Pulseless afib

[leviathan]

Just had a practice question on a patient with afib in the 150-180 range who was hypotensive and then went pulseless. I thought the answer was to either defibrillate (treat it similar to pulseless vtach) or sync cardiovert, and decided to go with the former answer. They wanted CPR for the answer and said you "can't shock PEA". Thoughts?

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[goodoldalky]

Atrial fib without a pulse is PEA. Therefore you are in the PEA algorithm, not the Vf/Vt algorithm, or a tachycardia algorithm, etc.. All you can do for PEA or asystole is CPR and epi, you can try atropine if you want for asystole but really at that point its not likely to matter.

 

[Doctor4Life1769]

The only shockable rhythms are VF or VT

 

[Rendar5]

pulseless = start CPR, then do whatever else is available to correct that rhythm whether it's drug or electrical therapy. even if it's VFib. the only time you would ever shock first is if you're talking to the person, they're on a monitor, they suddenly go into pulseless VFib/VTach and you have paddless/pads on them within seconds (not minutes).

 

[Farmer2DO]

I don't think this is a straight up answer. You have to look at the reasons behind the presentation.

If you came upon someone in this rhythm without pulses, then I would go down the PEA algorithm.

However, this is a patient that WAS perfusing and no longer is. Likely his problem is that the elevated HR is compromising ventricular filling. He most likely has coordinated contractions (for now), but they are too fast and weak to produce a pulse. Synchronized cardioversion may actually provide him with a chance. Epi is not going to convert him back to a perfusing rhythm.

Textbook vs. real world. Just my opinion.

 

[overthebars]

The key idea to management here is hypotension vs dead. Assuming this patient is really pulseless and unresponsive she/he needs coronary perfusion pressure before a non-VT/VF shock is considered which isn't going to happen without CPR. A premature attempt at sync'd cardioversion is a waste of really valuable time. The other thing to consider is that the pulselessness isn't due to AFib, but a compensatory tachycardia with their chronic Afib. Afib doesn't protect you from PE, tamponade, LGIBs and sepsis.

 

[tkim]

The only shockable rhythms are VF or VT

Code-wise, I know you mean.

 

[Doctor4Life1769]

Code-wise, I know you mean.

👍

 

[leviathan]

pulseless = start CPR, then do whatever else is available to correct that rhythm whether it's drug or electrical therapy. even if it's VFib. the only time you would ever shock first is if you're talking to the person, they're on a monitor, they suddenly go into pulseless VFib/VTach and you have paddless/pads on them within seconds (not minutes).

The scenario in this question was someone who codes right in front of you. It's a weak scenario since the hypothetical patient should have already received electrical cardioversion due to their hypotension and unstable condition. What changes now that they've gone from a weakly palpable pulse to one that is absent? If I choose an arbitrary point and say you lose carotid and femoral pulses at SBP of 60, then what in the patient's dynamics changes that you shock them at a pressure of 60 but not a pressure of 59?

On the flip side, are you guys arguing that patients who have a barely palpable pulse are at a point on the continuum where they likely won't respond to a shock anyway and instead need CPR + epi?

 

[GeneralVeers]

There is always a tendency to "over-think" these answers. For the purposes of exams, as Doctor4Life said, there are only two shockable rhythms: VF and VT. Everything else is PEA or Asystole.

 

[Birdstrike]

For testing purposes, you're right, follow the protocols strictly. However, in the real world, "protocols" are just that, protocols, ie, guidlines, not laws. Not every real life situation necessarily fits one of the algorithms. Personally, if I had an Afib patient that was also pulseless, I think I'd throw a synchronized cardioversion in there at some point; sooner rather than later. How long does it take, 3 seconds, to charge and shock? That's a crappy test question, in my opinion. They're tempting you to violate the protocol which you really can't do until you're beyond protocols. If you have just enough knowledge, you'll get that question right. If you know too much, you may be tempted to give the wrong answer, which if you're smarter that the ACLS test question writer, may actually be the right answer. Protocols are designed to tell you what to do, when you don't know what to do.

 

[TysonCook]

...agree with Birdstrike. Start CPR (PEA protocol) but I'd get a shock in there ASAP. They are guidelines, not written in stone "thou shall not pass" (spoken in a Gandalf voice) type of things 🙂

 

[WilcoWorld]

The only shockable rhythms are VF or VT

Unstable SVT & unstable afib are shockable rhythms.

