acls algorithms

[aujax]

Hi everyone, I'm just about to take my nremt-p practical (passed my written over the summer) and am a little confused. The pulseless arrest algorithm makes perfect sense, but when it comes to the bradycardia and tachycardia algorithms, I can't seem to get a straight answer on which rhythms get which treatments - atropine, pacing, adenosine, cardioversion. I know the most common ones - i.e., svt gets adenosine, unstable svt gets cardioversion, but when it comes to a rhythm like junctional with compromised co, or second degree type one AV block with poor perfusion, I keep getting conflicting answers. My textbook doesn't clear it up either. Is there a source online or elsewhere that clearly defines how to treat each rhythm? I would think the American Heart Association might, but can't find anything on their website...

thanks,

aujax

[chbare]

http://circ.ahajournals.org/content/122/18_suppl_3/S729.full.pdf

My best word of advice is do not make it more complicated than it needs to be. You know how to treat it if there is ischaemic chest pain, altered mentation and so on. Even the algorithms call for expert consultation on the tachycardias. Often, I defer to what I call the conservative action principle. When in doubt, choose the most conservative action. I'm leery of pumping proarrhythmic medications into my patients if I have any concerns or doubts about what is going on.

[aujax]

Hi chbare,

Thanks for the reply. I guess I'm a little concerned that, when I'm taking the test, I should be able to explain every treatment option should the patient deteriorate into a grave condition. I know that in the field, half of the stuff they teach you never gets used. I just want to pass the test...

[tniuqs]

Hi everyone, I'm just about to take my nremt-p practical (passed my written over the summer) and am a little confused. The pulseless arrest algorithm makes perfect sense, don't forget relative hypovolemia with DHI Dynamic Hyperventilation but when it comes to the bradycardia and tachycardia algorithms, I can't seem to get a straight answer on which rhythms get which treatments - atropine, pacing, adenosine, cardioversion. Yes you do ! I know the most common ones - i.e., svt gets adenosine, unstable svt gets cardioversion, but when it comes to a rhythm like junctional with compromised co, or second degree type one AV block with poor perfusion, I keep getting conflicting answers. Early electricity! My textbook doesn't clear it up either. Yes it does. Is there a source online or elsewhere that clearly defines how to treat each rhythm? I would think the American Heart Association might, but can't find anything on their website...

thanks,

aujax

[zmedic]

As far as ACLS goes, you are dealing rhythms that are either too fast or too slow. Too slow and you speed them up (atropine or pacing), too fast you have to slow them down (syncronized cardioversion, diltiazem, beta blocker, adenosine) or they are a mess (fibrillatiing) and you shock them. Asystole they die. That's most of what you need to worry about.

If they rate is about right, and it's a narrow complex and something like first or second degree heart block, the problem isn't the rate or the rhythm. It's something else. So a 1st or second degree block, or a junctional rhythm with hypotension needs some other treatment (stopping bleeding, fluids, dopamine.) It's not really an ACLS problem in that case.

You say you can't get a straight answer. Here is what I have off the top of my head:

Adenosine-SVT

Cardioversion- unstable narrow complex tachycardia, unstable afib/a flutter

Defibrillation- unstable Vtach, Vfib

Atropine- bradycaria

Pacing- symptomatic bradycardia

Mag-Torsades

Epi- PEA, vfib/pulseless vtach

Diltiazem- afib/aflutter that doesn't need electricity and is new onset

There is ACLS in a nut shell.

[tniuqs]

Zee Medic Eh?

Welcome !

No beta blockers in your cook book ? hmmmmm .

[Kaisu]

You say you can't get a straight answer. Here is what I have off the top of my head:

Cardioversion- unstable narrow complex tachycardia, unstable afib/a flutter

Any unstable tachy rhythm

Defibrillation- unstable Vtach, Vfib

only dead people.. live people is cardioversion

Atropine- bradycaria

Narrow complex only in the absence of 2nd degree not Mobitz or 3rd degree blocks

Diltiazem- afib/aflutter that doesn't need electricity and is new onset

Wrong - diltiazem if you don't want to convert to sinus (sometimes will anyway) - thus over 48 hours and/or unknown onset

There is ACLS in a nut shell.

You really need to understand what you are doing. Memorizing the algos will mess your patients up

edited to take out an extra line

Edited November 21, 2011 by CrapMagnet

[chbare]

Atropine is not contraindicated in high grade AV blocks, it's just not likely to work. AHA only tells us to avoid relying on atropine in these situations. Regarding tachycardias, it's pretty clear everybody has an opinion when there is a "stable" tachycardia present. I would argue that following the AHA algorithm in this case is a good idea as it can prevent large deviations in care and from standards of care. However, even AHA recognises the complexity of tachycardia care and suggests expert consultation. I translate that as a caution against performing chemistry experiments on my patients in the back of an ambulance.

OP, national registry is fairly linear and you can expect to encounter fairly straight foreword situations in your dynamic and static cardiology stations.

[romneyfor2012]

I applaud your wish to go to the "nth" degree, but you will mess yourself up with National Registry if you go down this path. Stick to the cookbook and keep it simple for now, once you pass the registry you can dig way deeper into all kinds of scenarios that are outside of the ACLS book. The registry exam is stressful enough, you do not need to add anything that can confuse you.

[zmedic]

Zee Medic Eh?

Welcome !

No beta blockers in your cook book ? hmmmmm .

Didn't mention them because a lot of ambulances here in the US don't carry them.

And I'm sorry that my one liners didn't have the complexity that some people were looking for. One of the previous posters said that they couldn't keep straight when to use which treatment so I generally broke them out. Sure there are specifics on which afib to use diltiazem, which bradycardia get atropine. Hence why you can't learn ACLS from a internet post that takes 30 seconds to read.

For the test, you need to know the cookbook. And in practice during a cardiac arrest it should be fairly automatic. Seeing vfib without a pulse should automatically trigger CPR, defib, epi/vasopressin.