# Question about CPR



## JohnH (Mar 21, 2011)

Hi everyone,

I had a quiz in my EMT B class today and I just had a few questions about CPR

I had a question that said "You arrive on scene and find a unresponsive 60 year old male. He is not breathing and has no pulse. His family states that he has been on ground for 8 mins. What would you immediately do?"

At first I wasn't sure on this one. I put C but then I changed it to A. I remember reading that the quicker the AED is used the better. 
In this case, would you do A. 2 mins of CPR then apply AED, B. 5 cycles of CPR with ventilation and then apply AED, or C. immediately apply AED and analyze?


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## Anjel (Mar 21, 2011)

JohnH said:


> Hi everyone,
> 
> I had a quiz in my EMT B class today and I just had a few questions about CPR
> 
> ...



The answer is A. It is an unwitnessed arrest. CPR has not been preformed. 

You need to "prime the pump" before you get a whole bunch of deoxygenated blood circulation again. 

UNWitnessed = two minutes of cpr then AED
Witnessed= Immediate application of AED.

Confused though... Whats the difference between cpr and cpr with ventilation?


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## exodus (Mar 21, 2011)

Anjel1030 said:


> The answer is A. It is an unwitnessed arrest. CPR has not been preformed.
> 
> You need to "prime the pump" before you get a whole bunch of deoxygenated blood circulation again.
> 
> ...



The 5 rounds + Ventillation is saying to do this then:

2 mins, vent
2 mins, vent
2 mins, vent
2 mins, vent
2 mins, vent

Apply AED / Ana / Shock


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## Anjel (Mar 21, 2011)

exodus said:


> The 5 rounds + Ventillation is saying to do this then:
> 
> 2 mins, vent
> 2 mins, vent
> ...



oh ok...well that's stupid. lol

So answer is still A


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## 18G (Mar 21, 2011)

I would have picked A. 

Unwitnessed arrest gets two mins of CPR before defibrillation. The reasoning is the two minutes of CPR establishes a perfusion pressure which allows the heart to be oxygenated which makes the heart more likely to respond to the defibrillation attempts. 

Oxygenated heart responds better to defibrillation.


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## nonameheroes (Mar 22, 2011)

for NR purposes the correct answer is A. and this is straight from my text book "Prehospital Emergency Care 9th Edition" from Brady:

If defibrillation cannot be provided within 4-5 minutes from the onset of cardiac arrest, then the providers should give five cycles of 30:2 compressions/ventilations (about 2 minutes of CPR) prior to defibrillating. This is to provide oxygenated blood, glucose, and other metabolic substrates to the myocardium so that conversion from ventricular fibrillation to a perfusing rhythm is more likely with the defibrillation. If the arrest was witnessed or the known "downtime" has been less than 4 minutes, the provider should first apply the AED, follow the AED sequence, defibrillate if advised, and then initiate or resume CPR.


Hope that helps your understanding


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## cappello91 (Mar 29, 2011)

good clarification, thanks guys


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## lampnyter (Mar 29, 2011)

A and B are the same. 2 Minutes of CPR is the same as 5 cycles.


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## ELCR7984 (Mar 29, 2011)

I would choose "A" as the answer. I was reviewing my EMT text earlier and that's what it stated. Good luck with everything!


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## phideux (Mar 31, 2011)

exodus said:


> The 5 rounds + Ventillation is saying to do this then:
> 
> 2 mins, vent
> 2 mins, vent
> ...



Actually the 5 rounds are:
30 compressions-vent
30 compressions-vent
30 compressions-vent
30 compressions-vent
30 compressions-vent
That should take about 2 mins. Then you start with the AED.


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## Strap (Mar 31, 2011)

lampnyter said:


> A and B are the same. 2 Minutes of CPR is the same as 5 cycles.



Yeah I'm not seeing any difference between A and B either.


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## Veneficus (Mar 31, 2011)

D.

toss a sheet over his head, call the coroner, and go get something for lunch.


