Thursday, February 28, 2013

The Epinephrine Effect

The Effects of Epinephrine During a Pulseless Arrest 


Drug Therapy: Epinephrine
·         Epinephrine 1mg (1:10,000 solution) IV/IO q3-5min
·         ETT dose (1:1000 solution) 2mg diluted in 10cc of NS
·         Increases systemic vascular resistance (vasoconstriction)
·         Increase coronary and cerebral perfusion pressures during CPR
·         Escalating or high doses without demonstrable benefit
·         After drug delivery and approximately 5 cycles (or about 2 minutes) of CPR then recheck the rhythm 

Algorithms and dosages
·       Pulseless VF/VT  Epinephrine 1mg (1:10,000 solution) IV/IO q3-5min
·    Asystole:  Epinephrine 1mg (1:10,000 solution) IV/IO q3-5min
·    PEA:   Epinephrine 1mg (1:10,000 solution) IV/IO q3-5min
·    Unstable bradycardia  Epinephrine 2-10 mcg/min infusion


The effects of epinephrine usually last about 3-5 minutes.   Initially one may observe a ventricular tachycardia, wide complex tachycardia, or a narrow complex tachycardia, depending upon the underlying problem.  The patient may even have a strong or bounding pulse and an elevated blood pressure reading   But as the effects wear off, the heart rate begins to slow down as observed in the following strips.

I have observed that some people want to treat the tachycardia, especially if it is either a wide-complex tachycardia or ventricular tachycardia with a pulse.  I caution against giving the patient an antiarrhythmic because once given, you cannot take the medication back and most of the time the tachydysarrhythmia is the result of the epinephrine doing what it is supposed to do.   I  have observed some successfully defibrillate this rhythm to a bradyasystolic rhythm.   During this brief time of return to spontaneous circulation focus on correcting the underlying causes of the arrest (the Hs and Ts) and continue respiratory support, fluids, and perhaps begins some catecholamines that will sustain not only the heart rate but the blood pressure.  Any thoughts on this?


Initial rhythm:  idioventricular rhythm (pulseless)















Epinephrine 1mg IV given















Wide complex tachycardia after epinephrine















As the epinephrine begins to wear off the heart rate is slowing down.
Accelerated idioventricular rhythm











Accelerated Idioventricular rhythm










Accelerated idioventricular rhythm









Idioventricular rhythm (weak peripheral pulse)









Idioventricular rhythm (pulse by doppler)

Idioventricular rhythm (pulseless) resumption of CPR




Wednesday, February 27, 2013

Basic ECG Rhythm Test 05

EKG Practice Test

Identify the following rhythms.

1.














2.













3.













4.














5.














6.














7.














8.















9.














10.




11.















12.















13.















14.


15.











16.














17.












18.














19.








20.


21.










22.














23.









24.


25.















For another Basic ECG Rhythm Test click here


Answers

1.
1st degree AV block














2.
2nd degree AV block type II














3.
Accelerated idioventricular rhythm














4.
Asystole














5.
Supraventricular tachycardia (Atrial flutter with rapid rate)














6.
Ventricular fibrillation 














7.
Failure to pace














8.
Junctional rhythm














9.
Normal sinus rhythm with PACs














10.
Normal sinus rhythm with a PJC














11.
Torsades de pointe














12.
Ventricular paced














13.
Ventricular tachycardia













14.
2nd degree AV block type I


15.
Accelerated idioventricular rhythm


16.
Agonal rhythm


17.
Atrial fibrillation with a unifocal couplet


18.
Atrial paced


19.
3rd degree AV block













20.
Accelerated idioventricular slowing down to idioventricular rhythm



21.
Junctional tachycardia


22.
Normal sinus rhythm with electrical artifact


23.
Ventricular fibrillation


24.
Ventricular standstill (P wave asystole)














25.
Sinus arrhythmia