rcpals

Second degree type II. Fixed p-r, then drops a beat.

Several recent studies, document rates between 150 and 200 chest compressions. Survival starts to drop as compression rates get greater than 120. So 100-120 is optimal.

According to multiple studies, there is no improvement in neurologically intact survival to hospital discharge, if you intubate during a code. Many hospitals no longer routinely intubate until the patient gets ROSC or they are having difficulty ventilating the pt or it's a primary respiratory issue. Chest rise is chest rise. Intubation is the number one thing that pulls us off the chest during CPR. It seems hard to justify routine intubation during CPR.

Hi Brama, One of the reasons we don't like to push amiodarone, if the patient is alive, is the high rate of hypotension and bradycardia. Generally this is an infusion related issue occuring in up to 25% of patients. Per your scenario, it doesnt seem like that would be such an issue. The community standard of care is Amio 150mg over 10 minutes followed by a 1mg a minute for six hours... Per the manufacture website... "Infusion: Amiodarone: I.V. DOSE RECOMMENDATIONS -- FIRST 24 HOURS -- Loading infusions. The recommended starting dose of Cordarone I.V. is about 1000 mg over the first 24 hours of therapy, delivered by the following infusion regimen: [COLOR=#3366ff]First Rapid: 150 mg over the FIRST - 10 minutes (15 mg/min). Add 3 mL of Cordarone I.V. (150 mg) to 100 mL D5W. Infuse 100 mL over 10 minutes. [COLOR=#3366ff]Followed by Slow: 360 mg over the NEXT 6 hours (1 mg/min). Add 18 mL of Cordarone I.V. (900 mg) to 500 mL D5W (conc = 1.8 mg/mL). [COLOR=#3366ff]Maintenance infusion: 540 mg over the REMAINING 18 hours (0.5 mg/min)." The problem with going outside the standard of care is legal risk. It would be appropriate to question an order that is outside the norm and document your concern to cover yourself. What if the doctor said lets give 600 mg of AMIO. Would you give it because he said to? That went out along time ago. Not a critique of you at any means. Just saying. @ESME. Adenosine is not a preferred drug for VT. It's in the AHA VT algorithm as a diagnostic technique, to be used only in the rare instance you can't tell if its SVT w/ abberancy or VT. Vagals and Adenosine only work on areas of the heart that are inervated by the vagus nerve. Thats the SA and AV node. Since V tach is below that level, adenosine or vagals will not work for true V-tach. @[COLOR=#003366]midinphx Your statement is thoughtful, accurate and the best so far. We call that constructive intervention. @[COLOR=#003366]8jimi8ICURN. Stable relates to perfusion not conciousness.

Hey all, Atropine works by blocking areas of the heart that are innervated by the vagus nerve. We know the vagus nerve only connects to the SA and AV node directly. The reason atropine is contraindicated in High level blocks (2nd type II and 3rd/CHB) is these blocks are below the level of the AV node. 2nd degree type 1 is usually at the level of the AV node and might benefit from atropine/vagal blockade. 2nd degree type II and 3rd degree/CHB originate below the AV node. Imagine we give atropine and it blocks the parasympathetic system/Vagus nerve (which is the brake pedal for the heart). It should increase SA to AV rate. Since 2nd degree type II and 3rd degree originate below the AV node, we run the risk of increasing the disassociation between the atria and ventricles. In 2nd degree type II and CHB/3rd degree all or most of the impulses from from the atria are not getting to the ventricles. That’s why we we have P waves that are not causing contractions in 2nd degree II and 3rd degree. If we just increase atrial rate that will not help our patient. We need to increase the ventricular rate to increase blood pressure. The atrial impulses can’t get to the ventricles so we run the risk of increasing the atrial rate with out concurrently increasing the ventricular rate. You can make 2nd degree type II in to 3rd degree or 3rd degree into ventricular aystole. So you might be able to increase SA-AV rate, but since 2nd degree II and 3rd degree is beneath the AV you would not concurrently increase the ventricular rate therefore increasing the dissociation. Pacing is the treatment of choice for the high level blocks. Unfortunately your instructor was wrong. We are not supposed to give atropine to 3rd degree as a primary intervention. The guidelines state “prepare for immediately pacing for higher level blocks”. I hope this helps Jeff Laabs RCP

