Cardiac Arrests: Stopping To Check Pulses?

[FL_Medic]

Nah I still treat pt's 100% of the time. Those damn monitors are far too hard to cannulate and intubate for me to treat them effectively - LOL.

Monitoring certainly dictates your treatment algorhythm during confirmed cardiac arrest. However should monitoring take over and negate pt assessment? I think not and believe that there is great danger in advocating there is "no point in doing pulse checks until you see an organised rhythm on the monitor" - as was suggested. In examining whether this approach is appropriate I would appreciate if anyone could answer this question. Are there any "disorganised" (your term, not mine) rhythms that can generate a pulse?

Stay safe,

Camulos

I believe the point that they were making was that it is pointless to check v-fib/asystole for a pulse. To respond to your first paragraph.. I meant in cardiac arrest, your monitor will dictate your treatment. Your patient assessment should lead you to the conclusion that they are in cardiac arrest, and then you will treat per your rhythm-dictated algorythm. Of coarse there are exceptions to every rule. If your patient's Hx indicates a possible special condition such as OD, hypoglycemia, acidosis, etc... You should probably change your treatment accordingly.

[AnthonyM83]

AHA DOES say to go straight into CPR after shocking, without pulse check. No pulse check after shock until 2 minutes of CPR.

[Camulos]

I believe the point that they were making was that it is pointless to check v-fib/asystole for a pulse.

I understand that is the point they were making and I still strongly believe that approach is WRONG!!!! Please tell me you check your pt's even if your monitor shows what are interpreting as VF/Asystole etc. I've seen VF looking rhythms that were caused by interference, I've seen asystole looking rhythms caused by leads falling off, in fact I've seen a whole host of spurious ECG rhythms caused by a multitude of factors. Whether you use "signs of life" or a pulse check, please check your pt's despite what the monitor may show. Come on, this is so basic!!!! Surely EMS has progressed beyond this???

To respond to your first paragraph.. I meant in cardiac arrest, your monitor will dictate your treatment. Your patient assessment should lead you to the conclusion that they are in cardiac arrest, and then you will treat per your rhythm-dictated algorythm.

Didn't I say exactly this in my second paragraph???? LOL

Stay safe,

Camulos

[Richard B the EMT]

I concur with that assessment. I have heard, even before the advent of the SAED, of EMS people, even ER/ED Doctors, being fooled by artifact showing normal sinus rhythm on the EKG screen, when the patient was, in fact, in asystole, discovered by checking for a carotiod pulse that was not found.

Treat the patient, not the machines.

[celticcare]

Ok I'll write my current CCU nurse routine and then ems one ok, and remember other country, other drugs, other protocols we have the New Zealand Resus Council guidelines not the AHA so no post pissing as we are governed by a different set of rules and regs here not the same as america. Just writing that before I start as I have read some of the posts and it is like a pissing match at times.

VF/VT/ on the monitor *patients are wired to telemetry*

Assess patient

Precordial thump

CPR

In the last 30 seconds, charge the defib and assess rhythm,

200 Joules biaphasic shock

2 mins cpr

200 joules shock

2 mins cpr with 1mg adrenaline pushed in this time

200 joule shock.

If, at any stage, we see an output capable rhythm, for one to two minutes we do CPR to give the heart time to recover. However, if they sit up and are trying to punch me off, then I stop CPR.

Asystole, similar however No shocks unless you are thinking potentially fine VF, then follow that protocol.

If we respond as a code team to somewhere in the hospital, hopefully the other nurses have put at least one shock through and we then take over with the above algorhythm.

EMS

Arrive - Assess.

2 mins CPR, in this time, the four chest leads are applied and the defib pads *ugh pads*

in the last thirty seconds charge defib to maximum output.

shock

resume CPR

Adrenaline

Charge again and if needed, shock again or dump charge.

This is the general run of arrest alogorhythm here. Now in terms of pulse checking, me personally, I do check for a pulse as last I checked, that is part of DRABC. I see the monitors flash enough saying VF and VT when its artifact. I do personally check for a pulse during compression rounds if I am not doing compressions, as I do want to gauge the effectiveness of compressions and also gauge skin warmth if we are getting perfusion occuring.

Its what I do personally, and I base it on science on the fact air goes in and out, blood goes round and round. The comment of "how can we move forward as a profession" that is bullshit. how does checking or not checking a pulse hold back an entire profession. You will have MD's RN's technicians, Paramedics, first aiders, will still feel for a pulse, because we want something to either A) keep our hands busy, reasure we are doing the right things and c) because it can be a sign of adequate compressions.

So answer the question, we feel for a pulse during compressions, at assessment and if we see a rhythm that is perfusing with life.

Scotty

[tniuqs]

Intersting topic to say the least ... for myself its a manpower issue or multi tasking.

If the Airway Person has a tube in-situ, whats wrong with keeping a finger on Carotid with or without CPR ?

If a #3 man/woman (while CPR is being done) then Femoral.

There is a reason (whatever the research says) To keep a finger on the pulse ! (even if it just an old saying) What if a lead comes off ?

hey I even talk loud btw to all my arrest patients too ... I guess I am just a touchy feely kinda guy

I do agree that immediately post shock for Vfib or V tach initiate compressions and then check pulse, if a rythum change occurs. as you are "discharging" all electrical activity when you D-Fib and compressions do produce a small amount electrical stimulus after repolarization hopefully with a more organized rythum.

cheers

[Richard B the EMT]

With a nod towards celticcare that we are now going over international borders with the training, I will remind some here, that in the US, the precardial thump was the way one started CPR after determining Airway, Breathing, and Circulation. It underwent many changes from when I first learned CPR back in the dark ages of 1974, to the current 2009.

If your training in New Zealand has you doing the Precardial Thump, per your protocols, then for Pete's sake, do the thump. Mine are, as indicated, different.

So...

There is NOBODY here that can say if the American Heart Association CPR is ahead of "the curve", or if the New Zealand Resus Council guidelines CPR is ahead of "the curve". I'll follow MY guidelines, celticcare will follow the local protocols (and I'll be in Scotland afor ye {where did THAT come from?}), and we'll hope for a good outcome for our respective patients.

[crotchitymedic1986]

Hate to break the bad news to you, but it really doesnt matter in most areas. Due to our long response times, and an uneducated public that will not start CPR, you are basically working a corpse. Unless the percentage of cardiac arrests patients that walk out of a hospital has changed, the vast majority of these patients are dead, and will stay dead, but if you pump enough drugs in them over 20 minutes, you might get the heart beating again long enough to drive L&S to the ER so they can be pronounced there or in the ICU. So check a pulse every second, check one every 20 minutes -- doesnt matter. And dont worryabout AHA too much, as they change the rules every two years, solely for the purpose of making you buy a new text book.

[celticcare]

Crotchity, I will try and find the stats for you but in our last revalidation day, the statistics are showing about 25% survival to discharge from out of hospital cardiac arrest with about 20% with no or extremely little neuro impairment. Maybe we are a smaller country and able to spread the message about CPR easier and its taught as part of your cirriculum in school and nationally funded cpr courses are held annually for the public. Defib is a standard part of your first aid course now, its not a seperate course, you learn CPR and AED.

[AnthonyM83]

As a side note, AHA is scheduled to come out with new guidelines in Dec 2009.