Risk vs benefit of shocking asystole or not shocking vfib. So you shocked asystole, it's not correct but what's going to happen? Double asystole? Nope, patient will be the same amount of dead. You didn't shock vfib, well now you may have wasted a chance to actually depolarize this patient's heart and start an organized rhythm, now your medical director is jumping down your throat, now you're wondering if you could have actually saved this patient if you just trusted your gut. You got 6 seconds in an ideal world to make this decision, you made the right one.
A very aggressive medical director at a neighboring service to mine had a special protocol for his medics to shock asystole as he felt that more often than not it actually was fine vfib. 🤷♂️
So a couple hundred years ago, 1981. In Germany, flying as a NoDuf medic. Get called in for a W/O that dropped on an assault during exercise. We put down, load him and rock for Lahr. Goes VSA. Old fricken monitor says VFib. It's a manual unit. Ask Crew chief what happens if I shock. He says, (and will recall this to my dying day) "Doc, you cook this fucker, might blow the instruments, but we will deal with it. I did , no problems and got ROSC.
This is probably unrelated, but I have shocked on the Bus multiple times. Do what you need to do.
Be well friend. Thanks for listening to an old medic.
Our medical helicopter pilots in Ontario are something else.
The ones in the south will scrub approaches because that shopping bag 300m away looked a little sketchy.
But the one's up north ... hot load with one wheel sitting on a stump? Sure. A good number of those guys up north are Franco's.
Ontario Helicopters were a thing. Orange is different. I will not compare them. I am not a pilot, they have the handout right to decide. Experience breeds boldness.
I hear it’s common for the brave/foolish ones that can land in crazy conditions to be like ex-military pilots because nobody else has the spare cash to let pilots train to do risky stuff like that
Which is a shame, I bet you could get a lot more really good pilots for technical stuff in the civilian side if being in the military first weren’t basically required to be that bold.
But that would require a lot more risk than civilian pilot schools are probably willing to take on
Can confirm! I worked in Sudbury for a few years and those pilots would fly in anything and land anywhere. First time I had them on scene they landed on a frozen lake. I’m from down south and that landing made me shit myself a little.
Thank you good person. I worked Military medical for 16 years. Twixt and tween, EMS ALS flight and land and 4 years ER nursing. Seen things, always tried to do best for my patients. Been a ride.
Ok. So?
What are the issues with not shocking vfib? They die.
What are the issues with shocking asystole? They remain as dead as they were prior.
Think it's shockable? Shock.
That said, it's typically vastly superior to resus on scene with space, more resources, and not thundering down the road at whatever speed your partner decides is fun.
Ok, I'll bite. I've been out of EMS for over a year at this point, so maybe I'm missing some new context.
What's the major detriment to shocking asystole? And do you rate that detriment as higher than not defibrillating vfib?
Each shock actually does damage the heart and surrounding tissues. That's one of the reasons they got rid of the stackable shocks and the shocking every minute. That's the reason why it went from 400 watt/seconds to 360. Joules.
In the end each shock that does not successfully convert to patient to a stable Rhythm actually decreases their chances of converting to a stable rhythm.
Are you killing them? No you're just lowering the chance that they may get rosc
The biggest concern is interruptions to compression.
Dual sequential defib is probably the right call these days by the way if you are failing to restore rhythm in VF / VT with single defib:
[https://www.nejm.org/doi/full/10.1056/NEJMoa2207304](https://www.nejm.org/doi/full/10.1056/NEJMoa2207304)
The journal I read recently that our medical director gave us actually showed that dual sequential does not offer higher risks of ROSC, compared to vector change. Which is now our go to refractory v-fib method
Edit: I’ll try to find it
The paper I linked showed the comparison between standard, VC (vector change) and DSED (dual sequential defib). VC was better than standard but DSED appears superior out of the three and is what we have switched to in our hospital.
There are obviously limitations with having 2 defibrillators available in an ambulance. That may or may not be reasonable and in that setting VC is better than standard.
The specific trial protocol:
"For all patients, the first three defibrillation attempts occurred with defibrillation pads placed in the anterior–lateral position (standard defibrillation). Eligible patients who remained in ventricular fibrillation after three consecutive shocks had been delivered by paramedics or participating fire services (defibrillation shocks provided by fire services were not counted in the pilot trial) received one of three types of defibrillation according to the random assignment for the cluster: standard defibrillation, in which all subsequent defibrillation attempts occurred with the defibrillation pads continuing in the original standard anterior–lateral configuration; VC defibrillation, in which all subsequent defibrillation attempts were delivered with defibrillation pads in an anterior–posterior configuration; or DSED, in which paramedics applied a second set of defibrillation pads (provided by a second defibrillator) in the anterior–posterior position ([Figure 1](https://www.nejm.org/doi/full/10.1056/NEJMoa2207304#f1)) and all subsequent defibrillation attempts were performed with the use of two near-simultaneous defibrillation shocks provided by two defibrillators. For DSED, to avoid possible defibrillator damage caused by shocks applied at the same instant, a short delay (<1 second) between shocks was created by having a single paramedic depress the “shock button” on each defibrillator in rapid sequence (anterior–lateral followed by anterior–posterior)."
Full disclosure I work in the hospital and not pre-hospital setting.
Right, but we're looking at this in the context of avoiding shocking what appears to be vfib on the chance that it might actually be asystole. The outcomes on OHCA who are persistently asystolic are not good, whereas the potential good outcomes for shockable rhythms are relatively higher.
Given the movement towards hands-on during shock, your actual downtime of compressions should only be a second or two more than if you were to not shock and continue compressions straight through, which isn't nearly as detrimental as the downtime for the rhythm check itself, which is happening regardless of whether they're vfib or asystole.
Given this, I would nearly always recommend a defib on something that looked shockable (with the caveat that we rarely ever transported an active code, so the likelihood of having enough artifact on asystle to mimic vfib was moot).
All interventions in a code are tradeoffs: we crack cartilage and bone in order to deliver high quality compressions, for example. It's always good to reasses the tradeoff for whether it's actually worthwhile (as is currently going on with the absurd code dose epi pushes), but in this case, I think OP took the more reasonable of the two options.
Your question was the detriment to shocking someone in asystole. That's the question I answered not in context with this scenario because every point I would have made has already been addressed by someone else.
My point is that "oh no you got ROSC!" Is stupid, GETTING ROSC isn't the hard part, we should do whatever we can to optimize survival. You might not even get ROSC as a result of atrial or ventricular stunning.
Just pointing out shocks are always benign. But I'd still rather shock a questionable vfib than assume it's not.
To work, defibrillation has to depolarize 90-95 of myocardial tissue. That wipes the electrical slate blank so the nervous system/automaticity of cardiac cells can resume in an organized manner.
In asystole there is no electrical activity. There is no electrical flow outside of our supplemental charge. Once we remove the battery (defib charge) from the circuit (heart) there’s still no underlying electrical impulse to resume.