ok, here's a basic method. there are three discinct areas of the heart; atrial, junctional and ventricular. each area has specific markers of origin. the atria. the identifiers are an upright p-wave. generally all atrial beats must have an upright p-wave. we know all p waves dont look the same. please remember, there are hundreds of potential pacemakers in the atria. so if the sa node does not fire generally one of the other atrial pacemakers should fire. we also know all potential atrial pacemakers have there own size and shape of p-waves. we know what a sa node pwave looks like. big and round. if your presented with a p-wave thats small or peaked or biphasic its still an atrial p-wave but probably not a sa node p-wave. most likely its coming from one of the other atrial pacemakers. bottom line all atrial beats must have the atrial identifier, an upright p-wave and be narrow. the junction this area also has its own distinct identifier. the four rules for junctional beats are 1. absent pwave 2. inverted p-wave 3. a pwave that occurs after the qrs. 4. be narrow both atrial and junctional beats are mostly narrow with qrss that are less than or equal to .12 seconds. both the atrial and juntional area are above the ventrical and are termed "supraventricular". the reason we describe these specific areas is because we have an easy way of determining if the qrs originates in the supraventricular area or the ventricular area. the width of the qrs is very helpful. you need to remember this point if you want to be good at reading ecgs. generally here are the rules for identifying supraventricular and ventricular rhythms. almost all supraventricular rhythms are "narrow" (ie a qrs almost all ventricular rhythms are "wide" (ie a qrs greater than .12 seconds) so if anyone asks what is the width of the qrs for any atrial or junctional rhythm, you already know the answer. if someone asks whats the width of the qrs for any ventricular rhythm you already know the answer > .12 seconds. the ventricular area. the ventricular identifier is a qrs > .12 seconds. generally if a qrs originates in the ventricles the qrs will be wide and bizarre ie. greater than .12 seconds. the wider the qrs is, the more it confirms ventricular. i totally agree about dale dubins ekg book. i hope this helps and didn't confuse you.:nuke: jeff rcp

ok, here's a basic method. there are three discinct areas of the heart; atrial, junctional and ventricular. each area has specific markers of origin. the atria. the identifiers are an upright p-wave. generally all atrial beats must have an upright p-wave. we know all p waves dont look the same. please remember, there are hundreds of potential pacemakers in the atria. so if the sa node does not fire generally one of the other atrial pacemakers should fire. we also know all potential atrial pacemakers have there own size and shape of p-waves. we know what a sa node pwave looks like. big and round. if your presented with a p-wave thats small or peaked or biphasic its still an atrial p-wave but probably not a sa node p-wave. most likely its coming from one of the other atrial pacemakers. bottom line all atrial beats must have the atrial identifier, an upright p-wave and be narrow. the junction this area also has its own distinct identifier. the four rules for junctional beats are 1. absent pwave 2. inverted p-wave 3. a pwave that occurs after the qrs. 4. be narrow both atrial and junctional beats are mostly narrow with qrss that are less than or equal to .12 seconds. both the atrial and juntional area are above the ventrical and are termed "supraventricular". the reason we describe these specific areas is because we have an easy way of determining if the qrs originates in the supraventricular area or the ventricular area. the width of the qrs is very helpful. you need to remember this point if you want to be good at reading ecgs. generally here are the rules for identifying supraventricular and ventricular rhythms. almost all supraventricular rhythms are "narrow" (ie a qrs almost all ventricular rhythms are "wide" (ie a qrs greater than .12 seconds) so if anyone asks what is the width of the qrs for any atrial or junctional rhythm, you already know the answer. if someone asks whats the width of the qrs for any ventricular rhythm you already know the answer > .12 seconds. the ventricular area. the ventricular identifier is a qrs > .12 seconds. generally if a qrs originates in the ventricles the qrs will be wide and bizarre ie. greater than .12 seconds. the wider the qrs is, the more it confirms ventricular. i totally agree about dale dubins ekg book. i hope this helps and didn't confuse you.:nuke: jeff rcp

