It is indeed irritating when it all changes (again).
However, regarding the atropine for slow PEA I don't think anyone wouild really have objected to its use before these latest guidelines.
Although I'm only a baby in the world of resus, I did raise that specific point at my last ALS course - as an anaesthetic SHO, I occasionally see patients with systolics under 80, and therefore little or no palpable pulse - especially when the orthopod is hammering away on the femur. A touch of atropine (if brady), or ephedrine (eg, if spinal anaesthetic) and the BP comes up, and a pulse is readily palpable. I don't jump straight into an arrest algorithm. Of course, we do have the advantage of, eg, being able to see the patient's CO2 production as well as a BP reading!
It is therefore not that rare to have "EMD" in anaesthetics, which is obviously "pseudo" in that there is a BP but it's just not paplable.
To get back to the question raised at the ALS course, the answer (from an RTO, not a doctor!) was that of course atropine may be useful in a bradycardic "EMD", and as doctors we are free to use our clinical judgment to add/amend the ALS guidelines as appropriate. The guidelines are just that, guidelines. For doctors who know what they're doing, to use them as rigid protocols is pretty lame. For those who are less experienced however, the ALS guidelines should obviously be adhered to - with the unfortunate consequence that didactic teaching will have to be updated regularly.
Cheers!
Giles.
On Thu, 11 January 2001, Adrian Fogarty wrote:
>
> What slightly irritates me about these amendments is that, for example, some
> of us have been using atropine for slow EMDs for years, and have even been
> known to shock pulseless SVTs, much to the chagrin of our local resus
> officers. Now it's OK!! With some of the evidence base being "tentative" as
> you put it, isn't it about time for the resus council to allow some more
> flexibility in practitioners' approach, or at least to be less didactic? At
> least that way they wouldn't be seen to perform embarrassing U-turns every
> few years and they might command a little more credibility among a wider
> audience!
>
> One question Andrew, how do they recommend one gives the amiodarone, i.e.
> centrally or peripherally, fast or slow? Brits don't like to give peripheral
> amiodarone but I know this practice is common in other countries...
>
> Adrian Fogarty
>
>
> ----- Original Message -----
> From: Andrew Lockey
>
> > Advanced Life Support
> >
> > Drugs
> > - Amiodarone 300mg IV to be considered in cardiac arrest due to pulselss
> VT or
> > VF after the third shock.
> > - No "high dose" epinephrine any more
> > - No bretyllium any more
> > - Atropine 3mg for PEA < 60 bpm
> > - Amiodarone preferable to lidocaine for peri-arrest tachyarrhythmias
> >
> > Algorithm
> > - Amiodarone is now include in the universal cardiac arrest algorithm as a
> > consideration (see above)
> > - there is a new peri-arrest algorithm for atrial fibrillation
> > - narrow complex tachcardia with no pulse with no palpable pulse should
> now be
> > cardioverted (previously recoomended that it was treated as PEA with
> > epinephrine for some bizarre reason!)
|