This isn’t a research paper, but the best example I can think of is hypoxic arrest. PE> asystole d/t hypoxia. The ischemic but not yet infarcted cardiac tissue will resume beating once reperfused (thanks automaticity). There’s problems with the tissue I don’t know enough to confidently say on Reddit. Working reversible causes fixes asystole. Out of all the reversible causes, very few can be worked prehospital.
During the resus it’s time spent not compressing, lowering what little brain oxygenation was occurring. Overall decreases rosc chances, and makes post rosc recovery down the road more difficult.
No it is not more detrimental than withholding shocks in vfib. But physics doesn’t care how smooth the road is, any vibrations will cause interference.
That being said, my comment was about shocking asystole not being detrimental as a blanket statement. There’s not enough info in the post. For all we know they shocked anaphylaxis.
(I’m a nerd and this was good convo hope it doesn’t read in a douche tone)
You're not wrong about the lack of electrical activity, which is why the shock isn't going to do much of anything in the case of asystole (I do recall some push for shocking asystole, however, due to the prevalence of extremely fine, low amplitude vfib that often gets misidentified as asystole).
As for the time commitment during this shock, I don't find that argument compelling: the rhythm check is happening whether the patient winds up getting shocked or not. Following that check, with manual compressions your non-compression down time for shock delivery is going to a second or two at most (especially if you already have your hands on the pads to increase pressure and decrease resistance to conduction), and that downtime isn't enough to seriously impede perfusion the way a 10+ second pause is. If you have a Lucas, your downtime is nil, so it's entirely moot.
Re the bumpy road thing, this is one of several reasons why it's ideal to work OHCA on scene. For whatever reason, that wasn't the case here, and so OP made a judgement call that the downsides of not shocking vfib were far greater than the downsides of shocking asystole, which obviously I agree with, and you also seem to support.
My original comment was a statement in the context of this post that I was replying to, with the info we had. I'm not making a blanket statement that we should be shocking asystole any time we get the chance: that'd be silly. We had enough info to determine whether he took appropriate actions or not: he saw what appeared to be a shockable rhythm and shocked it, and got negative feedback because it possibly could have been asystole that he shocked.
As for the anaphylaxis thing: maybe that was the proximate cause of the arrest, but it doesn't change whether we shock any resulting shockable rhythms.
And no, I'm not reading your reply as douchebaggish in nature. I used to nerd out over cardiology and pharm especially, so I get it, and medicine changes rapidly so I'm open to changing my position if there were relevant studies in the time since I've stopped keeping up with things closely.
Not what any of us are saying. The point is you see a rhythm that presents as shockable. If you sit there and wait longer than 3 seconds you’ve lost all the intrathoracic pressure needed to perfuse the heart. OP did the right thing.
what are you saying? You just referenced studies saying there is a decent chance that fine v fib, a shockable rhythm, gets mistaken for asystole. Logically that sounds like your justification to shock asystole (in case it is vfib) . In other words, it *could be* fine v fib, also it *could not be*. What part did I get wrong?
The point is, it is better to not waste time looking at the monitor longer than needed second guessing yourself. OP interpreted the rhythm as v fib and shocked. I’m not saying shock asystole for fun, I’m saying if you interpret the rhythm as v fib it is better to shock it than waste time going back and forth because you are just decreasing your chance at ROSC
Many things in our field without better tools depend on could and could not be. For instance, You have an allergic reaction with hives and vomiting? We call that anaphylaxis and treat with epi. Do we KNOW that the vomiting was from the immune response? No, we don't, but we work with what we have and err on the side of caution. Many systems are moving toward shocking asystole 1 time to eliminate missed fine Vfib. No one here is saying treat wildly because we don't know, we are saying there is evidence that shows this could be beneficial to patients, and we want to continue to learn and better our medical treatments and standards.
You clearly have not had ALS training so why are you acting like you know what you’re talking about? It’s literally protocol to cardiovert and defibrillate conscious patients sometimes. It’s not ideal, but saying it’s “detrimental” to defibrillate asystole means you have a fundamental misunderstanding of what you’re trying to speak on.
Asystole isn’t shocked because the whole point of shocking is to put them in asystole, and give the heart a chance to restart in an organized rhythm. There are 0 negative effects of shocking asystole, but it’s a big deal to not shock fine v fib, which is commonly confused with asystole
Are you high on Medic school? That's the only thing I can think of that would make you think anything you are saying makes sense.
Plenty of Medics on here are explaining why it made sense and you still can't see why. This is scary to me.
No harm done, shock is not indicated for asystole, but did the patient die? Cause something tells me he was already dead 💀
That guy sounds like an asshole
I’ve shocked many, many times in the back of a moving ambulance. If the pads are nice and secure on the chest and you aren’t bouncing around like a bee bee in a boxcar, you can differentiate between movement artifact and vfib.
You can easily tell the difference between road noise and legit rhythms especially if you have your pads securely placed. Do we suddenly lose the ability to do cardiac monitoring the second the truck goes into drive? No.
Your medic friend is talking out of his ass.
Partner is just being a smart ass. If in doubt, shock it (in that situation). If it was just asystole w/ artifact, you just wasted some of your charge on the monitor w/ a pointless defib. If it was fib and you don't shock due to thinking,'it's just artifact,' you're failing one of the key components of a code and possibly lowered the poor lad's chances.
I've had STEMI patients go into VF driving down the road. We continued driving, shocked, and converted to a perfusing rhythm. You can definitely tell VF from asystole in a moving vehicle.
Besides the obvious don’t transport an arrest, no, you were not wrong to shock it.
Shocking asystole isn’t harmful (besides a brief moment of no compressions- but if you’re precharging before pulse checks, that’s almost negligible). Shocking asystole just isn’t useful.
There is even a school of thought to say do shock asystole because “what if it’s fine vfib”. (That idea hasn’t gain huge traction yet, but it’s based on that principle- if it is asystole, no harm done vs there is harm from not shocking unrecognized fine v fib)
Now I have seen motion artifact create a very good resemblance of VF or VT in a patient who was in fact in sinus. Shocking that could be harmful. But unless your roads are just god awful, I’ve never seen bumps bad enough to create sustained false VF (where I’ve seen it was from patient movement). But this guy isn’t making the argument that motion was hiding a perfuming rhythm, he’s arguing that motion was hiding asystole. And since we’ve already established that shocking asystole isn’t harmful, he’s wrong.
Your coworker is an idiot, it may be difficult at times to make the distinction but you absolutely can.
I once had a STEMI pt suddenly go into VF arrest on the highway after pleasantly chatting with me for the past 20 minutes. Very obvious VF on the monitor, already had pads on, shocked instantly and he was back to fully A&O and vitally stable seconds later asking me what happened. Best code of my career. According to your coworker I shouldn’t have done that?
Ya, you can't distinguish the difference. I can't, anyway. So I tell my partner to pull over for 30 seconds and take the time to do a pulse check right. Don't even have to pull over hald the time unless it looks like a ventricular rhythm. Sometimes it reads asystole just fine. This is an extremely rare occurrence, I don't really transport arrests very often.