Hey Guys, Generally the best way to determine adequate perfusion during compressions is with a A-line. It displays actual pressure numbers and you can see a difference in compressed BP depending on your compression technique. Recently I was pushing on the chest and had A-line BPs of 140/80. Someone else took over and the BP immediately dropped to 40 over 0( the new compressor was much smaller and couldn't push as hard). About the ECG waveform as a good indicator of compression depth/perfusion. This method is not accurate at all. While I have seen nice wide, almost Vtach like tracings due to excellent compressions, but I have also seen excellent compressions being performed with a very flat line (ie no reaction due to compressions). The final kicker is there is no scientific data that says it is accurate. About generating carotid or femoral pulses with chest compressions. Again there are no scientific studies (that I'm aware of) that say pulses correlate with good forward blood flow. Most studies indicate that pulses felt during cpr are generally venous pulsations. The concept being the valves in the SVC and IVC become floppy during arrest and non functional so about 10% of the blood is actually pushed backwards. The kicker is there are no studies saying compressed pulses are actually accurate to determine forward blood flow. While we still like to feel those compression pulses, generally its not very accurate. One final way is exhaled CO2. Since Co2 delivery is dependant on pulmonary blood flow, Measuring Co2 and trending CO2 generally is one of the best ways. We perform many interventions based on hypothesis and tradition, not on the basis of science. So it all comes down to the science. Anecdotal evidence is generally vaild. If you don't have a reproducible,valid study, please question those traditions... It's all good Jeff RCP Regional faculty ACLS,PALS,BLS

Hey happy nurse, Very interesting. Is that all preop cabg patients? Could you kindly ask the doc on the specifics off why you use nasal bactroban for afib? I would love to learn a new technique. See if he can give you info on the study/author/journal that he used to rationalize his choice. I have looked online but could not find anything. Thanks, Jeff

Hi All, This is a cool thread. First let me say I am a totally open to all opinion's. I don't necessarily agree but thats cool. I have laughed at many,many things in code blues. I am not against a little levity in just about any situation. To me it did seem like a sexual inuendo, not a warning of a impending diffucult airway. I may be wrong. Lets not debate over the intention of the statement. If it was sexual in nature it should just stay out of the ER or any workplace. Period. This is a very simple concept. We are just human, but should at least try to control our tongues. It just seems logical that sexual referenced jokes at the patients expense is just plain wrong. I agree with Nemhain post. "I never get too worked up about it. I do speak up in I think someone is being cruel or highly insensitive and regarding the example given I don't think in was extremely inappropriate given some of the other things I've heard doctor's/nurses say. I do believe, however, that cracking a joke in a tense moment is okay to cut the tension; I would just like it to be made about the situation and not the patient." Is it really appropriate. Who knows. I always bring it to a personal level. Would you want your mother or father or baby resuscitated in that way? Is this the professionalism we are so desperately looking for? What is the difference if the family is there or not. Do we run stop lights if the cops arent there? Can we act appropriate if even if someone isnt watching us? What if your 21 yo daughter, new grad RN is working next to some guy who loves to say these things. Would you be ok with that? What do we teach our daughters and sons to say and do if someone is offending them. Augustus said ~~ wrong is wrong even if everyone is doing it. I look at it this way. I wouldnt have confronted this guy or even said one thing to him. I do not sweat the small stuff. I have MD,RN,RT,EMT friends that occasionally do those things in codes. I have have heard references to large apendages whether male or female. I have seen rns lifting up the pt gown to ogle at a large male appendage. There has to be some line we at least try not to cross. We are not calling for people to be written up for some levity. We know some people will be upset and offended. Why take a chance. Is it that important? I dont think this person should have been written up, or fired or whatever. I never called for him to be written up. If it did bother someone that person should have told him face to face. It is simply not ethical to make sexually referenced jokes at a patients expense. It sure seems like a easy thing to do. I have never had the need to communicate that way but many people do. So it is a personal choice. Do you encourage this or try and discourge this. Its your choice. Don't complain if your written up. Would I write you up? No. Would I have said something to you, No. But someone else might. "why should i be thinking more of how to and what to say so i dont affend you a co-worker rather than focussing on those very guidelines. perhaps this is one reason many are not simply following them, because they are worried more about the people blasting them for what they say intent of focussing on what their actions are. reporting a little thing like this is actually going to have a negitive effect on patient care and cut off communications between the staff. if i was to work with someone that might get mad and report me for something like this i will be less likely to jump in and help when they might need it, out of fear of getting into trouble." Is potty talk so pervasive that we have a diffucult time speaking non-slang english in a emergency? Most I know do not have that problem. We just say "hey this is a difficult airway" Not. "This guy has a big tongue and Im sure he was very popular with the ladies" Maybe thats just me being politically correct. You be the judge. Most people dont have to think about saying the wrong thing. Are you saying if we talk potty talk our patient care will be better? I do enjoy your passion and I hope you take this in a good natured debate. No hard feelings OK... I wouldnt freak out about this guy. I Just think some MDs/RNs/RTs push the line. I promise you neither Max Harry Weil MD, nor I think the above is the reason people follow don't follow the guidelines. It is a great article by the way. Good Luck.

