropriate between all of those meds.

Also, if you find yourself with an asystole/ PEA patient, simply replace the antidysrhythmic meds in the previous cadence I mentioned with a cycle of no medication, as epi is the only med we give in that algorithm (unless you are correcting an overdose, toxins or acidosis, but those are special considerations) , and again, it's timing is every 3-5 mins.

so yeah, sorry for the long winded reply, but hopefully there was something of value there for you...I was a flight paramedic for 13 years before med school and have taught all the card courses for longer than I can remember. This is by far the easiest way I've found that works in both principle and practice...

 

[alpinism]

ACLS is a joke.

The best thing you can do is unlearn that garbage.

Not to mention, the use of epinephrine during cardiac arrest is strongly associated with decreased survival and worse functional outcomes.

http://www.ncbi.nlm.nih.gov/pubmed/22436956
http://www.ncbi.nlm.nih.gov/pubmed/25465423
http://www.ncbi.nlm.nih.gov/pubmed/21745533
http://www.ncbi.nlm.nih.gov/pubmed/22115931

We do not have any studies that have been done well enough to justify using epinephrine. In fact, most of the current research suggests that it does more harm than good. We never should have let it become the standard of care without evidence.

It actually makes sense physiologically if you think about it.
Epinephrine causes coronary and cerebral vasoconstriction, which isn't very good for the brain or heart.

I was also a medic and used to teach all the alphabet soup courses. Then I started reading the literature and realized that I didn't know anything after all.
Early quality compressions and defibrillation if they have a shockable rhythm. Thats it.

 

[Rendar5]

And anti-dysrhythmics for purely rhythm issues 🙂

epi will help with ROSC, it just won't help with survival. So just because you see it work doesn't mean the above people are full of it. It's not shown to work in a meaningful way, not shown to do nothing at all, just like bicarb in most code situations (will allow transient improvement in response to pressors, won't save lives).
The only thing you need to do is separate epi and amio in your mind, two different uses in ACLS, it's not an either/or or a first/last. give em both if you need.
All I ask is that you give calcium to patient's with hyperkalemia/ESRD as hyperK is actually a rather easily reversible cause of arrest.

 

[Instatewaiter]

They are doing a randominizecd placebo controlled trial in England for out of hospital cardiac arrest- Paramedics2.