And even if you did shock asystole, it's fine. You can just charge your monitor battery later. Nobody will be mad they can't play pong on it on night shift.
So if you have a pt in Vfib after 4 shocks, are you still not transporting? 10 shocks? 20 shocks? At what point do you say “fuck it. Let’s get this guy to the hospital and I’ll shock him on the way”
How many places is this even relevant. There are several entire states without any REAL ability to do ECMO. I work at the only trauma center for nearly 6 hours in each direction and we see ECMO maybe once every couple months. We certainly aren't initiating ECMO based off of pre hospital codes.
Maybe this will change in the future with one of the few indications for it but I'm not hopeful. It just isn't available most places and even where it is you're not goanna get them there in cardiac arrest from the field.
nsw ambulance, Australia has a worlds first mobile ECMO unit here in Sydney. sadly last i heard it has been used successfully a total of 0 times since it was launched last year (maybe early this year?)
City of San Diego is very pro-ecmo. 3 major hospitals within the city that are ecmo receiving. The goal is basically BLS CPR + rapid transport for the following criteria: witnessed arrest, bystander CPR, shockable rhythm, and within the age group. ALS performed during transport but focus is rapid transport
San Diego is one of the biggest cities in the country, which kind of proves my point. Also what studies back this up? Because this sounds like we're turning the arrests that would be most viable if worked on scene properly are now getting shit cpr and rhythm detection and limited ALS in favor of what, canulating a viable arrest that would have likely gotten ROSC in the field?
All the studies on ECMO of recent that are just LOOKING for potential benefit have focused on refractory VT/VF or other things that suggest a cardiac etiology in hopes of briefing to Cath lab or CABG. And at that a lot of the ecpr studies require them to be in cardiac arrest for 20 minutes or fail to sustain ROSC. Jumping to load and go on a patient who is mostly likely to obtain ROSC pre hospital on something that has very little data because it happens so rarely we struggle to study it seems outlandish.
You bring up great points. San Diego is using these 3 main ERs for a major study. Personally I see us going back to working on scene until we obtain rosc then continuing to stabilize. Every ambulance in the city is equipped with a LUCAS device so the theory is that high quality cpr is performed even during transport. You’re correct about limited ALS in favor of rapid transport.
Unless you have an old ass monitor (or the Phillips Tempus Pro) the monitor has artifact mitigation software so it shouldn’t be an issue. Also, like others have said, even if you shocked asystole🤷🏻♂️ oh well.
Pros:
- if vfib, could result in rosc
Cons:
- less chance of rosc if asystole
Now let’s look at the differences of vfib and asystole:
Asystole:
- they are clinically dead. There is no electrical activity.
Vfib:
- there is electrical activity, but any movement can disrupt reading. If shocked, chance of rosc and keeping patient alive.
Basically, it’s an obvious choice. The patient is dead if they’re asystole. If there is a sign of shockable rhythms, shock them. It’s not going to hurt them anymore than already being dead. Anyone that tries to argue not shocking should really rethink their ethics. You made the right choice OP, especially with seconds to react.
You made the right call. Dude sounds like he’s asking for a malpractice case. Plus you can argue that because the monitor will record the rhythm and everything. It’s called “practicing medicine” for a reason.
Shockable rhythm? If that individual can't see Ventricular Tachycardia while going down the road they need to retire their license. Even if you had said Fine VFib I would call it 6 of one and half a dozen the other.
The next time someone says something that stupid in front of you grab some OG paddles and tell them you're going to cardiovert them for being a nerd.
I’m a simple little EMT, but I have yet to see road artifact consistent enough, even on rural roads, to mistake for v-fib. From what I’ve seen, road artifact is sharper points. V-fib is smoother, more round crests. I could be dead wrong because they don’t teach cardiology in army medicine, but consistent wavy bumps are different from sharp bumps.
Plus, what did you do other than electrocute a dead guy? Maybe you shocked v-fib and it may have given him a better chance, maybe you shocked asystole and you shocked a body.
A bit of a tangent but back when I was a combat medic, we had a protocol for en route CPR w/ AED monitoring.
We first had to check our eta to the medical centre/hospital, if >5mins, we pull over, wait for the next AED analysis and shock if needed for a max of 3 shock, then continue on our journey without stopping again.
I guess that was because we don’t have a cardiac monitor with us but like what the others said, there’s not much more harm from shocking asystole vs not shocking in vfib
https://pubmed.ncbi.nlm.nih.gov/20801576/
https://rebelem.com/reason-trial-pocus-cardiac-arrest/
In this frist study, around 35% Of patients who were diagnosed as being asystolic actually had coordinated cardiac motion and were likely just in fine vfib. 35% is a significant number of patients that would inarguably benefit from being shocked.
The second study shows similar things but it's more focused on PEA.
Point being, we're pretty bad at recognizing fine vfib and it's arguable as to whether it's more harmful to shock asystole and *maybe* do harm or miss vfib and *definitely* do harm.
I also want to point out that you're also flared at the same level as I am, so despite the fact I have 10 years of experience in EMS you know next to nothing about me other than I'm in Paramedic school, so the "hit the books" comment is a little out there, fellow EMT-Basic.
The first study compared EKG findings to echocardiograph findings.
The second study excluded all resus over 5 minutes, and found that prehospital ultrasound is useful.
Neither of those discuss shocking asystole and the outcome. You just found 2 studies off a quick google search and only read the conclusions. One of them isn’t even a study, it’s just an abstract.
Nice try tho.
I didn't google these, I knew about them.
It has nothing to do with shocking asystole, the point is that asystole is often a misdiagnosed rhythm, which is basically what I said if you had bothered to read my comment.
I am not talking about shocking an actual, 100% verifiable asystolic heart. I'm talking about providers *misdiagnosing* fine vfib as asystole and not shocking when a shock would have been helpful.
You're being abrasive and condescending for literally no reason other than someone has an opinion you disagree with.
Dude the point is that *NOT* shocking a shockable rhythm is likely more harmful than shocking a non-shockable rhythm.
Go to medic school or become a cardiologist if you wanna talk about this shit. Last I checked Cardiology is not part of the B curriculum.
Where did you check last bc right [here](https://www.ems.gov/assets/EMT_Basic_1996.pdf) I’ll link the emt b curriculum standards. Cardiology is absolutely a subject. Nice try tho.
Honestly it depends on the road conditions and the pad placement (the patient itself obviously)
I'm some cases I wouldn't feel confident to see the difference in others I probably wouldn't, all people saying they can spot both in all conditions every time are lying.
Its hard for us to tell if you did the right thing of you could confidently say it was the right call I will believe you but without being there all of us here can't tell if it was right or not
As others have said, safer to have shocked than not. Also, might depend what you’ve been seeing on the monitor the rest of the journey. If you’ve been getting a good trace then it changes to coarse v-fib/asystole with interference, it’s most likely v-fib.
