Asystole is Stable

Archive for March, 2009

A college-aged female patient was brought to the ED for an alcohol overdose. After two doses each of 2 mg lorazepam (Ativan) and 5 mg haloperidol (Haldol), she developed a complete heart block. Recovery was spontaneous after ventilatory support.

View a PDF of the entire experience.

I learned a very systematic way to interpret EKGs (thanks to Dr. Karduck at the Conemaugh School of EMS). The basic premise behind the process is that no matter how screwed up something looks at first glance, you can identify what it is by following the rules. It’s amazing how many people in healthcare practice rhythm identification by what it looks similar to (i.e. the “textbook” rhythm).

The rules help not only to identify elusive rhythms, but also to ensure that rhythms are falsely identified as a similar, more common counterpart.

1. P waves
   • Present/absent
   • Normal/abnormal
   • Always precedes a QRS complex?
2. PR interval
3. QRS complex
   • Always follow a P wave?
   • Duration
   • Morphology
4. Atrial rate
5. Ventricular rate
6. Regularity
   • Regular/irregular
   • Pattern to the irregularity?

I made up an EKG rhythm study sheet when I was going through class to help me learn all of the characteristics.

Last night I was told, “treat the patient, not the monitor” in response to a discussion over an EKG. I’ve probably been guilty of telling people this before, but I hope that I haven’t passed that advice on to anyone since becoming a paramedic. It sounds innocuous enough, but in reality the monitor has some very useful and pertinent information in determining treatment. It ought to — otherwise we’re wasting perfectly good money (to the tune of $20,000) on a useless machine.

The key in determining treatment is to use information from the patient and the monitor. If you have any doubt about this, look no further than the ACLS algorithms. Every single algorithm requires you to obtain and use patient information (e.g. stability, history, etc.) in determining the course of treatment. Looking at the monitor alone will no doubt give us an incomplete patient picture, but ignoring it is just as likely to yield a poor overall awareness of the situation: there are a number of rhythms that can represent different patient conditions, and, at the same time, a number of patient conditions that can be represented by different cardiac activity.

BLS provider training focuses on interpreting physical signs, and at the BLS level it may be more appropriate to base clinical decisions on a gross physical exam alone. Despite that, more and more frequently programs are entrusting BLS providers with various monitoring equipment such as pulse oximetry and blood glucose monitoring (these were the two electronic tools given to me when I first became an EMT and, in the case of pulse oximetry, the tool that I was told not to use in treatment decisions). The reality of any machine is that it has its limitations, and those include being wrong from time to time.

Those limitations are why we still have people in the healthcare business. If a machine was capable of assessing a patient and then determining and administering treatment by itself, our jobs would quickly become obsolete. Likewise, if machines were truly as useless as some might believe, why is their use so widespread? The reality of the situation lies somewhere in the middle:  machines are a useful tool when employed by people who know their trade as well as how and when to use (or not use) a machine.