The shock worked. The rhythm converted. And then V-fib came right back. Now what?

Part two of this series explores the physiology and pharmacology driving recurrent V-fib so you can respond confidently when shocks aren’t enough.

You'll learn how the body's sympathetic nervous system response keeps the heart unstable, why epinephrine can both help and hurt, when to reach for lidocaine over amiodarone, and what the research says about the emerging role of esmolol to target the storm itself (not just the arrhythmia).

Topics discussed in this episode:

• The sympathetic nervous system and cardiac arrest
• Why epinephrine both helps and hurts
• Amiodarone vs. lidocaine: which is better?
• Key findings from the ROC-ALPS trial
• Why antiarrhythmics don't replace defibrillation
• The evidence behind esmolol in refractory V-fib
• 3 lessons for codes when ACLS isn't enough

Mentioned in this episode:

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This special episode was recorded and released on the Nurse Gwenny Podcast. We talked about some of those early signs of deterioration that are often missed and how we can speak up and advocate before the patient crashes.

Check out this episode and so many more over at the Nurse Gwenny Podcast

And, you can join the Nurse Gwenny Library to earn CE credits for listening to the show!

Use code: rapidresponsern

to get a discount on your membership:

https://library.nursegwenny.com/bundles/nurse-gwenny-library-membership

Sometimes V-fib doesn't respond to the shock at all. Sometimes it converts and comes right back. Those are two completely different problems.

In this episode, Sarah breaks down the science behind why defibrillation fails, how to recognize the difference between refractory and recurrent V-fib, and respond when shocks aren't working. You'll learn how to start approaching the electrical storm at the bedside — that means understanding transthoracic impedance, optimizing your pad placement, and knowing when to reach for double sequential defibrillation.

Topics discussed in this episode:

• Refractory vs. recurrent V-fib
• The physiology of ventricular fibrillation and re-entry tachycardias
• Misconceptions about defibrillation
• Transthoracic impedance and how to reduce it
• Anterior-lateral vs. anterior-posterior pad placement
• Double sequential defibrillation: evidence and objections
• Key findings from the DOSE VF trial

American Heart Association. (2025). 2025 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation.

Cheskes, S., Dorian, P., Feldman, M., McLeod, S., Scales, D. C., Pinto, R., Turner, L., Morrison, L. J., Drennan, I. R., & Verbeek, P. R. (2020). Double sequential external defibrillation for refractory ventricular fibrillation: The DOSE VF pilot randomized controlled trial. Resuscitation, 150, 178–184. https://doi.org/10.1016/j.resuscitation.2020.02.010

D. Hasegawa, A. Sharma, Y. I. Lee, & R. Sato. (2023). A systematic review and meta-analysis of esmolol for refractory ventricular fibrillation and pulseless ventricular tachycardia. Chest, 164(4 Suppl.), A1568. https://doi.org/10.1016/j.chest.2023.07.1077

International Liaison Committee on Resuscitation. (2025). 2025 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations (CoSTR).

Mentioned in this episode:

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Imagine being able to cut your hospital's code blue events outside of critical care in HALF in just six months. That's exactly what happened when Sarah built her hospital's rapid response team from the ground up.

Nurse Gwenny takes over the show to find out how she did it, from the pitch that got the program started to the skills that actually matter on rapid response teams. She also shares what disqualifies a candidate even when the resume is perfect, why so few resources exist for rapid response training, and how she’s filling that gap herself.

Whether you're hoping to start a rapid response program at your hospital or just want to feel more confident the next time you call one, this episode is for you.

Topics discussed in this episode:

• How Sarah became a rapid response nurse
• The backstory behind the Rapid Response RN Podcast
• The impact of having a rapid response team
• How you can start a rapid response program
• Rapid response education and (lack of) resources
• Hiring red flags that override a strong resume
• Soft skills nursing school never teaches
• Trusting nursing intuition when vitals look fine

Join the Nurse Gwenny Library to earn CE credits for listening to the show!