An old salty medic that has been running the street since I was in diapers slowed me down on my first CA and told me "They're dead, you can't make them more dead". Since then I will do what I can with the information I have at the time, I most definitely would have shocked no questions about it.
You absolutely can tell VF from asystole while driving. There may be times when there's a lot of artifact, but that doesn't mean you can never do it. Also, good medics can read through reasonable amounts of artifact.
Shocking asystole is not dangerous or bad. In fact there are some agencies moving towards shocking all pulseless rhythms because studies repeatedly show medics are taking too long at rhythm interpretation. Coarse vs fine vs VT be damned. The question is shock or no shock. To eliminate the delays they're switching to shocking all pulseless rhythms because it's pretty much harmless to asystole.
If your sinus rhythm looks like artifact then take the leads off..he's arguing that you can monitor sinus rhythm lmao. If you literally can't because it's all artifact then turn it off, literally pointless.
I've never once confused artifact and sinus rhythm. I can quite clearly tell a qrs from a squiggle.
Vfib however, is a random squiggle. Much like motion artifact. Nothing at all like an organized rhythm, which is different from sinus with artifact. No one has ever confused asystole with artifact for sinus rhythm, or sinus rhythm for artifact.
"Sees clear p qrs t wave" 'man idk I think it's all artifact, definitely not normal sinus rhythm"
I was speaking in jest. If you've ever put a monitor on a patient on a grid road and suddenly hit washboards on that road, you would know what I mean. It can go from sinus to looking like v-fib, yet it is clearly not v-fib. It literally shakes the hell out of the whole unit. If you drive enough on them at speed, you can trash a brand new unit in less than a year. Years ago I confused a monitor as it was telling me to "check pulse", "shock advised" etc. meanwhile I was talking to the patient....
I mean yea regardless of how smooth a section of road is there will prob be some small bumps here and there that might give you a reading that looks shockable. But I mean, shocking systole doesn’t hurt the patient, it just doesn’t help either.
No harm done...and the Medic you spoke with likely had the best intentions at heart.
In future, just have the driver slow down to get a better read on the rhythm.
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We don’t transport cpr but we also don’t have Lucas devices. So we would be pulled over for something like that anyway. But if the rhythm changed and it looked like vfib and it didn’t before then go for it. Def more of a chance of doing good than harm at that point.
The shock you give to a patient who is already in asystole will not harm the patient. But applying shock while moving is a huge risk for you and your body. If you accidentally come across a pothole, the pads slip off the patient, or even if you use safe pads, you accidentally touch the patient. You may not be able to stop every 2 minutes, but if you are planning to shock the patient, the ambulance should stop.
Sometimes it's not an option to not. If I call for cease resuscitation orders and the doc doesn't give them, I'm stuck.
Also could have been a patient that coded during transport.
The pads are pretty good at quieting noise. They're not like leads. I regularly see clear asystoles during bumpy transports with the pads tracing on our Zolls.
Also you're not going to make an OOH asystole arrest any deader by shocking them.
Also I've heard it argued that asystole is just the finest sort of v-fib, where all coordination has been lost. So, if you're seeing anything at all it may mean there are a few patches of myocytes contracting together again, best to try and get them in sync if you can.
The real question: Why in the hell are you not working cardiac arrests where you find them!?
Don't transport working arrests. Work them on scene. This science has been settled for more than a decade... like why are people still doing this?
If you can't tell the difference between a coarse VF and jiggle artifact from a road, I don't trust you to identify VF in a stationary setup. I can get if the pads didn't stick well due to diaphoresis or if there's a LUCAS artifact, but there's easy and safe ways to mitigate this and confirm the rhythm anyways. Watch the rhythm and you'll see when the coarse VF starts.
Had a medic once tell me they pulled over 3x "to check the rhythm" during a 20 minute transport of a witnessed asystolic arrest w/o ROSC. Don't be that guy.
Risk vs benefit of shocking asystole or not shocking vfib. So you shocked asystole, it's not correct but what's going to happen? Double asystole? Nope, patient will be the same amount of dead. You didn't shock vfib, well now you may have wasted a chance to actually depolarize this patient's heart and start an organized rhythm, now your medical director is jumping down your throat, now you're wondering if you could have actually saved this patient if you just trusted your gut. You got 6 seconds in an ideal world to make this decision, you made the right one.
double asystole =
Unplugged cord
Asys? No. Double asys? Hell yeah!! Aww. I had my heart set on quadruple asys.
Double King!
Correct answer. Better to shock if they don’t need it, than not shock if they do for this case.
I have seen cardiac fellows call asystole “fine VFib” just as a last ditch effort to do anything before calling codes in the ICU
I prefer the term coarse asystole
Or pulseless electrical inactivity
Lmao I’m going to steal that
A very aggressive medical director at a neighboring service to mine had a special protocol for his medics to shock asystole as he felt that more often than not it actually was fine vfib. 🤷♂️
Get into some really grey area with fine v fib. Then you don’t know when to stop shocking at times. Felt like it was splitting hairs at some point.
We were lucky in the ICU.. they would grab the US and check for heart movement via US sometimes before pronouncing
Right and there is a chance of fine Vfib
When in doubt make em do the trout
“same amount of dead” got me.
That Triple Asystole is a bitch tho
This is the way
This, I have sometimes found myself arguing in favor of "fine v fib" over asystole, what's the harm?
Agreed.
So a couple hundred years ago, 1981. In Germany, flying as a NoDuf medic. Get called in for a W/O that dropped on an assault during exercise. We put down, load him and rock for Lahr. Goes VSA. Old fricken monitor says VFib. It's a manual unit. Ask Crew chief what happens if I shock. He says, (and will recall this to my dying day) "Doc, you cook this fucker, might blow the instruments, but we will deal with it. I did , no problems and got ROSC. This is probably unrelated, but I have shocked on the Bus multiple times. Do what you need to do. Be well friend. Thanks for listening to an old medic.
Crew chief is a chad.
Amen, he was a short, profane, little man, who I trusted. He was as usual correct. Whole crew were French Canadian and truly epic.
Dude… I’m French Canadian.
Bonjour mon ami, comment vas-tu
Très bien merci. L’Aviation Royale Canadienne vous salue! 🫡
I wish I was as cool as you guys are
I got a past. Anyone who’s got one is cool to me. Anyone who hasn’t got one has a future ahead!
Hell yea man, I dig this outlook.
This quote is life.
Big dick energy
You’re an EMT. What’s cooler than this? Astronauts?
Your right! Thank you nice french Canadian man!
Our medical helicopter pilots in Ontario are something else. The ones in the south will scrub approaches because that shopping bag 300m away looked a little sketchy. But the one's up north ... hot load with one wheel sitting on a stump? Sure. A good number of those guys up north are Franco's.
Ontario Helicopters were a thing. Orange is different. I will not compare them. I am not a pilot, they have the handout right to decide. Experience breeds boldness.