But I agree with the above posters that, for the purposes of the test, pulseless afib = PEA, hence no shock.

 

[Doctor4Life1769]

yep, unstable afib you do shock.

 

[leviathan]

For testing purposes, you're right, follow the protocols strictly. However, in the real world, "protocols" are just that, protocols, ie, guidlines, not laws. Not every real life situation necessarily fits one of the algorithms. Personally, if I had an Afib patient that was also pulseless, I think I'd throw a synchronized cardioversion in there at some point; sooner rather than later.

This is how I felt about the situation and what I was looking for clarification on, for the real world applicability and not necessarily what was right on a test question. I agree as a robot following ACLS protocols or I guess answering a crappy test question, if you are following them mindlessly then no shocks and just CPR with epi and search for reversible causes.

In this case we know a reversible cause being a fast supraventricular rhythm that needs correction, whether that be just cardioversion or cardioversion plus searching for an underlying cause that precipitated the cardiovascular collapse from afib like sepsis or a PE...

 

[joeDO2]

I think the point that they are getting at here is that electrical activity in the heart does not necessarily coordinate with mechanical activity. So, for the purposes of a test question where they are telling you there is definitely no pulse, the answer would be to follow the PEA protocol with epi and searching for reversible causes. In actual practice, you may not be able to feel a pulse or aren't sure if you feel a pulse or not. One way to decide for sure is to take 10 seconds and put an ultrasound probe on the chest. If you have ventricular wall movement I would cardiovert. If there is no activity, proceed with PEA algorithms.

 

[JustADoc]

In reality, there is no such thing as rapid afib PEA. Your pulseless afib patient is the same as your shocky afib patient. PEA rhythms are not tachy rhythms.

Imho, it's a bad question written by an incompetent person. By the logic of the examiner, pulseless VT is also "PEA", and that's clearly wrong.

The argument for CPR, drugs, or electricity in a shocky afib patient can go on for days. In general, electricity is the answer.

 

[pinipig523]

Pulseless = cpr, shock only VT/VF.

Pulsed but unstable afib = cardiovert, synch.

 

[JLM]

Yup, for the test, its pulseless and electrical so i suppose you follow the PEA algorithm.

In the real world, I would give this guy a trial of electricity before we started pounding on his chest. Although anecdotal, I have just not seen that many true tachycardic arrests. I have seen some RVR with really sh*tty perfusion where I questioned the presence of a pulse. But never an actual cardiac arrest.

 

[Arcan57]

If someone has a.fib and no pulse, its probably not the a.fib that's the main problem. While not PEA, I've been having a run of septic shock patients that also had a.fib and have shocked a few because of the hypotension. And the main thing I've found is that the electricity doesn't convert them. Fluid resuscitation then rate control does seem to do wonders. As a question, is anyone using neosynephrine for hypotension in septic patients with a.fib w/RVR now that levophed is on back-order till the end of April?

 

[JLM]

Yup, for the test, its pulseless and electrical so i suppose you follow the PEA algorithm.

In the real world, I would give this guy a trial of electricity before we started pounding on his chest. Although anecdotal, I have just not seen that many true tachycardic arrests. I have seen some RVR with really sh*tty perfusion where I questioned the presence of a pulse. But never an actual cardiac arrest.

 

[crewmaster1]

The only shockable rhythms are VF or VT

I'm a doctor, I can shock asystole if I want. ACLS is a guideline and shouldn't be midlessly applied to every situation.

If a patient had pulseless Afib with RVR, you bet I'm shocking it. It is a preload problem, if the heart is going too fast and in an uncordinated fashion you need to restore the appropriate rhythm. I'm damn sure that giving epi to someone with a-fib RVR isn't going to be a great fix! While they are techincally in PEA, they likely have some blood pressure, it is just super low. This is very different than a PEA rhythm with electrical cardiac activity and no cardiac muscular activity. Just like torsades....grab the mag, right? Sure will when it comes from pharmacy in 1 hour, nope, hit it with some electricity which is much faster and readily available and it will fix torsades just fine!

 

[xaelia]

As a question, is anyone using neosynephrine for hypotension in septic patients with a.fib w/RVR now that levophed is on back-order till the end of April?

