What do you use to guage CPR adequacy?

[chbare]

If the patient walks out of the hospital, your efforts were adequate. Sounds crass, but CPR by EMS rarely matters as our response times are too long, and we are not involved enough in teaching community CPR so that the patient can get CPR when it matters.

Its like a Chef who blames his staff for his cooking failures, because they didnt buy the right ingredients. If it is that important, he/she should shop for themselves. If you are serious about saving cardiac arrest patients, you should begin by making the first link of the chain stronger. How many CPR Saturdays has your department had this year ? Teach community CPR so you do not have to do it.

A good thought, and I would take that even further by saying we should be teaching people about risk reduction and prevention. However, this is not the point of the thread. In fact, we are not even discussing outcomes.

Take care,

chbare.

[HERBIE1]

If the patient walks out of the hospital, your efforts were adequate. Sounds crass, but CPR by EMS rarely matters as our response times are too long, and we are not involved enough in teaching community CPR so that the patient can get CPR when it matters.

Its like a Chef who blames his staff for his cooking failures, because they didnt buy the right ingredients. If it is that important, he/she should shop for themselves. If you are serious about saving cardiac arrest patients, you should begin by making the first link of the chain stronger. How many CPR Saturdays has your department had this year ? Teach community CPR so you do not have to do it.

I agree that when a patient survives to discharge without deficits, it is the ultimate indication of a save, but it is NOT the only positive outcome.

Let's say we get a person back, they survive long enough for the family to maybe come in from out of town to say their good byes. Hugely important for some people to be able to properly start their grieving process. Also, organ donation is a possibility-even just corneas and bone grafts.

[DwayneEMTP]

It is essentially blood flowing in the opposite direction. In this case, he is talking about blood essentially flowing away from the heart in the venous system as a potential explanation for the presence of femoral pulsatile sensations during CPR.

Nod, I get that. But it seems what's being said is that, if we use the given numbers, the total cardiac output during CPR, at best is 20%. So somehow that meager volume of blood will drive the blood backwards, through all of the veinous valves, back through the capillary beds, with enough force and volume to create a femoral pulse?

Does this make sense to everyone else or am I the only one that's not getting why/how/if this happens?

Dwayne

[ERDoc]

Nod, I get that. But it seems what's being said is that, if we use the given numbers, the total cardiac output during CPR, at best is 20%. So somehow that meager volume of blood will drive the blood backwards, through all of the veinous valves, back through the capillary beds, with enough force and volume to create a femoral pulse?

Does this make sense to everyone else or am I the only one that's not getting why/how/if this happens?

Dwayne

Dwayne, I think what he is trying to say is that you will have backflow of blood through the venous system leading to the production of a pulsation in the femoral vein. It has me thinking. Could we use ultrasound to assess for arterial flow so that we could differentiate between a venous and an arterial pulsation? That being said, having run a few codes, Ive put in a central line or two. To put a central line in the femoral vein, you feel for the femoral artery and go medial. Every code I've had where I placed a central line, I've been able to palpate a pulse and have found a large vein medial to it. Makes me wonder.

[Jwade]

Dwayne, I think what he is trying to say is that you will have backflow of blood through the venous system leading to the production of a pulsation in the femoral vein. It has me thinking. Could we use ultrasound to assess for arterial flow so that we could differentiate between a venous and an arterial pulsation? That being said, having run a few codes, Ive put in a central line or two. To put a central line in the femoral vein, you feel for the femoral artery and go medial. Every code I've had where I placed a central line, I've been able to palpate a pulse and have found a large vein medial to it. Makes me wonder.

ERDoc,

I will try using the Sonosite the next time I drop a Femoral Line during a code to see if your premise is correct. It makes me wonder as well. One of my main thoughts on the subject is having worked as a First Assist in Trauma Surgery in Detroit, I have done countless IAM / IVM with contrast and I just have not seen all that much forward flow going on, even when we had an open chest and I was doing open cardiac massage with my hands and watching on the C-ARM.

It would make for an interesting animal study i think.

Dwayne,

I think if you pull up the following study off Medline and read in entirety, it should help to clarify things for you about how Retrograde Anatomy and Flow can cause Femoral Pulsations.

Connick M, Berg RA. Femoral venous pulsations during open-chest cardiac massage. Ann Emerg Med. 1994; 24: 1176–1179.

Respectfully,

JW

[Siffaliss]

Herbie, I think you need a bigger rig. I will admit that I have not reviewed the original article or the sources cited in it. Lack of evidence is not the same thing as evidence against. If you don't have an ideal test you have to accept the next best thing. I agree with Mobey, maybe the OP had good intent by bringing up this thread but the way it was carried out was very condescending.

Quite ...