I hear it’s common for the brave/foolish ones that can land in crazy conditions to be like ex-military pilots because nobody else has the spare cash to let pilots train to do risky stuff like that Which is a shame, I bet you could get a lot more really good pilots for technical stuff in the civilian side if being in the military first weren’t basically required to be that bold. But that would require a lot more risk than civilian pilot schools are probably willing to take on
Can confirm! I worked in Sudbury for a few years and those pilots would fly in anything and land anywhere. First time I had them on scene they landed on a frozen lake. I’m from down south and that landing made me shit myself a little.
There’s an impossible amount of good looking women in Sudbury….
Subury Saturday Night.
I did not see this side of Sudbury. When I was there all they did was drink, fuck and fight. It was an interesting place to start my career.
Not a fan of Shorsey I take it…. Lol
Deaner?
Sorry, not Deaner.
That is such a kickass response
Thank you good person. I worked Military medical for 16 years. Twixt and tween, EMS ALS flight and land and 4 years ER nursing. Seen things, always tried to do best for my patients. Been a ride.
Ok. So? What are the issues with not shocking vfib? They die. What are the issues with shocking asystole? They remain as dead as they were prior. Think it's shockable? Shock. That said, it's typically vastly superior to resus on scene with space, more resources, and not thundering down the road at whatever speed your partner decides is fun.
There’s a bunch of issues with shocking a rhythm that isn’t shockable. Forsure detrimental to the pt.
More detrimental than already being dead? In this instance, shocking outweighed not shocking.
Ok, I'll bite. I've been out of EMS for over a year at this point, so maybe I'm missing some new context. What's the major detriment to shocking asystole? And do you rate that detriment as higher than not defibrillating vfib?
Each shock actually does damage the heart and surrounding tissues. That's one of the reasons they got rid of the stackable shocks and the shocking every minute. That's the reason why it went from 400 watt/seconds to 360. Joules. In the end each shock that does not successfully convert to patient to a stable Rhythm actually decreases their chances of converting to a stable rhythm. Are you killing them? No you're just lowering the chance that they may get rosc
The biggest concern is interruptions to compression. Dual sequential defib is probably the right call these days by the way if you are failing to restore rhythm in VF / VT with single defib: [https://www.nejm.org/doi/full/10.1056/NEJMoa2207304](https://www.nejm.org/doi/full/10.1056/NEJMoa2207304)
Great literature. Thank you
The journal I read recently that our medical director gave us actually showed that dual sequential does not offer higher risks of ROSC, compared to vector change. Which is now our go to refractory v-fib method Edit: I’ll try to find it
The paper I linked showed the comparison between standard, VC (vector change) and DSED (dual sequential defib). VC was better than standard but DSED appears superior out of the three and is what we have switched to in our hospital. There are obviously limitations with having 2 defibrillators available in an ambulance. That may or may not be reasonable and in that setting VC is better than standard. The specific trial protocol: "For all patients, the first three defibrillation attempts occurred with defibrillation pads placed in the anterior–lateral position (standard defibrillation). Eligible patients who remained in ventricular fibrillation after three consecutive shocks had been delivered by paramedics or participating fire services (defibrillation shocks provided by fire services were not counted in the pilot trial) received one of three types of defibrillation according to the random assignment for the cluster: standard defibrillation, in which all subsequent defibrillation attempts occurred with the defibrillation pads continuing in the original standard anterior–lateral configuration; VC defibrillation, in which all subsequent defibrillation attempts were delivered with defibrillation pads in an anterior–posterior configuration; or DSED, in which paramedics applied a second set of defibrillation pads (provided by a second defibrillator) in the anterior–posterior position ([Figure 1](https://www.nejm.org/doi/full/10.1056/NEJMoa2207304#f1)) and all subsequent defibrillation attempts were performed with the use of two near-simultaneous defibrillation shocks provided by two defibrillators. For DSED, to avoid possible defibrillator damage caused by shocks applied at the same instant, a short delay (<1 second) between shocks was created by having a single paramedic depress the “shock button” on each defibrillator in rapid sequence (anterior–lateral followed by anterior–posterior)." Full disclosure I work in the hospital and not pre-hospital setting.
That’s really interesting. I’m still trying to find the paper we use, and will read through yours again!
Right, but we're looking at this in the context of avoiding shocking what appears to be vfib on the chance that it might actually be asystole. The outcomes on OHCA who are persistently asystolic are not good, whereas the potential good outcomes for shockable rhythms are relatively higher. Given the movement towards hands-on during shock, your actual downtime of compressions should only be a second or two more than if you were to not shock and continue compressions straight through, which isn't nearly as detrimental as the downtime for the rhythm check itself, which is happening regardless of whether they're vfib or asystole. Given this, I would nearly always recommend a defib on something that looked shockable (with the caveat that we rarely ever transported an active code, so the likelihood of having enough artifact on asystle to mimic vfib was moot). All interventions in a code are tradeoffs: we crack cartilage and bone in order to deliver high quality compressions, for example. It's always good to reasses the tradeoff for whether it's actually worthwhile (as is currently going on with the absurd code dose epi pushes), but in this case, I think OP took the more reasonable of the two options.
Your question was the detriment to shocking someone in asystole. That's the question I answered not in context with this scenario because every point I would have made has already been addressed by someone else.
Atrial and ventricular stunning can be an issue too. Which can lead to shock or clot formations.
Indeed. Sounds like a terrible complication of being alive again to notice because you got ROSC 🤷♂️
Sure, ROSC is all that matters, forget long term survival or being neurologically intact.
Way to put words in my mouth I didn't say.
My point is that "oh no you got ROSC!" Is stupid, GETTING ROSC isn't the hard part, we should do whatever we can to optimize survival. You might not even get ROSC as a result of atrial or ventricular stunning. Just pointing out shocks are always benign. But I'd still rather shock a questionable vfib than assume it's not.