I have used neosyn as a pressor in hypotensive afib with RVR that failed electricity. I had them on cardizem and neosyn to improve diastolic filling.

They lived.

n=1.

 

[iridesingltrack]

I have used neosyn as a pressor in hypotensive afib with RVR that failed electricity. I had them on cardizem and neosyn to improve diastolic filling.

They lived.

n=1.

Agree. I've done this as well without complication.

I use push dose neo by mixing 1ml of 10mg/ml of neo in 100ml of 0.9%NaCl creating a 100mcg/ml solution safe for peripheral administration. Then once I've got pressure, start dilt.

As to the OP question, agree bad test question. Honestly, the guy you are presenting gets shocked by me. I agree, I can shock PEA if I want too.

iride

 

[Rendar5]

Agree. I've done this as well without complication.

I use push dose neo by mixing 1ml of 10mg/ml of neo in 100ml of 0.9%NaCl creating a 100mcg/ml solution safe for peripheral administration. Then once I've got pressure, start dilt.

As to the OP question, agree bad test question. Honestly, the guy you are presenting gets shocked by me. I agree, I can shock PEA if I want too.

iride

Scott Weingart over at Sinai takes the same approach to his hypotensive afibbers. I'd love to try it but only have two attendings over here that would go for push dose pressors.

 

[Dwindlin]

Arg! I just got the same damn question as the OP and made the same damn mistake. . . 😡

 

[leviathan]

Arg! I just got the same damn question as the OP and made the same damn mistake. . . 😡

I'm guessing we were using the same question bank. Still agree that the test answer = CPR but real life where you're using your brain = shock while doing CPR and searching for reversible causes that might be compounding the situation beyond the afib with RVR.

 

[MassEDRN]

pulseless = start CPR, then do whatever else is available to correct that rhythm whether it's drug or electrical therapy. even if it's VFib. the only time you would ever shock first is if you're talking to the person, they're on a monitor, they suddenly go into pulseless VFib/VTach and you have paddless/pads on them within seconds (not minutes).

that is incorrect. V-fib/v-tach you shock. Shock once, CPR continually. PEA you treat according to the pulseless algorhythm. Any rhythm without a pulse that is NOT V-fib/V-tach is not shockable. I am not writing about unstable rhythms that require cardioversion....

 

[tkim]

that is incorrect. V-fib/v-tach you shock. Shock once, CPR continually. PEA you treat according to the pulseless algorhythm. Any rhythm without a pulse that is NOT V-fib/V-tach is not shockable. I am not writing about unstable rhythms that require cardioversion....

Sounds like you're saying the same thing but different.

 

[Hamhock]

that is incorrect. V-fib/v-tach you shock. Shock once, CPR continually. PEA you treat according to the pulseless algorhythm. Any rhythm without a pulse that is NOT V-fib/V-tach is not shockable. I am not writing about unstable rhythms that require cardioversion....

jj

 

[leviathan]

that is incorrect. V-fib/v-tach you shock. Shock once, CPR continually. PEA you treat according to the pulseless algorhythm. Any rhythm without a pulse that is NOT V-fib/V-tach is not shockable. I am not writing about unstable rhythms that require cardioversion....

If you're following ACLS algorithms like a robot without any supratentorial input, then I agree with you. Imagine a patient with afib in the room, pressure is in the 70s-80s, lethargic, short of breath, you go and grab the monitor and sync, get ready to cardiovert and then the nurse tells you the patient just lost a pulse. You're not going to shock them now when 5 seconds earlier you were?

Think about the objectives of PEA: treat reversible causes of arrest. Yes, afib with RVR should normally not in and of itself cause a low enough pressure to make someone pulseless, and you should look for the Hs and Ts that might be compounding their afib and tipping them over the edge. At the same time, you can also reverse at least one acute problem that is contributing to their arrest in the first place by giving some electricity. I'm just a lowly med student, so let me know where I'm going wrong in my reasoning if I am wrong. Cheers.

 

[Rendar5]

that is incorrect. V-fib/v-tach you shock. Shock once, CPR continually. PEA you treat according to the pulseless algorhythm. Any rhythm without a pulse that is NOT V-fib/V-tach is not shockable. I am not writing about unstable rhythms that require cardioversion....

recheck current (2010) ACLS guidelines and re-read what I wrote.