"It cant be PEA if the rate is over 150" -- ??

[AZCEP]

B.) Defib ing these pts can often put them into as noted previously, IVR, V-fib and or Asystole.

C.) You need to know what and why you are treating something rather than throwing meds at symptomatology to 'help' you diagnose your 'guess' as to the underlying d/o.

So with a pulseless patient, no blood flow, electrical system still working-or trying to-with no mechanical activity to move blood, metabolic demand remains high due to the stimulation that the heart is working under, available energy stores rapidly exhausted, rate slows down and continues into asystole.

Every countershock, whether synchronized or not, should produce asystole. The hope being when the dominant pacemaker takes over it will do so at an acceptable rate. IVR would be an acceptable alternative as long as it could generate a pulse. It indicates that the subordinate pacemakers are attempting to work following the elimination of all stimuli. VF might be troublesome, but since we already have our equipment applied to fix the problem, we should be able to fix it fairly quickly.

If the patient is truly in a pulseless SVT, then there is a fairly good possibility that the underlying cause is any number of hyperdynamic states. Hypovolemia would probably be the most common, but sympathomimetic toxins are a possibility as well. So while epinephrine would be indicated for the pulseless arrest, it would not be the best idea to use it in this case.

[Ace844]

Well Ace, you've just confused the heck out of me, what don't you get? If you have a pulsless pt in PEA, and the rate is below 60, why wouldn't you push atropine, along with the epi and the fluids?? You will have to explain the rant that you just had, maybe we are on a different page, dunno, do clarify.

The defib comment is cut and dry, if they are in fib, or tach, (without a pulse) you NEED to defib. You are right, it could put them into a whole bunch of different rhythms, your other alternative is THEY DIE. Cardiovert pulses, defib the less unfortunate.

"Fire,"

If your talking about in reference to this.. re: your atropine statement?

I don't get it..What? What does that mean?!?!?

I was being facetious, kidding, joking, no rant...as far as thats concerned. Sorry I tried to use the smilies to set the 'tone' for that. As far as the defib, yeah, I agree with you. Sometimes you have no alternative, and for me whenever possible cardioversion is preferred to defib. It should be noted that the higher joule energies 'Defibrillation' brings with it all too often fatal side effects. It was meant as more of an FYI is all as I was surprised at some of the comments made in this topic.

Hope this helps,

ACE844

[AZCEP]

As far as the defib, yeah, I agree with you. Sometimes you have no alternative, and for me whenever possible cardioversion is preferred to defib. It should be noted that the higher joule energies 'Defibrillation' brings with it all too often fatal side effects.

However, the most recent guidelines recommend an initial countershock at the highest possible level. The problem, as I see it, with the current research dealing with defib results is the lack of perfusion during the escalation. If an appropriately applied countershock is delivered in a shorter period of time the most common negative is a transient conduction delay.

The threat is absolutely valid however. As I said, if a countershock is going to work, there should be a period of asystole following it.

[firefighter523]

"or there is a history consistent with a cardiac etiology of the arrest"

???? So you mean that if someone WAS in VF or VT, but isn't now then you should defib??? Is that what you mean? Please explain your rational....

[Punisher]

"or there is a history consistent with a cardiac etiology of the arrest"

???? So you mean that if someone WAS in VF or VT, but isn't now then you should defib??? Is that what you mean? Please explain your rational....

Meaning that say the person abruptly grabbed their chest and collapsed, and is found in a narrow complex tachycardic rhythm, then chances are good that it's cardiac in origin, as opposed to someone who was complaining of tearing abdominal pain or as a result of a trauma then arrests. If there is a high likelihood that the heart isn't to blame, cardioversion/defib is not going to do anything for the arrest, except maybe seal the patient's fate. That is what I mean. Are we clear now?

[Ace844]

So with a pulseless patient, no blood flow, electrical system still working-or trying to-with no mechanical activity to move blood, metabolic demand remains high due to the stimulation that the heart is working under, available energy stores rapidly exhausted, rate slows down and continues into asystole.

Every countershock, whether synchronized or not, should produce asystole. The hope being when the dominant pacemaker takes over it will do so at an acceptable rate. IVR would be an acceptable alternative as long as it could generate a pulse. It indicates that the subordinate pacemakers are attempting to work following the elimination of all stimuli. VF might be troublesome, but since we already have our equipment applied to fix the problem, we should be able to fix it fairly quickly.

If the patient is truly in a pulseless SVT, then there is a fairly good possibility that the underlying cause is any number of hyperdynamic states. Hypovolemia would probably be the most common, but sympathomimetic toxins are a possibility as well. So while epinephrine would be indicated for the pulseless arrest, it would not be the best idea to use it in this case.

I agree with your point, except it should also be noted that 'defibing' a pt at higher energy settings with a monophasic defib will also cause mycardial ischemia and tissue damage thus interfereing wiht the process with which you describe above! As well as increasing the chances that after 'multiple or even as few as one or two counter shocks' the pt will not recover from said bout of iatrogenic induced "IVR, V-fib, and or asystole or other associated arrythmias". Next based on your response you fail to take into consideration any underlying electro-phys abnormalities, and or PMH, which may have altered or 'damaged' this patients heart. Thus one must consider the potential theat 'the DOMINANT Pacemaker' may in fact be the one causing 'the re-entrant tach, and or be at an undersirable location. That was my point, sometimes we don't have a choice, but we should understand what happens as a result physiologically as well. Below is a quick 'article' to serve as a point of refrence for you.

[web:7f3010760f]http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=14580735&dopt=Abstract[/web:7f3010760f]

[web:7f3010760f]http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=14991189&dopt=Abstract[/web:7f3010760f]

[web:7f3010760f]http://defibrillation.biography.ms/[/web:7f3010760f]

Hope this helps,

ACE844

[Ace844]

Hello Everyone,

In case there are some of you out there who are wondering the differences between V-tach and SVT with aberrancy, read the document below and see pg. 6, in particular. Also, it's a very basic starting point if you have no idea what I'm talking about.

Hope this helps,

ACE844

[web:f914d86fde]http://edr.medctr.ohio-state.edu/Downloads/ACLS_FILES/Acute_Coronary_Syndrome.pdf[/web:f914d86fde]

[firefighter523]

Well, you might have seen a pulsless SVT, that is called PEA!!! Chances are if you find SVT, they probably have a pulse, you just couldn't feel it. If they really didn't have a pulse and you saw SVT, it is STILL considered PEA, and the treatment is fluids, and sympathomimetics, along with Calcium, and Bicarb possibly.

The definition of PEA is ANY electrical activity in the heart, without a pulse, except VT, and VF.

I am clear, only on THIS!!!

[Ace844]

Well, you might have seen a pulsless SVT, that is called PEA!!! Chances are if you find SVT, they probably have a pulse, you just couldn't feel it. If they really didn't have a pulse and you saw SVT, it is STILL considered PEA, and the treatment is fluids, and sympathomimetics, along with Calcium, and Bicarb possibly.

The definition of PEA is ANY electrical activity in the heart, without a pulse, except VT, and VF.

I am clear, only on THIS!!!

Who and or which post are you addressing-commenting on?

ACE

[firefighter523]

"Meaning that say the person abruptly grabbed their chest and collapsed, and is found in a narrow complex tachycardic rhythm, then chances are good that it's cardiac in origin, as opposed to someone who was complaining of tearing abdominal pain or as a result of a trauma then arrests. If there is a high likelihood that the heart isn't to blame, cardioversion/defib is not going to do anything for the arrest, except maybe seal the patient's fate. That is what I mean. Are we clear now?"

Sorry ACE, hope this helps.