Hi Hilary, This is how I believe it works. If you have a Ventricular Septal Defect (VSD) / rupture, the high pressure in the LV will push a little (or alot depending on the size of the VSD / Rupture) oxygenated blood into the RV through the VSD. This will increase Svo2 in the RV and PA because freshly oxygenated blood from the LV will be mixing with the purely venous blood of the RV. The larger the hole the closer RV and PA Svo2 will approximate arterial Sao2. So if post anteroseptal MI the patients Svo2 suddenly rises we might suspect VSD / rupture. I hope this helps. I believer the PCW sat she is talking about is just Svo2. It's not actually a wedged sat. The PAC is just floating in the PA. The correct answer is D if you replace RA with RV. ( I believe this is accurate.) Anyone else??? I'm sure some CCRN's and Cardiothoracic RNs can help out on this. Jeff RCP

I would politely ask if you feel other sexual inuendo (SP?) are also acceptable. What about a reference to a large or small phallus? or Breasts. Is that also appropriate . How would legal and administration look at your statement? Would they tell you good job, way to communicate. Do you think any of your legal nurses or dept managers would approve of such a crude statement? Please come in the to the 90's. This in not 20 years ago. You just can't make statements like that with out pissing someone off. Is that reasonable? You would be wise not to communicate in that manner. Someone will get you. Eventually. At least look at it in a legal administrative view. Please answer this question. Why does anyone, man or woman have to make sexual jokes or inuendos at a code blue. What does that add to our team effort??? I definitly know a few nurses (men and women) that would write you up for that offense. If you honestly think he was trying to warn us that we might have a difficult intubation, he could have said "lets prepare a rescue airway (LMA,Combitube,COPA etc...) in case he cant get it in next time. If you want to inform the staff of an impending problem just speak in clear medical terms that we all can understand. In terms of following simple guidelines, we pray that you do. Please read the latest issue of CC Magazine and the article by Max Harry Weil MD a noted scholar and researcher with hundreds of articles. His biggest problem is that few people really follow the "simple guidelines. If we could follow the simple guidelines that would be a great start. There is lots of room for improvement. We do like and encourage critical thinking. Yes, of course. No cookie cutter medicine, but the guidelines are there for a reason. Good luck and control the tongue

The lawyers are the best part and I did read the other posts. In medicine today we have to be as accurate as possible. Picture this, you document PVCs with afib and something went wrong with your pt. The lawyer gets you up on the stand and asks about your documentation. Specifically about the PVC and afib statement. He would try and prove that you were inaccurate about your description and force you to say " ok you cant have PVCs in Afib and I did not accurately chart it." All he has to do is put some doubt about your clinical skills into the LAYPERSON jurys mind and your in trouble. This is not to say that the inaccurate description made a difference clinically but the lay people jury dont know that. They just know that if your wrong on this you might be wrong at other things also. Now they doubt you... I just want to emphasize the importance of accuracy. Word mean things and people will judge you by the words you speak or write. Is that reasonable? Have a great day all... Jeff:specs:

Hi Dinith and thanks for the post. First lets understand one basic thing. The AHA algorythms are community standards and we should be using it on most patients. This is not to say we can't deviate from AHA guidelines and try a new technique or drug if we have sound scientific evidence that shows the new technique or drug is as or more effecitive than the "standard". Bottom line. You should be using the ACLS protocols for all afib patients as a community standard. Im sure you get the gist : ) Have a great day... "Anybody know if there's a logarithm or protocol for Acute A-Fib that Dr's learn or count on? Papaw John" That was the question I was answering : ) Jeff RCP

The reason PAC blood is different than RA blood is this. RA blood just represents the sum of all venous blood returning to the heart. Blood from the pulmonary artery is "mixed Venous". In order to be mixed venous it must go through 2 heart valves to get mixed with blood coming from the coronary sinus etc... PA has a higher Saturation (around 70%) than RA. Simple, but basically correct

Here is a easy one for PEA. Possible causes( the h's and t's), Epinephrine, Atropine. The entire algorithm is in the initials PEA and in the correct order. Bradycardia. Another algorithm to drive everyone insane. Atropine, atropine, transcutanious, dopamine, epi and isuprel . This is the rt way. We have to keep is simple. Jeff

Look, its like this. Ventricular ectopy can happen in any rhythm. Premature beats generally happen on regular rhythms. We dont call a ventricular beat in afib a "PVC" It cant be premature in afib because we dont know when to expect the next beat. You are accurate to say the pt is in Afib with occasional ventricular complexes. Your inaccurate if you say pvcs. You know how lawyers are. They will look for small discrepencies to pick apart and show the jury that you dont really know what your talking about. Please be accurate in how you describe these things. What you document can save you or hang you. Its all good... Jeff RCP

Personally, I feel the obviously sexual nature of that comment is very inappropriate. I am not a prude or a stiff and do get amused at codes everyonce in a while. In todays age of quick lawsuits, I would advise that rn (male or female) to at least be careful. In many hospitals that statement could get written up in a incident report and interpreted as creating an hostile work environment. He might get fired...especially if he is known for that type of humor. A lawyer would love this guy. If a DON found out and did nothing she could get named in a lawsuit also. PS I probably would have laughed, but at this persons embarrassing statement at an inappropriate time. Some people just dont get it. People skills and being appropriate are good things. Being relaxed at codes is ok but not to relaxed. Recent studies show we perform very poorly at codes with avg compression rates of 50 instead of 100. Would you want your mom or dad resuscitated like that? In this months critical care magazine, Max Harry Weil MD writes about the sad state of in hospital code blues. One of his main complaints is that we rarely follow all the guidelines. Should we relax more or less.... Jeff RCP Advanced Life Support