[tniuqs]

Dwayne, I think what he is trying to say is that you will have backflow of blood through the venous system leading to the production of a pulsation in the femoral vein. It has me thinking. Could we use ultrasound to assess for arterial flow so that we could differentiate between a venous and an arterial pulsation? That being said, having run a few codes, Ive put in a central line or two. To put a central line in the femoral vein, you feel for the femoral artery and go medial. Every code I've had where I placed a central line, I've been able to palpate a pulse and have found a large vein medial to it. Makes me wonder.

Yes I too wonder about this too, in animal labs with an intact aortic valve we attempted to produce a retro flow as suggested in the CPR lit studies although the coronary artery are distal to the aortic valve the question remains with autoregulation of BP and subsequent loss of control (of the container) and darn near zero for SVR in an arrest I suspect.

It does become a quandary that the brain survives on occasions really with such low CPP.

Perhaps more alpha specific drugs would be adventitious to a positive outcome ? Do I dare suggest Levo ? Duck, weave and runs for bunker

Sure wish I had a Doppler US to take a peek of what is really going on.

cheers

[chbare]

Yes I too wonder about this too, in animal labs with an intact aortic valve we attempted to produce a retro flow as suggested in the CPR lit studies although the coronary artery are distal to the aortic valve the question remains with autoregulation of BP and subsequent loss of control (of the container) and darn near zero for SVR in an arrest I suspect.

It does become a quandary that the brain survives on occasions really with such low CPP.

Perhaps more alpha specific drugs would be adventitious to a positive outcome ? Do I dare suggest Levo ? Duck, weave and runs for bunker

Sure wish I had a Doppler US to take a peek of what is really going on.

cheers

Unfortunately, we have been giving a medication with profound alpha effects without much improvement in M&M. (Epinephrine) We are even giving a newer modality that attaches to its own receptors and supposedly acts in a very similar way to an alpha agonist. (Vasopressin and V1 & V2 receptors.) Not much in the way of improvement with vasopression either.

Dwayne, from a pure physiological perspective, some of the retrograde flow studies do make sense. (At least in the larger veins that do not have valves.) Even in a person with a beating heart, it is quite easy to increase intra-thoracic pressure to the point of decreasing venous return. (A pseudo back flow if you will) This is easily accomplished with poor ventilatory strategies that lead to the development of auto PEEP and air trapping. Remember, the "normal" CVP is only 2-6 mm/Hg in a healthy adult. In fact, the mechanics of normal breathing and intra-thoracic pressure changes actually assist with venous return.

Therefore, it is safe to assume (in a purely physiological sense) that the loss of a normally functioning system and the loss of a true driving pressure for the vascular network can lead to retrograde flow of the venous circulation is possible. This appears especially likely in the setting of CPR.

Take care,

chbare.

[tniuqs]

Dwayne, from a pure physiological perspective, some of the retrograde flow studies do make sense. (At least in the larger veins that do not have valves.) Even in a person with a beating heart, it is quite easy to increase intra-thoracic pressure to the point of decreasing venous return. (A pseudo back flow if you will) This is easily accomplished with poor ventilatory strategies that lead to the development of auto PEEP and air trapping. Remember, the "normal" CVP is only 2-6 mm/Hg in a healthy adult. In fact, the mechanics of normal breathing and intra-thoracic pressure changes actually assist with venous return.

Take care,

chbare.

Good point, in fact DHI (Dynamic Hyper Inflation) is in my opinion one of the least discussed or recognized in the EMS field when the topic of PEA surfaces.

Just reversing the pressures (as opposed to the normal patient) in Positive Pressure ventilation can be a complex study (and boring the crowd to tears) with the pulmonary mechanics topic ....zzzzzzz!

cheers

[Jwade]

Yes I too wonder about this too, in animal labs with an intact aortic valve we attempted to produce a retro flow as suggested in the CPR lit studies although the coronary artery are distal to the aortic valve the question remains with autoregulation of BP and subsequent loss of control (of the container) and darn near zero for SVR in an arrest I suspect.

It does become a quandary that the brain survives on occasions really with such low CPP.

Perhaps more alpha specific drugs would be adventitious to a positive outcome ? Do I dare suggest Levo ? Duck, weave and runs for bunker

Sure wish I had a Doppler US to take a peek of what is really going on.

cheers

Norepinephrine has been studied in only a limited fashion for treatment of cardiac arrest. Human data is limited, but it suggests that norepinephrine produces effects equivalent to epinephrine in the initial resuscitation of cardiac arrest.53,103 In the only prospective human trial comparing standard-dose epinephrine, high-dose epinephrine, and high-dose norepinephrine, the norepinephrine was associated with no benefit and a trend toward worse neurologic outcome (LOE 1).53