Does this follow ACLS guidelines?

Specialties CCU

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Specializes in CVICU.

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.

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Specializes in critical care, PACU.

Im curious to hear some people's answers regarding this too. Good question!

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Specializes in Med-Surg /Cardiac Step-Down/CICU/CTICU.

just being acls recertified...survey says...its always epi 1st...then spent some time with my educator last week going through the acls pretest...rhythms....always epi 1st...i once too thought atropine (in that particular situation) but it is epi all the way first and then you can give other meds. i'm sure that you could give the atropine but if the epi didn't work i doubt the atropine would...remember atropine is a weight based drug, and although we commonly give it...we are max'd at 3 doses for a reason. epi has no max...you can give as much as you want...well until they call it. as a acls certifed nurse, i think you would be held accountable if you did deviate away from the algorithm, if it was ever questioned or investigated. hope it helps...and correct me if i am mistaken.

side note: remember epinephrine is a vasoconstrictor and positive inotrope. increasing BP/HR

atropine-muscarinic antagonist...affects HR, little effect on BP.

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Specializes in Nurse Anesthesiology.

ACLS - Epi first, but that hypothetical just sounds like the person vasovagaled and the antimuscarinic effect stopped the vagal response.

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As a CCRN/P-EMT, working in cardiac cath labs and I saw my patient brady down to asys. It would be epi first, chest compressions, then the atropine. Epinephrine circulates to receptor sites in the myocardium and directly stimulates these receptors to restore or increase heart rate. Just remember you will never go wrong following the algorythyms of ACLS.

Just to add a twist, if this was a heart transplant patient which of your ACLS drugs won't work in most cases? Hint: the heart has lost vagus nerve innervation so it will not respond to this drug.

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Specializes in CVICU.

Then skip atropine and pace em if its symptomatic bradycardia. But as I think about it, wouldnt all heart transplants need a pacemaker? I've never dealt with that patient population but I'd think you would live in a permanent 3rd degree block otherwise.

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Specializes in CVICU, ED.

No, heart transplant patients do not need a pacemaker. Had a patient a couple of months ago that had had a heart transplant 1-2 (??) years prior. The patient had more than one p wave for each QRS. Turns out that his heart was still sending signals from what was left of his SA node as well as from his transplant's SA node. His signals didnt generate a QRS, only the transplant so his rate was WNL.

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Specializes in multispecialty ICU, SICU including CV.

I think in an emergency, if you think you have a differential that supports atropine, you can give it first. I have done this on a few occasions and averted a full arrest situation and have not needed epi. Is this on the algorithm? Probably not. Did it work and did the doc sign off on what I gave? Yes. I think worst case scenario, you give the epi 60 seconds later.

I would not do this if I had not witnessed a bradycardic event, knew the patient, and had a strong suspicion of what the problem was (all 3 of them.) I would never walk into a room with a bradycardic patient that was down and not go by protocol.

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Specializes in Critical Care.

Just to throw a bit of a monkey wrench in your scenario, what you see as asystole could possibly be fine Vfib...in which case you'd need to go with epi first anyway. But with the scenario you presented, epi first would be recommended. If it's just a brady without further advancement, then atropine.

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Specializes in ED, ICU, Education.
Just to throw a bit of a monkey wrench in your scenario, what you see as asystole could possibly be fine Vfib...in which case you'd need to go with epi first anyway. But with the scenario you presented, epi first would be recommended. If it's just a brady without further advancement, then atropine.

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.

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Specializes in Critical Care.
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.

I am well aware of what the guidelines for ACLS recommend. The question the OP provided was regarding a drug regimen not a question regarding compressions. And nowhere in the guideline does it say NOT to give drugs for Vfib..if you'd like to get into a discussion regarding filling times which will directly impact the hypothesis you presented..we can. But that's not on the topic the OP posted. And honestly, I don't see an elimination of code drugs with the upcoming revisions. I'm not sure where you have heard that rumor.

PS: As for the topic of compressions, more focus is being given on proper timing of compressions as well as depth..which will allow for the adequate filling the heart needs. Hence, the development of so many different devices to help the responder do proper compressions.

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Specializes in Critical Care Nursing AKA ICU.

aystole=chest compressions, epi, atropine............that order

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