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Chan Tha Soe says
According to the discussion about Q 17, it looks like we are supposed to ignore Atropine for the management of Mobitz type II and 3rd degree AV block.
Are we supposed to follow Bradycardia Algorithm strictly or Are we supposed to make exceptions about those particular rhythms?
To me, personally, I ‘d like to stick to Algorithms when it comes to emergency.
In addition, in bradycardia algorithm, they didnt put anything about exceptions.
Even on page 111, they just say ‘do not rely on atropine’ but they didnt say ‘do not give atropine’.
My opinion.
Jeff with admin. says
First, it is important to note that Mobitz II and Complete Heart Block are commonly associated with acute myocardial ischemia.
It is not so much that the Atropine won’t increase the heart rate when given for Mobitz II and Complete Heart Block. In fact it will probably increase the HR, but this has a high potential of inducing more myocardial ischemia as the HR will double or triple. This will also reduce diastolic filling time which will worsen coronary perfusion.
Since Mobitz II and Complete Heart Block are almost always associated with myocardial infarction, it would be ideal to keep the HR slow (50-60) to increase diastolic filling time. Anytime you increase HR, the diastolic filling time is what takes the biggest hit. Mobitz I is not usually associated with MI.
Transcutaneous Pacing should be the first line in symptomatic Mobitz II and Symptomatic Complete Heart Block.
Kind regards,
Jeff
Brandon Whatley says
Hi Jeff,
I am preparing for the ACLS skills test. I passed the heart code online test (part 1) fairly easily. However, I am a pre-physician assistant student, so I have never actually administered medication through IV/IO. Will I actually need to know how to physically perform an IV during the skills test?
Jeff with admin. says
You most likely will just have to verbalize that you would have an IV started and be prepared to give medications through the IV route. You should know which medications should be used and when. —Kind regards, Jeff
Barb Moelter says
Why would intubation not be an option if the patient is in third degree heart block and does not have spontaneous respirations? Why would cardioversion be the priority at this point?
Jeff with admin. says
If you could continue CPR while attempting the intubation, I suppose that it is an option. I have found that during most intubation attempts while the patient is remains pulseless precious seconds are lost for maintaining circulation which is the priority during CPR.
The longer that CPR is delayed during a pulseless state, the less likely the return to ROSC.
In my experience, intubation occurs in the period of post arrest just after ROSC.
I have to say that this is a hard call and it could be an option if you felt that you would not compromise circulation.
Regards, Jeff
Susan Wright says
I love this one, PEA, I am providing CPR and while I providing CPR by myself I will also do
1. secure the airway.
2. start and IV.
3. provide the patient with O2.
I suppose I am suppose to use both hands, arms, legs and feet to accomplish all of these tasks by myself. Really want to see a video for this scenerio.
Jeff with admin. says
It is assumed in this scenario that there is a team effort. The scenario reads: “A 65 year old male collapses as he is out for his morning walk. A bystander witnesses the collapse, activates EMS, and begins CPR. The EMS team arrives shortly, takes over CPR, and attaches a defibrillator.
This clearly states that you are not alone. I am not sure why you thought that you would be alone.
Kind regards,
Jeff
Amy Nichols says
Your comment is misquoted. He does not word the scenario to say that you are doing CPR and other tasks simultaneously. Use common sense and read more closely.
Karen Bruyere says
You are not consistent in your codes when you get a rhythm change during an arrest.
You indicate in one code to continue CPR for another 2 minutes after the change in rhythm, then act after the second rhythm check to check the for a palpable pulse.
In another scenario, you have them do a pulse check right after the change in rhythm and act upon it. I am a little confused.
Jeff with admin. says
I am not aware of which scenarios you are referring to. Thousands of people have reviewed these scenarios and this is the first time that this has been suggested. If you can please be specific about which ones you were referring to, I would be glad to take a look at them and see if corrections are needed.
During the VF/VT Algorithm with pulselessness, you will always shock then complete 5 cycles of CPR and then perform a rhythm check. If the rhythm is changed to anything that appears to be an organized rhythm, then you will perform a pulse check.
