1. Unable to recognize ventricular
fibrillation or ventricular tachycardia
There are some students who cannot
differentiate VF from PEA. This is a
potentially fatal mistake because for VF, the one intervention besides CPR that
is proven to increase survival to hospital discharge is defibrillation (but not
for PEA).
AHA CPR Guideline 2015:
In addition to high-quality CPR, the
only rhythm-specific therapy proven to increase survival to hospital
discharge is defibrillation of VF/pulseless VT. Therefore, this
intervention is included as an integral part of the CPR cycle when the rhythm
check reveals VF/pulseless VT.
Other ACLS interventions during cardiac
arrest may be associated with an increased rate of ROSC but have not yet
been proven to increase survival to hospital discharge. Therefore, they are
recommended as considerations and should be performed without compromising
quality of CPR or timely defibrillation. In other words, vascular access, drug delivery, and advanced airway
placement should not cause significant interruptions in chest compression or
delay defibrillation.
There are also students who are not able to
differentiate VF from polymorphic VT. This mistake is still not too bad
because, according to the AHA CPR Guideline 2015:
“…if a patient has polymorphic VT,
treat the rhythm as VF and deliver high-energy unsynchronized shocks
(ie, defibrillation doses). If there is any doubt whether monomorphic or
polymorphic VT is present in the unstable patient, do not delay shock delivery
to perform detailed rhythm analysis: provide high-energy unsynchronized shocks
(ie, defibrillation doses).”
2. Not putting the paddles back and resuming
CPR immediately after defibrillation.
The whole purpose of providing CPR
immediately after defibrillation is to minimize interruptions to CPR. DO NOT
check rhythm, DO NOT check pulse. It is only AFTER the 2 minutes CPR
post-defibrillation, you check RHYTHM.
AHA CPR Guidelines 2015:
After the patient is “clear,” the second
provider gives a single shock as quickly as possible to minimize the
interruption in chest compressions (“hands-off interval”). The first provider resumes
CPR immediately after shock delivery (without a rhythm or pulse check
and beginning with chest compressions) and continues for 2 minutes. After
2 minutes of CPR the sequence is repeated, beginning with a
rhythm check.
3. Checking pulse immediately after
defibrillation and not resuming CPR immediately
AHA CPR Guidelines 2015:
When a rhythm check by an automated
external defibrillator (AED) reveals VF/VT, the AED will typically prompt to
charge, “clear” the victim for shock delivery, and then deliver a shock, all of
which should be performed as quickly as possible. CPR should be resumed
immediately after shock delivery (without a rhythm or pulse check and
beginning with chest compressions) and continue for 2 minutes before the next
rhythm check.
4.
Checking rhythm immediately after defibrillation and not resuming CPR
immediately
This mistake is almost similar to the
previous one. Both should not be checked before CPR post-defibrillation. One
does not need to re-look at the cardiac monitor but rather, CPR should be
resumed immediately (with a sense of urgency)
AHA CPR Guidelines 2015:
…when VF is terminated, a brief period
of asystole or pulseless electrical activity (PEA) typically ensues and a perfusing
rhythm is unlikely to be present
But after a 2-minute CPR, the rhythm should
be checked first; and only if an organized rhythm is found, the pulse check is
performed. Otherwise, for persistent shockable rhythm such as ventricular
fibrillation, one does not need to check pulse. It makes no sense.
AHA CPR Guidelines 2015:
Rhythm checks should be brief, and if
an organized rhythm is observed, a pulse check should be performed.
5. Checking blood pressure, explaining to
patient/taking informed consent, giving sedation, etc for a patient in VF.
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