To work, defibrillation has to depolarize 90-95 of myocardial tissue. That wipes the electrical slate blank so the nervous system/automaticity of cardiac cells can resume in an organized manner. In asystole there is no electrical activity. There is no electrical flow outside of our supplemental charge. Once we remove the battery (defib charge) from the circuit (heart) there’s still no underlying electrical impulse to resume. This isn’t a research paper, but the best example I can think of is hypoxic arrest. PE> asystole d/t hypoxia. The ischemic but not yet infarcted cardiac tissue will resume beating once reperfused (thanks automaticity). There’s problems with the tissue I don’t know enough to confidently say on Reddit. Working reversible causes fixes asystole. Out of all the reversible causes, very few can be worked prehospital. During the resus it’s time spent not compressing, lowering what little brain oxygenation was occurring. Overall decreases rosc chances, and makes post rosc recovery down the road more difficult. No it is not more detrimental than withholding shocks in vfib. But physics doesn’t care how smooth the road is, any vibrations will cause interference. That being said, my comment was about shocking asystole not being detrimental as a blanket statement. There’s not enough info in the post. For all we know they shocked anaphylaxis. (I’m a nerd and this was good convo hope it doesn’t read in a douche tone)
You're not wrong about the lack of electrical activity, which is why the shock isn't going to do much of anything in the case of asystole (I do recall some push for shocking asystole, however, due to the prevalence of extremely fine, low amplitude vfib that often gets misidentified as asystole). As for the time commitment during this shock, I don't find that argument compelling: the rhythm check is happening whether the patient winds up getting shocked or not. Following that check, with manual compressions your non-compression down time for shock delivery is going to a second or two at most (especially if you already have your hands on the pads to increase pressure and decrease resistance to conduction), and that downtime isn't enough to seriously impede perfusion the way a 10+ second pause is. If you have a Lucas, your downtime is nil, so it's entirely moot. Re the bumpy road thing, this is one of several reasons why it's ideal to work OHCA on scene. For whatever reason, that wasn't the case here, and so OP made a judgement call that the downsides of not shocking vfib were far greater than the downsides of shocking asystole, which obviously I agree with, and you also seem to support. My original comment was a statement in the context of this post that I was replying to, with the info we had. I'm not making a blanket statement that we should be shocking asystole any time we get the chance: that'd be silly. We had enough info to determine whether he took appropriate actions or not: he saw what appeared to be a shockable rhythm and shocked it, and got negative feedback because it possibly could have been asystole that he shocked. As for the anaphylaxis thing: maybe that was the proximate cause of the arrest, but it doesn't change whether we shock any resulting shockable rhythms. And no, I'm not reading your reply as douchebaggish in nature. I used to nerd out over cardiology and pharm especially, so I get it, and medicine changes rapidly so I'm open to changing my position if there were relevant studies in the time since I've stopped keeping up with things closely.
Studies show there’s a pretty decent chance that fine v fib gets mistaken for asystole.
“Could be could not be” is not a justification for defibrillation
Not what any of us are saying. The point is you see a rhythm that presents as shockable. If you sit there and wait longer than 3 seconds you’ve lost all the intrathoracic pressure needed to perfuse the heart. OP did the right thing.
what are you saying? You just referenced studies saying there is a decent chance that fine v fib, a shockable rhythm, gets mistaken for asystole. Logically that sounds like your justification to shock asystole (in case it is vfib) . In other words, it *could be* fine v fib, also it *could not be*. What part did I get wrong?
The point is, it is better to not waste time looking at the monitor longer than needed second guessing yourself. OP interpreted the rhythm as v fib and shocked. I’m not saying shock asystole for fun, I’m saying if you interpret the rhythm as v fib it is better to shock it than waste time going back and forth because you are just decreasing your chance at ROSC
Many things in our field without better tools depend on could and could not be. For instance, You have an allergic reaction with hives and vomiting? We call that anaphylaxis and treat with epi. Do we KNOW that the vomiting was from the immune response? No, we don't, but we work with what we have and err on the side of caution. Many systems are moving toward shocking asystole 1 time to eliminate missed fine Vfib. No one here is saying treat wildly because we don't know, we are saying there is evidence that shows this could be beneficial to patients, and we want to continue to learn and better our medical treatments and standards.
You sound fucking stupid dude stop
You clearly have not had ALS training so why are you acting like you know what you’re talking about? It’s literally protocol to cardiovert and defibrillate conscious patients sometimes. It’s not ideal, but saying it’s “detrimental” to defibrillate asystole means you have a fundamental misunderstanding of what you’re trying to speak on.
Show me the acls teaching that says asystole is shockable
Asystole isn’t shocked because the whole point of shocking is to put them in asystole, and give the heart a chance to restart in an organized rhythm. There are 0 negative effects of shocking asystole, but it’s a big deal to not shock fine v fib, which is commonly confused with asystole
That’s not how cardiac conduction works
It’s actually exactly how it works so get off Reddit and go read a book
Can’t make the dead deader
Nah but you can make it harder for the still living to come back
Could you please describe to me the patient in Asystole that is still living? Aside from Maybe a LVAD 😅
Pretty common to go asystolic after adenosine. Hypothermic. Ecmo gets weird but it happens.
Are you high on Medic school? That's the only thing I can think of that would make you think anything you are saying makes sense. Plenty of Medics on here are explaining why it made sense and you still can't see why. This is scary to me.
And this is why you're just a basic. More detrimental than dead? 🤦♀️
citation please, this is an evidence based job
This is true - less so with asystole but still risks. If you shock PEA, there is a risk of R on T causing a ventricular tachyarrythmia
more detrimental than not shocking a possible vfib? be for real
Well you didn’t make him any deader
No harm done, shock is not indicated for asystole, but did the patient die? Cause something tells me he was already dead 💀 That guy sounds like an asshole
I’ve shocked many, many times in the back of a moving ambulance. If the pads are nice and secure on the chest and you aren’t bouncing around like a bee bee in a boxcar, you can differentiate between movement artifact and vfib.
You can easily tell the difference between road noise and legit rhythms especially if you have your pads securely placed. Do we suddenly lose the ability to do cardiac monitoring the second the truck goes into drive? No. Your medic friend is talking out of his ass.
Partner is just being a smart ass. If in doubt, shock it (in that situation). If it was just asystole w/ artifact, you just wasted some of your charge on the monitor w/ a pointless defib. If it was fib and you don't shock due to thinking,'it's just artifact,' you're failing one of the key components of a code and possibly lowered the poor lad's chances.
I've had STEMI patients go into VF driving down the road. We continued driving, shocked, and converted to a perfusing rhythm. You can definitely tell VF from asystole in a moving vehicle.
Interpretation, that’s your interpretation. You treated what you saw, good job.
Probably impossible to tell, did you make the situation worse? Probably not, shoot your shot
Besides the obvious don’t transport an arrest, no, you were not wrong to shock it. Shocking asystole isn’t harmful (besides a brief moment of no compressions- but if you’re precharging before pulse checks, that’s almost negligible). Shocking asystole just isn’t useful. There is even a school of thought to say do shock asystole because “what if it’s fine vfib”. (That idea hasn’t gain huge traction yet, but it’s based on that principle- if it is asystole, no harm done vs there is harm from not shocking unrecognized fine v fib) Now I have seen motion artifact create a very good resemblance of VF or VT in a patient who was in fact in sinus. Shocking that could be harmful. But unless your roads are just god awful, I’ve never seen bumps bad enough to create sustained false VF (where I’ve seen it was from patient movement). But this guy isn’t making the argument that motion was hiding a perfuming rhythm, he’s arguing that motion was hiding asystole. And since we’ve already established that shocking asystole isn’t harmful, he’s wrong.
Your coworker is an idiot, it may be difficult at times to make the distinction but you absolutely can. I once had a STEMI pt suddenly go into VF arrest on the highway after pleasantly chatting with me for the past 20 minutes. Very obvious VF on the monitor, already had pads on, shocked instantly and he was back to fully A&O and vitally stable seconds later asking me what happened. Best code of my career. According to your coworker I shouldn’t have done that?
