Algorithms in theory vs. in practice

[TLSpaz]

Share with me, if you will, your perspectives on following algorithms, like ACLS, in the clinical setting. I am interested in this from the perspective of employing algorithms exactly as recommended, especially with regard to timing of drug doses, compression cycles, defibrillation, etc.

[TLSpaz, ASN, RN]

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.

[GrannyRRT]

The patient still had a pulse. While the CT Scan might have been a little extreme it did show non survival injuries. Sometimes doctors have to make tough calls and want something concrete to back them up. Had the physician stopped while this patient still had a pulse without confirmed evidence of the massive nonsurvival injuries, there probably would have been a discussion about that also. There are many examples of those who were thought to have non survival injuries but somehow survived. Watching the World Series in San Francisco there was mention of Brian Stowe and his life changing events. Some probably thought they went to extremes to save his life also. He and his family seem glad they did.

Sometimes it is very difficult to feel a pulse even on those who are very much alive. Many EDS now have portable ultrasound to assess cardiac function or lack of rather than relying just on finding a pulse and a possible PEA.

Some hospitals are teaching their own ACLS designed specifically for their team members and their patient population. AHA ACLS is guidelines which are generally appropriate for unknown patients. Guidelines are not concrete. You need to check your hospital's protocols to see if the AHA ACLS guidelines are followed exactly or what amendments or additions have been made per the Critical Care and ED medical directors and confirmed by the medical staff board.

[TLSpaz, ASN, RN]

I know it has been several days since this thread had any activity, but I had to come back to share this post that I stumbled upon. It comes from an EMS blog, and it talks about ST and how to treat it. It covers some of those "nuances" I referred to in a previous post. If you decide to check it out, be sure to read the comments that follow the post, as well. Of course, this may be old-hat for lots of you, but as I alluded before, I still feel spankin' new when presented with ACLS scenarios in real life, because I simply haven't had very many encounters with patients who are unstable due to acute CV illness/injury. As long as y'all are still ok with a relative newbie asking "stupid" questions, I will probably keep coming back.

Here's the post: The Trouble with Sinus Tachycardia | EMS 12 Lead

[TLSpaz, ASN, RN]

@GrannyRRT:

Thank you. "Guidelines are not concrete" is quite the succinct answer to the theory vs. practice question.