Algorithms in theory vs. in practice

I don't understand your questions. Are you asking if we deviate from the ACLS algorithm during a code? My answer is, to my knowledge, we generally do not.

The protocols are there to help you work as a team and provide the best chance for a positive outcome, so no, we try to not deviate from the protocols. I'm not saying it has never happened, I'm sure it has, but that would generally be an atypical situation and most likely to happen when someone doesn't want to give up even though everyone on the team knows what the outcome will be.

I've never seen someone deviate from compression cycles, shocks per protocol, have you? Is this someone wanted to or did do in a code, or are you wondering if their is a reason to do so?

As for drug timing, I've had people call for drugs out of order during a code, but we typically correct them. There are drugs that are optional, and don't effect the order/timing of epi for example. Things like narcan can be given whenever based on the teams assessment of the Hs & Ts.

What specifically prompted the question? Maybe we can give a better answer.

Example: tachycardic in 160s (narrow complex, essentially regular rate), with "pressure" in chest, and feeling short of breath

Algorithm says synchronized cardioversion first, but may consider adenosine for regular, narrow complex tachyarrythmia

Doc wants adenosine, so it's not a deviation from the algorithm, but an alternative.

Another one: vasopressin after epi vs. epinephrine alone during resuscitation

I'm just wanting to hear about scenarios where different variations are used and why the variations are selected. Is it just "habit" or preference? Are there nuances to individual patient's cases that come into play?

In particular, I am thinking of a traumatic arrest: use of epi WAAAAAY after the window from the previous dose...after cessation of compressions...pt to CT scanner with PEA (dispute about whether it was "just bradycardia" vs PEA, but regardless, tx was interrupted to go to CT-if pt has inadequate circulation, who gives a crap what the CT shows?!) several other things that were not protocol. Felt like we were playing "let's see what happens if we do this." Maybe it was a case of not wanting to give up...

I should add...in this last example I gave...there really was nothing that was going to change the outcome for this pt. What should have lasted about 10 minutes just dragged on...and on...and on...

Ever read John Varley's Tango Charlie?

Example: tachycardic in 160s (narrow complex, essentially regular rate), with "pressure" in chest, and feeling short of breath

Algorithm says synchronized cardioversion first, but may consider adenosine for regular, narrow complex tachyarrythmia

Doc wants adenosine, so it's not a deviation from the algorithm, but an alternative.

Another one: vasopressin after epi vs. epinephrine alone during resuscitation

I'm just wanting to hear about scenarios where different variations are used and why the variations are selected. Is it just "habit" or preference? Are there nuances to individual patient's cases that come into play?

Actually in that case the algorithm says adenosine. Going directly to synchronized cardioversion is only for when you don't know the rhythm in a symptomatic patient, in which case you assume a shockable rhythm.

In the hospital setting this typically isn't how it works and for pretty good reason. For one thing you're typically going to be able to see a rhythm before you shock, either because they're on tele or when you hook them up to the defib. If the patient's only complaint is some chest pain and you decide to cardiovert without knowing whether it is a shockable rhythm, good form says you should give a little sedation, so now you've lost your ability to assess mental status in exchange for an interventions which you don't even know the patient needs. With adenosine it has the potential to fix the problem, or if it doesn't fix the problem it at least serves a diagnostic purpose, since it makes it easier to see the rhythm even if it doesn't fix it.

Thank you for that feedback. That makes sense to me, but unless I am just missing something, the algorithm published by AHA doesn't explain it the way you just did, MunoRN.

In working through the scenarios on the ACLS online course, part 1, when I addressed the scenario with adenosine, the narrative afterwards gave feedback that synced cardioversion should be the considered choice, not that the adenosine was wrong. However, at the bedside of an actual pt, the doc wanted adenosine, so it got me thinking about what nuances make a difference. Seems like, at least in this case, what we would do in the ER is one thing, while what EMS would do in the field PTA would be another. Is that an accurate conclusion to draw?

I know these are the questions of a novice, which is what I still consider myself in these cases. I only have about two yrs in the ER, and my hands-on experience in ACLS is very limited. We just didn't see a lot of it where I worked. I am starting a new job next week in an ER that sees greater numbers of higher acuity pts, so I am probably overthinking everything and psyching myself out a bit.

I am looking at the algorithm for Tachycardia with a Pulse on the AHA card, and my understanding is that if a narrow complex tach is producing symptoms of INSTABILITY, i.e. hypotension, chest pain, signs of shock, acute heart failure, then synchronized cardioversion is indicated (not for sinus tach), but if the patient's symptoms are not as severe and are not causing instability, then you would proceed to the blue box on the bottom of the AHA card on the left (which you did not show), which lists options for treatment including Adenosine.

Not sure why the card looks this way. I actually did do a screen shot of the complete algorithm but it didn't show up in the post, for some reason.

RE: Tachy w/ pulse, chemical vs electric. I was always taught you jump to electric when they are unstable. Stable pt, you try meds first which is what your card seems to be showing as well. So in the case you described above, what makes you think the patient is unstable? I think I would be ****** if my dad walked in with a HR of 180, narrow complex, walking, talking, hemodynamically stable, O2sat ok, did mention some pain in his chest, but otherwise not collapsing, no diaphoresis, etc and you jumped to slamming him with juice. Now, I'd suggest putting the pads on while an EKG was being done, IV being started, and you kept talking to him to make sure he wasn't getting worse. But we have time at this point to go with the meds. I don't see that as against the algorithms.

On the other hand, if he was brought in by my mother, she brought him in via a wheelchair, dripping wet, clutching his chest, same HR, low O2, struggling to breath, couldn't answer my questions, you get the picture... No need to wait, light him up, get that pumper working again. Again, I think that's in keeping with the algorithms as well.

Hope that helps.

RE: Epi way after stopped compressions and sent pt to CT, I'm totally confused by this scenario. The pt had ROSC, was stable enough to be sent to a CT scanner and then.... what happened that made a provider order epi?

OK...background on this scenario first...I was a brand-spanking new grad when I observed this, so it's been a good minute since this took place, but here's what I remember: Pt was in cardiac arrest on arrival. Some cardiac activity was visible on the monitor after CPR, drugs, and volume resus with blood and fluids, but the pt was never stable and remained unresponsive for the entire ordeal. Pt was taken to CT while bradycardic with a barely palpable pulse (or a pulse that was never palpable, depending on who was checking at the moment. I never was able to feel a pulse myself but I was the newest of newbies, so what did I know? Doc said he could hear heart sounds.) Pt brady-ed down further on the CT table just as the CT was being completed. Approx 60 seconds later, back in the ED, pt was showing HR in the 30s, with no palpable pulse but again, doc said he could hear heart sounds, so he called for epi, and then someone said, "Don't you think we should start compressions?" Keep in mind, I was primarily there to observe. I think it may have been my fourth or fifth day in the ER at that point and I had not yet taken any ACLS classes, so my knowledge base was thin, to say the least. The team initially had me do some compressions, attempt to palpate pulses, and accompany them to CT, but otherwise I was there to observe. As far as I remember, the pt never got any atropine and was never paced...but again, I was new and lacking formal ACLS training, so maybe I just don't remember everything...and I don't know; maybe the lack of bradycardia interventions was moot at that point anyway. The CT showed a train wreck: facial crushing, head full of air, blood in the belly. I remember one of the trauma nurses saying, while we were in CT, that she couldn't believe he (the doc) was still going at it. I also remember thinking I was in way over my head, and feeling disgusted...literally sick... that heroic measures were still being attempted despite all of the evidence that the pt was incapable of sustaining anything even remotely resembling life at that point. It just didn't make sense.