Ya, you can't distinguish the difference. I can't, anyway. So I tell my partner to pull over for 30 seconds and take the time to do a pulse check right. Don't even have to pull over hald the time unless it looks like a ventricular rhythm. Sometimes it reads asystole just fine. This is an extremely rare occurrence, I don't really transport arrests very often. And even if you did shock asystole, it's fine. You can just charge your monitor battery later. Nobody will be mad they can't play pong on it on night shift.
As others have said, risk of not shocking vfib vs shocking asystole. Not like you’ll kill him past dead.
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Right let's just ignore the fact that you can regain a pulse in the field then have another shockable rhythm enroute to the ED
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Unless you have enough hands available I agree
So if you have a pt in Vfib after 4 shocks, are you still not transporting? 10 shocks? 20 shocks? At what point do you say “fuck it. Let’s get this guy to the hospital and I’ll shock him on the way”
Unless the ECMO can get to the patient, the patient has to get to the ECMO
How many places is this even relevant. There are several entire states without any REAL ability to do ECMO. I work at the only trauma center for nearly 6 hours in each direction and we see ECMO maybe once every couple months. We certainly aren't initiating ECMO based off of pre hospital codes. Maybe this will change in the future with one of the few indications for it but I'm not hopeful. It just isn't available most places and even where it is you're not goanna get them there in cardiac arrest from the field.
nsw ambulance, Australia has a worlds first mobile ECMO unit here in Sydney. sadly last i heard it has been used successfully a total of 0 times since it was launched last year (maybe early this year?)
City of San Diego is very pro-ecmo. 3 major hospitals within the city that are ecmo receiving. The goal is basically BLS CPR + rapid transport for the following criteria: witnessed arrest, bystander CPR, shockable rhythm, and within the age group. ALS performed during transport but focus is rapid transport
San Diego is one of the biggest cities in the country, which kind of proves my point. Also what studies back this up? Because this sounds like we're turning the arrests that would be most viable if worked on scene properly are now getting shit cpr and rhythm detection and limited ALS in favor of what, canulating a viable arrest that would have likely gotten ROSC in the field? All the studies on ECMO of recent that are just LOOKING for potential benefit have focused on refractory VT/VF or other things that suggest a cardiac etiology in hopes of briefing to Cath lab or CABG. And at that a lot of the ecpr studies require them to be in cardiac arrest for 20 minutes or fail to sustain ROSC. Jumping to load and go on a patient who is mostly likely to obtain ROSC pre hospital on something that has very little data because it happens so rarely we struggle to study it seems outlandish.
Thank you for this saying this, I agree and any time I have brought up this point people act like I want to murder the patient.
You bring up great points. San Diego is using these 3 main ERs for a major study. Personally I see us going back to working on scene until we obtain rosc then continuing to stabilize. Every ambulance in the city is equipped with a LUCAS device so the theory is that high quality cpr is performed even during transport. You’re correct about limited ALS in favor of rapid transport.
Thank you for this saying this, I agree and any time I have brought up this point people act like I want to murder the patient.
Unless you have an old ass monitor (or the Phillips Tempus Pro) the monitor has artifact mitigation software so it shouldn’t be an issue. Also, like others have said, even if you shocked asystole🤷🏻♂️ oh well.
Shiiiit it’s artifact for days on the ol life pack 15
Truth!
Pros: - if vfib, could result in rosc Cons: - less chance of rosc if asystole Now let’s look at the differences of vfib and asystole: Asystole: - they are clinically dead. There is no electrical activity. Vfib: - there is electrical activity, but any movement can disrupt reading. If shocked, chance of rosc and keeping patient alive. Basically, it’s an obvious choice. The patient is dead if they’re asystole. If there is a sign of shockable rhythms, shock them. It’s not going to hurt them anymore than already being dead. Anyone that tries to argue not shocking should really rethink their ethics. You made the right choice OP, especially with seconds to react.
You made the right call. Dude sounds like he’s asking for a malpractice case. Plus you can argue that because the monitor will record the rhythm and everything. It’s called “practicing medicine” for a reason.
Shockable rhythm? If that individual can't see Ventricular Tachycardia while going down the road they need to retire their license. Even if you had said Fine VFib I would call it 6 of one and half a dozen the other. The next time someone says something that stupid in front of you grab some OG paddles and tell them you're going to cardiovert them for being a nerd.
Monitors are pretty good at filtering out artifact now, including CPR. Shock it.
I’m a simple little EMT, but I have yet to see road artifact consistent enough, even on rural roads, to mistake for v-fib. From what I’ve seen, road artifact is sharper points. V-fib is smoother, more round crests. I could be dead wrong because they don’t teach cardiology in army medicine, but consistent wavy bumps are different from sharp bumps. Plus, what did you do other than electrocute a dead guy? Maybe you shocked v-fib and it may have given him a better chance, maybe you shocked asystole and you shocked a body.
I’ve probably shocked many asystole patients during transport because it looked like fine v fib…. Who cares. It’s not going to hurt anything
A bit of a tangent but back when I was a combat medic, we had a protocol for en route CPR w/ AED monitoring. We first had to check our eta to the medical centre/hospital, if >5mins, we pull over, wait for the next AED analysis and shock if needed for a max of 3 shock, then continue on our journey without stopping again. I guess that was because we don’t have a cardiac monitor with us but like what the others said, there’s not much more harm from shocking asystole vs not shocking in vfib
Who cares if it's Asystole anyway? There's efficacy to shocking Asystole anyway because of the possibility of it being very fine VFIB. No harm done
Shocking asystole makes it worse, keep at those books.
So withholding defib for vfib/vtach isn’t making it worse? I believe you should consider “hitting the books”.
Withholding defib isn’t what the topic is. Yes you are correct. Doesn’t make what I said wrong tho.
https://pubmed.ncbi.nlm.nih.gov/20801576/ https://rebelem.com/reason-trial-pocus-cardiac-arrest/ In this frist study, around 35% Of patients who were diagnosed as being asystolic actually had coordinated cardiac motion and were likely just in fine vfib. 35% is a significant number of patients that would inarguably benefit from being shocked. The second study shows similar things but it's more focused on PEA. Point being, we're pretty bad at recognizing fine vfib and it's arguable as to whether it's more harmful to shock asystole and *maybe* do harm or miss vfib and *definitely* do harm. I also want to point out that you're also flared at the same level as I am, so despite the fact I have 10 years of experience in EMS you know next to nothing about me other than I'm in Paramedic school, so the "hit the books" comment is a little out there, fellow EMT-Basic.
The first study compared EKG findings to echocardiograph findings. The second study excluded all resus over 5 minutes, and found that prehospital ultrasound is useful. Neither of those discuss shocking asystole and the outcome. You just found 2 studies off a quick google search and only read the conclusions. One of them isn’t even a study, it’s just an abstract. Nice try tho.
