Pulseless patients: shock or drugs

Specialties Emergency

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When coding a pulseless patient in VT or VF do you generally shock them first or use drugs in your practice?

Not only would you shock them three times, but if the rhythm is still the same and meds arent readily avail (say, in the field), you could shock them a 4th. (Dont forget, only 10% of all arrests survive....) You're relatively healthy person probably had a blockage of his Widow Maker, and little or no collateral development.

Its mos def more than appropriate to defib as the first, second and third lines of tx in vfib/pulseless vt. You can read all the studies if you'd like. There were thousands and thousands of studies done here and in Europe. You probably could have given him 10 rounds of drugs, to no avail. Dont forget, we are an EBP (evidence based practice).

Yes, you're right that it was more than likely inevitable and this was only one case. Having only witnessed a handful of codes with only one turnaround I see where you are coming from. I still find myself questioning whether or not this is an appropriate first line intervention.

Eric, I think all the literature supports the shock, shock, shock theory. The person you saw may have just been circling the drain anyway, and nothing was going to help. There are exceptions to every rule, you just have to go with the odds. I have rarely seen anyone come "back" after CPR, but have seen quite a few after potentially fatal arrhythmias.

Well by now you have got an answer - and a rather shocking one at that. - Think practical terms - wham bam - shock away - the electrical disosciation verses a potential chemical value of a bolus push is pretty clear (the heart works by an electrical wave impacting on muscle - with a shcok we are essentially saying start pumping again damn it.... with chemical swamping we are trying to help that electrical wave (something to try after a first, second or even third attempt at electrical jump starting (ie a shock). Or if you are more mechanically minded - when a cars battery goes we use jumper cables before we replace the battery fluid. (hey its a far stretch put the principle is similar)

cheers

Peter

Well its unanimous, if thats what the American public wants than a quick shock to the heart is what they'll get :)

Suggest you read this document if you remain at all skeptical.

http://www.erc.edu/index.php/doclibrary/en/viewDoc/24/3/?PHPSESSID=66012c1aa288d7274ee2a82e7772310e

In todays world it is better to base your practice on a solid research foundation.

And you should try to know this algorithm by heart

http://www.erc.edu/index.php/doclibrary/en/viewDoc/66/3/

Well its unanimous, if thats what the American public wants than a quick shock to the heart is what they'll get :)

for v fib or pulseless v tach

yes.

According to the American Heart Association in 2004 Some research suggests that there may be special resuscitation situations in which rescuers should administer medications, particularly adrenergic agents, before defibrillation. In the deterioration of VF to asystole there comes a point at which the shock is very likely to produce postshock asystole. Under these conditions the patient might be better served if medications were administered before defibrillation.

"In the deterioration of VF to asystole there comes a point at which the shock is very likely to produce postshock asystole. Under these conditions the patient might be better served if medications were administered before defibrillation."

Exactly, If you have VF deteriorating to asystole you would want to begin your ABC's and administer vasoactives and not shock (since in asystole, there is nothing to shock). As stated before, the ACLS protocol (Developed using Evidence Based Practice) states for Pulseless VT or VF to deliver 3 stacked shocks (the goal being to reset the electrical impulses being generated to something more organized then VT/VF), Assessing the rhythm between each shock, Assessing for a pulse after your stacked shocks and if no pulse to resume compressions and then move on to meds...

That's what we used to call fine Vfib... the unhappy VFib. And that's why people used to shock asystole- to r/o occult vfib. Now its a big no-no, of course....

According to the American Heart Association in 2004 Some research suggests that there may be special resuscitation situations in which rescuers should administer medications, particularly adrenergic agents, before defibrillation. In the deterioration of VF to asystole there comes a point at which the shock is very likely to produce postshock asystole. Under these conditions the patient might be better served if medications were administered before defibrillation.
Specializes in Emergency.

Unfortunately I know the kind of patient that the original poster talks of. A yong apparently health person codes is in v-fib is shocked to asystole and dies. As to why you need to delve a little deeper, read an autopsy or 2 from this kind of patient. Often times what has happend is a large infarct has occured and a large part of the heart is immediately deprived of oxygen. What happens is the shock resets everything but that heart is still deprived. You can pump on the chest, push all the drugs in the pharmacy but ultimately its not going to work.

Now to the oposite I have seen these same patients survive. The difference is that the large infarct has occured after a small MI and the patient is in the middle of a heart cath, the problem is caught immediately, treated and flow re-established with the other treatment occuring concurrently.

Rj

Speaking of shocks we had an amazing case over the weekend. Person came in with complaints of chest pain talking it up with the nurse then nose dive, started the pulseless VT/VF algorithm when all was said and done the pt was blasted 24 times and every ACLS drug known to man was given the patient did make it and was rushed to the cath lab for a pacer, it was unreal.

what good are drugs if there is no circulation?

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