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## RanchoEMT (Apr 3, 2011)

On a follow up note, we(BLS crew) were picking up out of a snf transporting code2 to the ER for ALOC(Not BLS by any means in San Bernardino County).  I began to assess the patient while partner was talking to the nurse about an unsigned DNR down the hallway... 
Patient is Pale, unresponsive, breathing at about 2 breaths a minute, has a pulse of 52 according to my little $20 Finger Oxy Sat.  I look at the Saturation, 80....60....40...30...nada. Pulse is now gone, not breathing and as I look up the patient is yellow. (this event was approx. 30 seconds)  Patient Codes, we put the AED on immediately (no shock advised) and start CPR.  About 30 mins. go by, by now fire and an ALS ambulance are now on-scene working her.  They push Epi/Atropine (i think) and we get a pulse back. Loaded her, and she died at the hospital.

This happened last night, although the patient  inevitably died, this was my first witnessed arrest and CPR go around, I was very impressed that with the addition of drugs we were able to restore a pulse for a short time… Anywho, Just wanted to spill my story, still kinda excited about it.


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## Sunyata (Apr 7, 2011)

RanchoEMT said:


> About 30 mins. go by, by now fire and an ALS ambulance are now on-scene working her.  They push Epi/Atropine (i think) and we get a pulse back. Loaded her, and she died at the hospital.



Just out of curiosity, *WHY* in the world did you guys wait over 30 minutes to transport this arrest patient?  To me, she would have been a priority patient (LOC, respiratory rate, and then the cardiac arrest) and would have been a load and go.


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## STXmedic (Apr 7, 2011)

There are MANY systems that do not transport the majority of cardiac arrests unless ROSC is obtained, with a few exceptions of course. Around here that is the norm if there is ALS on scene.


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## lightsandsirens5 (Apr 7, 2011)

Veneficus said:


> D.
> 
> toss a sheet over his head, call the coroner, and go get something for lunch.



Did that this morning actually.


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## lightsandsirens5 (Apr 7, 2011)

PoeticInjustice said:


> There are MANY systems that do not transport the majority of cardiac arrests unless ROSC is obtained, with a few exceptions of course. Around here that is the norm if there is ALS on scene.



I am HOPING that we go to that soon around here. It is idiotic to run an hour out to a CPR, spend a little while on scene getting an airway and hooking up a monitor, then transporting an hour and 15 minutes back, to a rural hospital. Why the heck, other than in cases of cold water dry drowning or hypothermic arrest would you even consider doing CPR for close to three hours before calling it?


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## Sunyata (Apr 7, 2011)

PoeticInjustice said:


> There are MANY systems that do not transport the majority of cardiac arrests unless ROSC is obtained, with a few exceptions of course. Around here that is the norm if there is ALS on scene.



Hmm...  That is interesting.  I may have to do a little research on that.  Although, I live in a fairly urban area, so we never have transports over 20 minutes.  Thanks for the info.  It is always neat to see how other systems do things.


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## STXmedic (Apr 7, 2011)

Sunyata said:


> Hmm...  That is interesting.  I may have to do a little research on that.  Although, I live in a fairly urban area, so we never have transports over 20 minutes.  Thanks for the info.  It is always neat to see how other systems do things.



Actually, my FT system is a major city FD with very short transport times, and we still work pts on scene. My PT is a progressive EMS only system and slightly more suburban (15-20min transports), and the pts are worked on scene there, as well.


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## RanchoEMT (Apr 13, 2011)

Sunyata said:


> Just out of curiosity, *WHY* in the world did you guys wait over 30 minutes to transport this arrest patient?  To me, she would have been a priority patient (LOC, respiratory rate, and then the cardiac arrest) and would have been a load and go.



We were BLS.... Fire rolled On-scene took over and ALS ambulance followed... they worked her for about 20 minutes on top of our ten.  We didn't take her because a certain company policy that states we are to wait until ALS shows up and assumes care.
There has been much discussion in my company about this very topic, my current county protocols state that if a hospital is closer than ALS, TRANSPORT.  If ALS is closer, WAIT.  Which is how things *should* run.  But my company "the big One" has a Stay and Play policy until ALS shows up.... Obviously this is for the BLS side of the company. Believe Me, I would like nothing more than to fire up the roof on a BLS IFT Ambulance(assuming they still work) and run code3 to the hospital. But! can’t do it, without a :censored::censored::censored::censored: storm to follow. At least Not until this :censored::censored::censored::censored:, gets taken care of (prolly won't)... Major Conflict of Interest Here. Company Protocol vs. County Protocol.  Maybe an opportunity for employee lawsuit is hidden here...