In the PEA/Asystole Pulseless algorithm, there are no shocks and therefore, the sequence would be like this:
CPR 5 cycles and give epi during cpr, rhythm check, If the rhythm is changed to anything that appears to be an organized rhythm, then you will perform a pulse check, if no pulse then CPR for 5 cycles, then rhythm check and so on.
Kind regards,Jeff
simisola Akindele says
I love this site. You make it very easy to learn the algorithms.
I had my test today and passed!!! thanks
Nada Al Kilani says
Why did chose to start TCP instead of giving atropine for the third degree heart block?
Jeff with admin. says
The patient is already attached to the defibrillator monitor and in the AHA Manual pg. 111 it states: “Do not rely on atropine in Mobitz type II second- or – 3rd Degree block.” It would be more appropriate and effective to pace for 3rd Degree block if it is readily available.–Regards, Jeff
Jennifer Baker says
Question #17,
If TCP is not available, why dopamine/epi instead of atropine? I was thinking we’d try atropine then a dopamine or epi gtt.
Thanks.
Jeff with admin. says
AHA Manual pg. 111 it states: “Do not rely on atropine in Mobitz type II second- or – 3rd Degree block.” It would be more appropriate and effective to pace for 3rd Degree block to provide a epinephrine or dopamine infusion.
katheirine applegarth says
I got caught on that one too.. on the street, how to do “all of the above”.. Misunderstood scenario i guess
Vesna Humo says
I am on the street, as I understed. How can I provide IV? Or oxygen? I can only help ,beside CPR, to opet aerways. Am I right?
Jeff with admin. says
EMS (emergency medical services) has arrived and it is assumed that you are in charge. EMS has everything needed to carry out the procedures you mentioned. (IV, oxygen, airway, etc.)—-Regards, Jeff
Rebecca Rodland says
Hi Jeff, Thanks for your site. It gave me a lot of confidence going into all the stations and having to be the team leader. I took ACLS on 4/19 and passed. This year the focus was on fast, slow heart rates, stable vs. unstable. Needed to know the order of steps. Anyway, are you going to have a site for PALS? If not can you suggest one. Thanks again.
Virginia Vizconde says
Scenario #3.
2. Why CPR for 5 cycles instead of shock 120 – 200 joules? thnks
Jeff with admin. says
The rhythm for this question is asystole. According to the right branch of the pulseless arrest algorithm, you do not shock asystole. The fist and most important intervention is to begin CPR.—regards, Jeff
Kimberly Sauder says
Rodrigo, you may have seen what you suggested in real-life practice, but ACLS guidelines say to perform immediate TCP. You can adequately BVM a pt, but if you have no perfusing rhythm you’re screwed.
Rodrigo says
The patient should have been intubated while he was in apnea, bradicardia and weak pulse. As he had a pulse and was in bradicardia, the first step in bradycardia algorithm should have been airway + breathing (intubation), NOT transcutaneous pacemaker.
Jeff with admin. says
It is possible this could be a step that you can take. In my experience intubation can be a time consuming process and since the patient is post-cardiac arrest with circulatory compromise, the case can be made to stabilize circulation since the airway is not compromised at this point. Thanks for the feedback on this. —Jeff
Elizabeth Stewart says
Mega code #3 again sorry, you list complete heart block 3rd but the p wave is getting longer and longer and then drops a beat. No irregular p waves isn’t this second degree showing in the diagram? Liz
Jeff with admin. says
The p-waves and the QRS complexes are completely disassociated. This is complete heart block. See this page for an explanation. https://acls-algorithms.com/rhythms/complete-heart-block
Sandra Houghton says
amiodarone is the correct answer.
Jeff with admin. says
The first dose of epi was given when the patent was in asystole. Technically, when the rhythm changes, you are supposed to start at the top of the algorithm. So the sequence from the top of the VT algorithm would be shock, CPR, rhythm check, shock, CPR/EPI. So the second dose of epi in this scenario was actually the first dose of epi once we moved to the treatment of VT.
In a real scenario, you would be ok to have used epi for the treatment of asystole and then with the rhythm change to VT gone straight to the amiodarone. In the scenarios on the site, I just try and stick strictly to the diagrams so that there is consistency with the AHA guidelines.
Thanks, Jeff