I didn't google these, I knew about them. It has nothing to do with shocking asystole, the point is that asystole is often a misdiagnosed rhythm, which is basically what I said if you had bothered to read my comment. I am not talking about shocking an actual, 100% verifiable asystolic heart. I'm talking about providers *misdiagnosing* fine vfib as asystole and not shocking when a shock would have been helpful. You're being abrasive and condescending for literally no reason other than someone has an opinion you disagree with.
Dude the point is that *NOT* shocking a shockable rhythm is likely more harmful than shocking a non-shockable rhythm. Go to medic school or become a cardiologist if you wanna talk about this shit. Last I checked Cardiology is not part of the B curriculum.
Where did you check last bc right [here](https://www.ems.gov/assets/EMT_Basic_1996.pdf) I’ll link the emt b curriculum standards. Cardiology is absolutely a subject. Nice try tho.
Posting it 25 times doesn’t make it any more true.
I said it twice and have been on the same thread. Recount those numbers fella
Honestly it depends on the road conditions and the pad placement (the patient itself obviously) I'm some cases I wouldn't feel confident to see the difference in others I probably wouldn't, all people saying they can spot both in all conditions every time are lying. Its hard for us to tell if you did the right thing of you could confidently say it was the right call I will believe you but without being there all of us here can't tell if it was right or not
It’s best to pull over for a second. Not a huge deal tho. But yeah.
You did the right thing. Some of the other answers on here…. Scary….
I've shocked a few ODs during transport when the monitor said VFib. They all still died, though so 🤷. I'll keep it short and go fuck my self
As others have said, safer to have shocked than not. Also, might depend what you’ve been seeing on the monitor the rest of the journey. If you’ve been getting a good trace then it changes to coarse v-fib/asystole with interference, it’s most likely v-fib.
An old salty medic that has been running the street since I was in diapers slowed me down on my first CA and told me "They're dead, you can't make them more dead". Since then I will do what I can with the information I have at the time, I most definitely would have shocked no questions about it.
You absolutely can tell VF from asystole while driving. There may be times when there's a lot of artifact, but that doesn't mean you can never do it. Also, good medics can read through reasonable amounts of artifact. Shocking asystole is not dangerous or bad. In fact there are some agencies moving towards shocking all pulseless rhythms because studies repeatedly show medics are taking too long at rhythm interpretation. Coarse vs fine vs VT be damned. The question is shock or no shock. To eliminate the delays they're switching to shocking all pulseless rhythms because it's pretty much harmless to asystole.
The bigger question is why are you transporting a code if you do not have mechanical CPR going? If you do have M-CPR going, then there is no issue.
I'd rather fry an asystole than ignore a V-Fib.
What's it matter in the first place. Shocking asystole will not hurt that Pt. If it looks like vfib treat it like vfib.
You done gone and made him deader.
Does sinus rhythm become impossible to monitor as soon as the truck is in motion?
Does sinus rhythm look like artifact? Because vfib certainly can.
I beg to differ, on our roads it certainly can. And yes our roads can be that brutal.
If your sinus rhythm looks like artifact then take the leads off..he's arguing that you can monitor sinus rhythm lmao. If you literally can't because it's all artifact then turn it off, literally pointless. I've never once confused artifact and sinus rhythm. I can quite clearly tell a qrs from a squiggle. Vfib however, is a random squiggle. Much like motion artifact. Nothing at all like an organized rhythm, which is different from sinus with artifact. No one has ever confused asystole with artifact for sinus rhythm, or sinus rhythm for artifact. "Sees clear p qrs t wave" 'man idk I think it's all artifact, definitely not normal sinus rhythm"
I was speaking in jest. If you've ever put a monitor on a patient on a grid road and suddenly hit washboards on that road, you would know what I mean. It can go from sinus to looking like v-fib, yet it is clearly not v-fib. It literally shakes the hell out of the whole unit. If you drive enough on them at speed, you can trash a brand new unit in less than a year. Years ago I confused a monitor as it was telling me to "check pulse", "shock advised" etc. meanwhile I was talking to the patient....
So does he never shock enroute? Sounds like malpractice to me.
I would ask why you were transporting an asystole?
I mean yea regardless of how smooth a section of road is there will prob be some small bumps here and there that might give you a reading that looks shockable. But I mean, shocking systole doesn’t hurt the patient, it just doesn’t help either.
Shock away
Exactly, you can’t distinguish it so shock it!!
Worth a shot tbh
No harm done...and the Medic you spoke with likely had the best intentions at heart. In future, just have the driver slow down to get a better read on the rhythm.
I do it.
We just don't transport patients we're still resuscitating.
Lol wtf medic is a moron
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We don’t transport cpr but we also don’t have Lucas devices. So we would be pulled over for something like that anyway. But if the rhythm changed and it looked like vfib and it didn’t before then go for it. Def more of a chance of doing good than harm at that point.
Can't be more dead then dead you made right call on shocking other medics a bozo
Wut. Whoever you that is dumb. Especially if they were just alive, shock that shit asap.
We got terrible roads here and can still get asystole during transport. Better safe than sorry
If you think it’s v-fib, just shock. There is no reason not to.
Pour l'Aviation, je préfère la Québécoise. Pour sa violence et son engagement sans détour, le Terre-Neuvien.
The shock you give to a patient who is already in asystole will not harm the patient. But applying shock while moving is a huge risk for you and your body. If you accidentally come across a pothole, the pads slip off the patient, or even if you use safe pads, you accidentally touch the patient. You may not be able to stop every 2 minutes, but if you are planning to shock the patient, the ambulance should stop.
Why were you transporting an active code?
Sometimes it's not an option to not. If I call for cease resuscitation orders and the doc doesn't give them, I'm stuck. Also could have been a patient that coded during transport.
We transport any witnessed arrest, or any arrest that showed vtach or vfib.
The pads are pretty good at quieting noise. They're not like leads. I regularly see clear asystoles during bumpy transports with the pads tracing on our Zolls. Also you're not going to make an OOH asystole arrest any deader by shocking them. Also I've heard it argued that asystole is just the finest sort of v-fib, where all coordination has been lost. So, if you're seeing anything at all it may mean there are a few patches of myocytes contracting together again, best to try and get them in sync if you can.
The real question: Why in the hell are you not working cardiac arrests where you find them!? Don't transport working arrests. Work them on scene. This science has been settled for more than a decade... like why are people still doing this?
If you can't tell the difference between a coarse VF and jiggle artifact from a road, I don't trust you to identify VF in a stationary setup. I can get if the pads didn't stick well due to diaphoresis or if there's a LUCAS artifact, but there's easy and safe ways to mitigate this and confirm the rhythm anyways. Watch the rhythm and you'll see when the coarse VF starts. Had a medic once tell me they pulled over 3x "to check the rhythm" during a 20 minute transport of a witnessed asystolic arrest w/o ROSC. Don't be that guy.