Does this follow ACLS guidelines?

[aCRNAhopeful]

Hypothetical situation: On the monitor a patient suddenly begins to brady downward --> asystole. The RN's begin CPR and bring in the crash cart. Now to choose the first drug: the RN gives atropine 1mg first because of the preceding bradycardia and it works, patient is saved. Was this appropriate and in accordance with ACLS guidelines or should 1 of epi have been given first and followed later by atropine? Lets say that based on the patient situation the RN suspects severe vasovagal stimulation as the initial cause of the bradycardia--> asystole. In my mind atropine seems like the right drug to give but does an ACLS nurse have that privilege or are we legally bound to progress through the algorithm in order with 1mg of epi first? Last question, can you give the 1mg of epi immediately followed by 1 of atropine or should you first let the epi do its thing and give atropine 3-5min later? Haven't been in many codes yet and was just wanting some clarification. Thanks in advance.

[Otessa, BSN, RN]

Each area where you work will have policies that guide those that are ACLS educated-some will let RN's use their clinical judgment-others will not-

check you institutional policy.

[aCRNAhopeful]

Since I've posted this I've been in a situation where I considered giving 1 of atropine first. Had a patient after a heart cath who moved the leg with the sheath in it and vasovagal'd his HR down to the 20s. I gave the 0.5mg and left the syringe attached, if they wouldve coded I would have given the rest. They did fine after the .5 and it wasn't necessary. Just an example of how one might deviate from ACLS guidelines just a little bit.

[getoverit, BSN, RN, EMT-P]

good example.

ACLS guidelines are just that....guidelines. they aren't set in stone. they're recommendations. Over the years I've seen people who get so wrapped up in "do this first...then this next...don't do this until after that".

Some things are like that, but most aren't. You use your clinical judgement. I've always thought of it like a recipe. How do I want this to turn out? the guidelines are my ingredients and I can use them to effect the finished result that is best for the patient.

and it's a good thing to give 0.5mg atropine if the patient has a pulse. Like you said, you could have given the rest...but if you had, then you couldn't take it back. I saw someone's hr go from 30s to 150s and wished I had only given half the amp, lesson learned and it was one of those things that only happen once.

[highlandlass1592, BSN, RN]

Since I've posted this I've been in a situation where I considered giving 1 of atropine first. Had a patient after a heart cath who moved the leg with the sheath in it and vasovagal'd his HR down to the 20s. I gave the 0.5mg and left the syringe attached, if they wouldve coded I would have given the rest. They did fine after the .5 and it wasn't necessary. Just an example of how one might deviate from ACLS guidelines just a little bit.

Actually, in hospitals where I've worked cardiology (and ended up pulling my own sheaths post-cath) we were covered by protocol not ACLS guidelines in that type of situation. We also had an order to give fluid.

One thing I REALLY like today about ACLS is the "seek expert consultation" phrase. We all do it, run across something we may not be sure what to do..we seek out the opinion of others to get ideas for treatment. I think we need to remember our patients have never read the ACLS book, they may act differently than any scenario we could think up. We need to use good judgement when treating patients...that is the most important point of all.

[IckuRN, RN]

Anyone know the changes that have been issued? I can't find them online.

[highlandlass1592, BSN, RN]

Anyone know the changes that have been issued? I can't find them online.

Here's one link, the updates are in the new issue of Circulation

http://circ.ahajournals.org/cgi/reprint/122/18_suppl_3/S729

Hopefully that will work for you, I accessed it from our work library. If it doesn't, as I said the new issue of the AHA journal Circulation has all the updates. VERY INTERESTING.

[icunurse42066]

According to ACLS for the experienced provider, we should now treat fine v-fib with chest compressions as the heart does not have enough blood in it for the shock to be 'successful.'

Coming soon....2010 AHA guidelines that will probably take all the ACLS drugs out of the equation.

Correct me if I'm wrong, but I didn't see the word "shock" in the post, all I saw was compressions, just sayin'

[emt123277]

not a theoretical situation for me. we had a pt who had coded pre-hospital and had rosc. while in the er prior to icu admission the pt did brady down and the pt received 0.5mg atropine while they still had an electrical rhythm (20's). i was charge nurse in the unit and we received the pt extubated and talking, aaox3. during the night, pt said "i don't feel well". pts rn is in the room and i went over to assist her. as i approached the room i drug the code cart to the door way because i'd rather get that out of the way now. just as i reached the door, the pts eyes rolled back and she went unresponsive, asystole on the monitor (2 leads) and no pulse per the pts rn. the pts rn began compressions and i slammed 1mg atropine first because in report i knew that was the drug that spun her around in the er. long and short of it, the pt woke up stating "damn, my chest is killing me".

did i follow the guideline? no, but the pt lived and the guidelines were the basis (guide) for my decision. no pt is going to live or die based on the first line acls drug you push however delaying cpr or defibrillation, that’ll make or break you.

[eCCU]

I see where they would have considered Epi when bradying down but as soon as the pt hits Asystole Epi is the 1st drug of choice for Asystole doesnt matter the explanation. Remember ACLS protocols are researched and tested then published. i always go with evidence based easier to argue in a court of law:cool:...just saying:lol2: