Trans-cutaneous pacing- What's not to love?

Preparation for Trans-cutaneous pacing (TCP) should be taking place as atropine is being pushed. If atropine does not alleviate symptomatic bradycardia, TCP should be started. If possible, the patient should receive sedation prior to pacing, as it is an uncomfortable experience. Unfortunately, if the patient is deteriorating quickly, it could become be necessary to begin TCP before sedation. Many forms of sedation may also further compromise blood pressure. The AHA now states that dopamine or epinephrine infusions are an equally effective alternative to TCP; however, these medications often take some time to get started. When a patient has symptomatic bradycardia with signs of poor perfusion (change in mental status, poor blood pressure, decreased capillary refill, etc.), trans-cutaneous pacing is the treatment of choice. Do not delay TCP for the patient with symptomatic bradycardia with signs of poor perfusion. The AHA recommends a 60/min beginning rate which can be modified up or down depending upon the patient’s clinical response. The dose for pacing ought to be set at 2mA (milliamps) higher than the dose that produces determined capture. A carotid pulse shouldn't be used for assessment of circulation as TCP will produce muscular movements which will feel like a n arterial pulse in this region of the neck. Assess circulation using the femoral pulse. TCP is contraindicated for the hypothermic patient, and isn't a suggested treatment for asystole or PEA.. Contributing factors ought to be thought about throughout the ACLS protocol since reversal of a non-cardiac cause can probably return the patient to a state of adequate perfusion.

A little about atropine

Atropine continues to be the first line medication used for acute symptomatic bradycardia in adults. Before administering atropine, it is important to assess whether the patient's symptoms are caused by the bradycardia, or, potentially the bradycardia is being caused by another issue, such as hypothyroidism, myocarditis, or medications. Generally, IV atropine in the recommended dosages (2010 guidelines dose is 0.5mg IV, repeatable every 3-5 minutes up to 3mg total) improves heart rate and alleviates symptoms associated with bradycardia. It is important to note, however, that atropine will generally be ineffective in 2nd degree type 2 (Mobitz 2) or third degree heart block, or in heart transplant patients. These patients are better treated with b-adrenergic drugs (low dose dopamine or epinephrine) or trans-cutaneous pacing. Be aware that small doses of atropine (smaller than 0.5mg IV) can have a paradoxical effect, causing a further drop in heart rate. Atropine has been removed from the pulseless arrests algorithms, as it was not found to be beneficial in these cases.

The good old precordial thump

According to the 2010 guidelines "The precordial thump may be considered for patients with witnessed, monitored, unstable VT (including pulseless VT) if a defibrillator is not immediately ready for use, but it should not delay CPR and shock delivery." The problem is that the guidelines do not explain how to do it. The precordial thump has really been de-emphasized when compared to the 2005 guidelines. A strong precordial thump can generate from 5 to 30 Jules of electricity. The heel of the fist is swung down over the lower half of the sternum forcefully, from a height of 12 inches or so. Some advocates say that to get the amount of energy needed, two hands should be used, at a height of about 2 feet. I have seen it approximately 5-6 more times, effective about half the time, and have performed it twice, with a 50 percent success rate of conversion of the rhythm. Research varies on overall percentages of success, but, at best, about 25 percent success rate overall.

The importance of CPR while an AED is charging.. and after shocking..

I am often asked in Healthcare provider classes about the importance of performing CPR while an AED or manual defibrillator is charging. Performing CPR while a defibrillator is readied is strongly recommended for all patients in cardiopulmonary arrest. Studies have documented that the shorter the amount of time between the last chest compression and shock delivery, the more probability that the shock will be successful. A reduction of even a couple of seconds in the interval from pausing compressions to shock delivery will increase the chance of shock success. Immediate resumption of CPR after a shock also increases the chances of the rhythm converting. This is one of the reasons for the strong emphasis in the guidelines of immediate resumption of compressions after a shock is delivered.

AHA classifications explained

Here is a brief chart based review of the AHA's classification scheme. Most Drugs fall into the 2A and 2B categories. Early CPR would be a Class 1, Level A