Hey guys this is my first post... This is what the AHA says about A-fib and A-flutter (they both have the EXACT same treatment / algorithm) The first question that must be asked after identification of AF/AF (or any tach, wide or narrow except the automatic tachs MAT,JT,ST ) is: Question #1 "Is the patient stable or unstable". You must remember these general rules: Stable = drugs (we have a little time) Unstable = immediate synchronized cardioversion for all patients except the automatic tachycardias (MAT, JT, ST). This is an absolute rule because we have no time! Every minute we wait leads to organ hypo-perfusion that leads to MOF (multi organ failure) which has a 40-80% mortality rate. American heart feels that afib > 48 hours = left atrial clots. If someone has afib for less than 48 hour you may convert the rhythm (chemically or electrically, both are acceptable) immediately because we dont have the fear of left atrial clots. The AHA guidelines for stable AF = Anticoagulate, control the rate and convert the rhythm. Stable afib for > 48 hours we must: *Begin anticoagulation (for 3 weeks) because of high probability of left atrial clots. * Control the rate if afib out of control (greater that 100 usually >120 +++) Remember the faster the heart rate the less efficient it becomes. Calcium channel blockers, beta blockers or dig are acceptable. Diltiazem is the preferred drug over verapamil (it has a less negative inotropic affect) Beta blockers are also acceptable. Do not give amiodarone because it might control the rate but might inadvertently convert the rhythm (it can do both). Dig takes the longest to control the pt. We don't use poly drugs / multi antiarrhythmics. It causes arrythmias. * Convert the rhythm: After 3 weeks of anticoagulation bring the pt into the hospital, perform a TEE (trans-esophageal echocardiogram, which is about 95% accurate for ruling left atrial clots). If there are no clots you may convert the rhythm. Post cardioversion care, is to place the pt on anticoagulants for an additional 4 weeks. * This is called delayed cardioversion Some MDs have a problem leaving there pt in new onset afib for three weeks while we antiacoag our patient. Remember, the longer the patient remains in afib, it might become their permanent rhythm. Some MD's, if it's close to the 48 hour window, will perform a TEE in the ER and if no atrial clots will cardiovert the pt immediately and then send them home on 4 weeks of anticoagulation. This is called early cardioversion. For unstable afib or any unstable tachs, wide or narrow except the automatic tachs (MAT, JT, and ST) we use immediate cardioversion. Period. Remember what unstable means and looks like. Are there signs of shock or hypo-perfusion? Is the patient hypotensive, cold and clammy with mottled color and thready pulses? Are there crackles halfway up the lungs? Does the pt have chest pain or SOB or ALOC? These common signs scream severe life threatening shock. We have to act fast. Someone's mom or dad is begging us "please save me"! Unfortunately, many clinicians allow their pt to remain hypotensive for a prolonged time while other things or tests are done. If someone is hypotensive and symptomatic, we must act quickly! Every minute of hypotension leads the patient towards multi organ failure (MOF). MOF has the highest mortality rates of almost all ICU admissions (40-80% depending on how many organ systems are injured). Think about what a single prolonged (or not) hypotensive insult to the organs will do. Would the organs be injured from cellular hypoxia? Yes. What happens when we injure something? It becomes swollen and edematous by the hour. Question: Why are the organs injured? Answer: From cellular hypoxia. Imagine if you punched a brick wall and broke your hand in multiple places. Would it become swollen? Of course. Could you use your swollen and injured hand well? No, your hand would not function well. Now, picture the swollen and heavy kidneys that gradually stop producing urine because their so badly injured by cellular hypoxia. So what's the treatment? Cautious fluids, diuresis or dialysis, dopamine etc... This is the beginning of MOF. (organ system dysfunction #1) The lungs also become swollen and heavy and stop oxygenating and ventilating well so we have to increase Fio2 and Peep and ventilatory support. (organ system dysfunction # 2) The gut dies and becomes necrotic = dead bowel + surgery (organ system dysfunction # 3) Etc... You get the point. Question: Why do we use IMMEDIATE synchronized cardioversion for all unstable tachs (except the automatic tachs MAT, JT)? Answer: Cardioversion is the definitive treatment for unstable tach. We do use concurrent administration of anti-arrhythmics. We ensure effective oxygenation (generally NRB) while preparing for immediate synchronized cardioversion with 50-100-200-300-360 joules in a step wise approach. Some docs start at 50j, some at 200j or higher. We don't sedate or wait for an IV it just wastes precious time. We immediately cardiovert. Question: If our pt was unstable, had all the classic signs of hypoperfusion but had afib for > 48 hours ( a high likely hood of atrial clots) would we use immediate cardioversion ? Answer: Yes, what other option do we have. If we don't convert the rhythm the patient will die form cellular hypoxia > MOF. We have to cardiovert immediately. If the patient did throw a embolic stroke we would use fibrinolytics. Were picking the lesser of two evils on that one. Hope this helps... Jeff RCP Anaheim CA