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## usafmedic45 (Apr 13, 2011)

> Hmm... That is interesting. I may have to do a little research on that. Although, I live in a fairly urban area, so we never have transports over 20 minutes. Thanks for the info. It is always neat to see how other systems do things.



Look for "termination of field resuscitation".  It should be standard practice.  There is nothing that the hospital can do for most paitents that we can't do in the field and besides, they will be long since brain damaged or brain dead before we get them there even if we have only a 20 minute transport time.


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## mycrofft (Apr 14, 2011)

*Sunyata, about "why" people keep at it/delay transport...*

Other than USAF's reply, the real answer is "Single Combat with Mr. Death". 

Someone asked about ventilationless CPR? That's all I hear about anymore. I take the instructor update on the 27th for ARC and have read the AHA notes, but the diff is primarily that some folks who would not do bystander CPR if they have to liplock some panhandler might do it if they don't have to apply the "kiss of life", and it might help.


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## usafmedic45 (Apr 14, 2011)

> "Single Combat with Mr. Death".



Actually, it's more like "small unit tactics against Mr. Death", but I'll give you the point anyhow.  I've worked a code more or less by myself for about 10 minutes (with a bystander doing CPR while I intubated, got an IV started, pushed drugs and worked the defib) and I'm glad that's not a common thing.  It was one of the most stressful things I've done.


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## attnondeck (Apr 14, 2011)

RanchoEMT said:


> On a follow up note, we(BLS crew) were picking up out of a snf transporting code2 to the ER for ALOC(Not BLS by any means in San Bernardino County).  I began to assess the patient while partner was talking to the nurse about an unsigned DNR down the hallway...
> Patient is Pale, unresponsive, breathing at about 2 breaths a minute, has a pulse of 52 according to my little $20 Finger Oxy Sat.  I look at the Saturation, 80....60....40...30...nada. Pulse is now gone, not breathing and as I look up the patient is yellow. (this event was approx. 30 seconds)  Patient Codes, we put the AED on immediately (no shock advised) and start CPR.  About 30 mins. go by, by now fire and an ALS ambulance are now on-scene working her.  They push Epi/Atropine (i think) and we get a pulse back. Loaded her, and she died at the hospital.
> 
> This happened last night, although the patient  inevitably died, this was my first witnessed arrest and CPR go around, I was very impressed that with the addition of drugs we were able to restore a pulse for a short time… Anywho, Just wanted to spill my story, still kinda excited about it.




and why weren't you bagging her/her at resp. of 2?????


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## RanchoEMT (Apr 14, 2011)

attnondeck said:


> and why weren't you bagging her/her at resp. of 2?????



Walk in Room (at 0 seconds)
Pt. Codes (at 30 Seconds)

Are you implying i should have 
A.)Bagged a person at 2 times a minute while their coding?
or
B.) Assess her, including figuring out that she's breathing at about 2 times a minute, setup a bag and start bag'n her at _2 times a minute_ in a 30 second time frame...Before she coded???

MY ANSWER to either: Should be Obvious.


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## reaper (Apr 14, 2011)

RanchoEMT said:


> Walk in Room (at 0 seconds)
> Pt. Codes (at 30 Seconds)
> 
> Are you implying i should have
> ...




Answer is "C"

Walk in room. Assess Pt and see that they are breathing 2 times a minute. Obtain BVM, Drop OPA and assist ventilations. All in under 30 seconds! 

It takes no more then a second or two to assess a pt and see that they are in distress. Shouldnt take 10-15 seconds to obtain and assemble BVM. 2 seconds to obatin OPA. 5 seconds to drop OPA. 2 seconds to start ventilations.

Have to be quick with decision making. It can costs lives. Do not wait for a SPO2 to tell you she needs assistance. You may be new and it takes time to get to that point, but learn all you can from it.


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## mycrofft (Apr 15, 2011)

*You mean like, "Why is my patient grey?".*

If the pulse ox isn't working, you know we can't eval people!  

USAF, I hear you, but my thinking about "Single Combat" etc is more on the line of BLS/lower capacity ALS target fixation than being forced into the Alamo. I've seen instances where a transportable pt who could have been loaded, tx enroute then delivered, were treated on scene past the point of immediate threat where they could be moved to the vehicle, and there you sit in a drift of  torn wrappers, used sharps from failed IV attempts, and etc with a straight-lined pt, or having to be bailed out by a firetruck load of huskies who can just physically haul and run for the ambulance, where the pt is most likely going to expire anyway.