Use code: rapidresponsern

to get a discount on your membership:

https://library.nursegwenny.com/bundles/nurse-gwenny-library-membership

Mentioned in this episode:

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We all know the many challenges facing the Nursing profession today. Nursing takes so much from us… but it also has so much to offer.

Recorded live at NurseCon at Sea, Sarah sits down with two nurses who hit their breaking point and found a way to keep showing up. This episode goes deep into the messy reality of nursing burnout, from the struggle to put yourself first to the boundaries, mindset shifts, and support systems that keep nurses in the game.

You don't have to manage burnout alone, so don’t miss this one.

Topics discussed in this episode:

• Self-care and resilience as a discipline
• The nursing choice: fracture or adapt
• Building a life that isn't fully defined by the institution
• Important things we don’t say to each other
• What patients actually need from their nurses
• Therapy, medication, and sleep as nursing tools
• An exercise to audit your cup-fillers vs. cup-drainers
• Why it’s so important to share your experience
• How leaders should respond when a nurse is nearing burnout

Learn more about NurseCon at Sea:

https://nurseconatsea.com/

Mentioned in this episode:

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Getting ROSC is not always the win we sometimes think it is. It's what we're looking for the entire resuscitation, but the real challenge begins once we get it… and what we do in the next few hours has a major impact on patient outcomes.

In this episode, Sarah shares a real rapid response case to walk through the physiology, decision-making, and advocacy of post-arrest care. The 2025 AHA post resuscitation guidelines have brought important shifts to post-ROSC management, from how aggressively to oxygenate to when it's safe to prognosticate. Don't miss the full breakdown!

Topics discussed in this episode:

• Oxygenation and ventilation: how to avoid hyperoxia and hypoxia
• Perfusion, pressors, and the limits of MAP
• Temperature management guidelines
• Sedation, analgesia, and the paralyzed-but-awake patient
• Diagnostics: timing, priorities, and what to rule out
• How to use neuroprognostication the right way
• How to talk to families without giving false hope
• Nursing priorities and how to advocate for your patients

Check out the new Post Resuscitation Guidelines:

https://www.ahajournals.org/doi/10.1161/CIR.0000000000001375

Listen to episode 73 — Resuscitate Before You Intubate: How to NOT KILL YOUR PATIENT When You Intubate: https://podcasts.apple.com/us/podcast/73-resuscitate-before-you-intubate-how-to-not-kill/id1535997752?i=1000630431016

Mentioned in this episode:

AND

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The AHA just updated the playbook on acute pulmonary embolism. The old classification system is gone. Heparin drips are no longer the default. And if your instinct is to push for intubation, that could be the thing that makes your patient worse.

In this episode, Dr. Mark Creager, lead author of the 2026 AHA Multi-Society Guideline on Acute Pulmonary Embolism, breaks down exactly what's changed, how the new guidelines help teams make better decisions faster, and what nurses need to know about frontline PE management.

Learn what the data says about oxygen therapy, anticoagulation, vasopressors, and the decisions that matter most when your PE patient starts to slide.

Topics discussed in this episode:

• The new A to E classification system and how to categorize patients
• Clinical signs that your PE patient is deteriorating
• Oxygen therapy: why intubation can be dangerous
• Vasopressor therapy and when to add vasopressin
• Low-molecular-weight heparin vs. unfractionated heparin
• PE response teams: when to activate and who should be on the team
• What you can do when your hospital has no PERT
• When to transfer by classification (and when it may be too late)
• The nurse's role in early recognition and escalation

And you can check out the full AHA/ACC 2026 updated PE guideline here:

https://www.ahajournals.org/doi/10.1161/CIR.0000000000001415

Mentioned in this episode:

Xshears are the best shears

check em out here:

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"There has to be a better way." We've all thought it. This episode is proof that nurses can be the ones to make it happen.

In this episode, Sarah is joined by Kat Siaron, rapid response nurse and co-author of the RRT STAR study that shows what happens when nurses are empowered to act before a clear stroke diagnosis is made. They walk through a patient case that exposed a dangerous gap in inpatient stroke response, traps like sedation hangover that mask stroke presentations, and how the nurse-led Code Stroke process has drastically improved time to crucial intervention.

