Puzzled... Pulseless VTac to v-fib but no shock?

[RunninOnCoffee]

A few weeks ago we had someone go asystole to v tach then finally v-fib. During a pulse check he was in pulse less vtach. When I said something about immediate shock the physician chose to push epi. Shortly afterwards he converted to v fib. When I mentioned it to someone later they said they would have been surprised if they shocked the pt because they were an open abdomen. Why should that have made a difference? You have to clear the pt anyways and even if there were a small risk of burn to the pt you can heal from a burn but you can't heal from dead. Maybe someone with a little more experience could shed some light on this for me.

Thanks!

[sapphire18]

"You can't heal from dead"- haha, I love it!

As for your question, I'm not sure:/. So even in vfib they didn't shock??

[RoamFreeRN]

Reason? Doc's 'judgement' trumped ACLS protocol.

[Biffbradford]

"Open abdomen"? as in wide open with just a sterile dressing? Who was running the code - surgeon or ICU doc? I assume that compressions were being done in the usual fashion? (dismissing my initial thought that the surgeon didn't want his work being ruined with anything traumatic being done - if that makes any sense to anyone. )

[msn10]

Since protocols change almost every year, it can be difficult for physicians and experienced nurses to keep up with and remember all the changes. Another challenge is that docs don't need to certify to run a code which is mind boggling to me.

Anyway, I always tell my students that they are learning the most up-to-date, evidence-based information and if they run into a situation like this they should say something to the effect of:

"Although you are asking for epi, current ACLS protocols would call for defibrillation at this time, would you still like me to give epi?"

You can do this while you are reaching for the epi as to not waste time.

This way, you are verifying that they are understanding what is going on and you are covering your self (although I have never heard of a nurse getting sued by following a doctor's orders in a code)

[brypoli]

Shock should be given even if the abdomen is open

[detroitdano]

Protocol is protocol. If you find someone trying to deter from what we are all trained to understand, you should make your best effort to speak up and prevent the error.

Agreed you're probably legally covered if the doctor is ordering interventions, but codes are a team situation. You can make suggestions, but if you're shot down, hey at least you tried.

I've been in codes where doctors have asked for wrong medicines or medicines they thought you were a good idea. When I have explained why something else is a better alternative, usually they are cordial and agree. I've had very few instances where the doctor in charge of the code was not open to suggestions.

[NPOaftermidnight, MSN, RN, NP]

I'm interested if anyone has anything else to say about this - I take care of a lot of open abdomens and have never heard of any contraindications to defibrillating them.

[JSBSN]

Exactly, you need to speak up when things aren't being done correctly, MD's make mistakes too even though they might disagree.

[Mully]

Shock shock shock! Shocking right now on a pt with pulseless VT or VF is the best tx period. Not knowing the exact dynamics of your situation, I can't tell you how to respond. However I would have probably said something like, "It's pulseless VT, this patient needs to be shocked," and then see what kind of response I got.

As far as the abdomen thing goes, I think you're exactly right. What goods an intact abdominal surgery if your hearts not beating?