You'll hear about the step-by-step workflow, where rapid response nurses and physicians fit in, and how you can advocate for change in your hospital.

Topics discussed in this episode:

• The patient case that led to Kat’s RRT STAR study
• Why inpatient stroke times lag behind ER stroke times
• The consequences of ordering stat CT instead of Code Stroke
• Symptoms and prognosis of basilar stroke
• The step-by-step Code Stroke process
• The rapid response team's role in stroke activation
• Results and impact of the study
• How they overcame pushback to drive institutional change
• Stroke mimics and what to do next
• How to advocate for a nurse-led stroke alert at your hospital

Read Kat’s article, “Use of Rapid Response Teams to Expedite Imaging and Treatment for Inpatients With Acute Stroke:”

https://aacnjournals.org/aacnacconline/article-abstract/36/4/317/32912/Use-of-Rapid-Response-Teams-to-Expedite-Imaging?redirectedFrom=fulltext

Mentioned in this episode:

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Listen to the In The Heart of Care Podcast

https://link.cohostpodcasting.com/6598429e-e927-45b0-9b57-7dd34a09d803?d=seASyqjs7

The stroke guidelines just changed and it’s exciting and nuanced! What you do in the first 30 minutes could drastically change your patient's outcome. In this episode, Dr. Shyam Prabhakaran, neurologist and chief writer of the new 2026 AHA Stroke Guidelines, explains what's changed and how these guidelines are changing practice at the bedside.

Stroke treatment decisions are getting faster, more nuanced, and more imaging-driven. Inclusion/exclusion criteria and whether to give thrombolytics, who is a candidate for thrombectomy, and when to touch the blood pressure have all been updated. Know the updates before your next stroke alert!

Topics discussed in this episode:

1. Introducing the classic extended window patient case
2. Thrombolytics vs. thrombectomy explained
3. EMS destination decision: Choosing primary vs. comprehensive stroke center
4. How reperfusion time windows have changed
5. Advanced imaging: ASPECTS and thrombectomy eligibility
6. Treatment options for patients presenting outside of the 4.5 hr window
7. Blood pressure management recommendations
8. What nurses should do in the first 15-30 minutes
9. LVO red flags at the bedside
10. Pediatric ischemic stroke

Check out the new AHA Stroke Guidelines:

https://newsroom.heart.org/news/new-guideline-expands-stroke-treatment-for-adults-offers-first-pediatric-stroke-guidance

Mentioned in this episode:

CONNECT

Listen to the In The Heart of Care Podcast

https://link.cohostpodcasting.com/6598429e-e927-45b0-9b57-7dd34a09d803?d=seASyqjs7

ARDS is one of the more complex syndromes we manage in critical care. More than just pulmonary edema, we are battling stiff lungs, refractory hypoxemia, rising pressures, and frequently making decisions that can either protect the lung or make things worse.

In this episode, I’m joined by respiratory therapist Melody Bishop for a deep dive into ARDS ventilator management through the lens of physiology, evidence, and real bedside practice. We break down what’s actually happening in the lung, why some long-held practices have fallen out of favor, and how nurses and RTs can work together to make more precise, lung-protective decisions.

If ARDS has ever felt like guesswork, this episode will help it make sense.

1. What ARDS looks like at the alveolar level and why surfactant loss changes everything
2. How inflammation leads to stiff lungs, poor compliance, and refractory hypoxemia
3. Why lung-protective ventilation is about avoiding harm, not chasing perfect numbers
4. Moving beyond tidal volume: how driving pressure reframes vent management
5. How RTs use compliance trends to judge whether lungs are improving or failing
6. PEEP selection: why tables are a guide, not the final answer
7. The physiology behind proning and why it’s one of the few ARDS interventions that saves lives
8. Why recruitment maneuvers fell out of favor (and what works instead)
9. What nurses should be watching on the ventilator to catch deterioration early

https://melodybishoprt.com/

Mentioned in this episode:

Rapid Response Academy Winter 2026 Cohort

https://www.rapidresponseandrescue.com/rra

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