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## RanchoEMT (May 12, 2011)

*a somewhat delayed response. sorry...*

-*Let's Get This Out of the Way*, Because I'm tired of reading about it...


reaper said:


> Do not wait for a SPO2 to tell you she needs assistance.


My Pulse Ox tells me her pulse, instantly, without the need to count for 15/30 sec. (For those who are counting to 30...)  Her saturation level is obviously inadequate, indicative of her skin signs "Skins Don't Lie" as she was "Pale", I know this. My efforts in putting on a Pulse Ox to a women that is blue serves more purpose than I think I'm being given credit for. Moving On...

*Let’s Review…*


RanchoEMT said:


> I began to assess the patient while partner was talking to the nurse about an unsigned DNR down the hallway...
> Patient is Pale, unresponsive, breathing at about 2 breaths a minute, has a pulse of 52 according to my little $20 Finger Oxy Sat.  I look at the Saturation, 80....60....40...30...nada. Pulse is now gone, not breathing and as I look up the patient is yellow. (this event was approx. 30 seconds)  Patient Codes, we put the AED on immediately (no shock advised) and start CPR.





reaper said:


> Answer is "C"
> Walk in room. Assess Pt and see that they are breathing 2 times a minute. Obtain BVM, Drop OPA and assist ventilations. All in under 30 seconds!
> It takes no more then a second or two to assess a pt and see that they are in distress. Shouldnt take 10-15 seconds to obtain and assemble BVM. 2 seconds to obatin OPA. 5 seconds to drop OPA. 2 seconds to start ventilations.



 I think jumping to conclusions  and declaring this a “respiratory case” is a little premature with regards to assessment. A patient can be in cardiac arrest and have Agonal Respirations of about 2 per minute, But one who grabs a BVM without checking a pulse is going to be less conversant to this. 
http://en.wikipedia.org/wiki/Agonal_respiration
http://www.youtube.com/watch?v=CBMxH4xtE8w

The Big Picture that I have apparently failed to convey is that regardless if it was 30 sec. or Mr. Reaper’s 24, this patient’s pulse  dropped off before a BVM could be established.

After establishing that the patient was breathing at about 2 times a minute, I immediately check for a Pulse with the Pulse Ox... 





RanchoEMT said:


> has a pulse of 52 according to my little $20 Finger Oxy Sat.


It reads "52". AS MY HEAD IS DOWN AND MY EYES ARE STILL ON THE PULSE OX LOOKING AT THE PULSE No more than a second later the saturation drops from 80 to 60 to 40 to 30..... And she becomes pulse-less. Almost No time spent assessing Pulse... National Registry teaches what??? Assess for 10 seconds??? My assessment of her pulse was less than that. While assessing the pulse she quite literally lost her pulse, secondary was the pulse Ox findings(80,60,40,30) which everybody seems to be stuck on for some reason.


The impression that I’m getting is that you think it was wrong of me to assess the presence of a pulse with a person who is breathing at a rate of 2 times per minute and time wasted in doing this could have been spent in setting up a BVM for ventilations. I don’t agree with this rationale.  Obviously, seconds later she coded, had I set up the BVM while she coded and had been ventilating her without the pulse check I would have only effectively been providing CPR without compressions….(Bagging a Pulseless Patient) What is your Logic here?



attnondeck said:


> and why weren't you bagging her/her at resp. of 2?????


 To Answer the Original Question, That's Why. Because I needed to assess the presence of a pulse to see if she was in cardiac arrest, and Behold, _while_ assessing her pulse, she coded. Indicating an immediate new treatment, *CPR*.


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## reaper (May 12, 2011)

So you are relying on a pulse ox to check a pulse? Rather then reaching down and checking for one?


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## JPINFV (May 12, 2011)

JohnH said:


> At first I wasn't sure on this one. I put C but then I changed it to A. I remember reading that the quicker the AED is used the better.
> In this case, would you do A. 2 mins of CPR then apply AED, B. 5 cycles of CPR with ventilation and then apply AED, or C. immediately apply AED and analyze?




I'll be the odd man out and argue that for testing purposes the answer is C. The NREMT exam explicitly states that they use American Heart Association Emergency Cardiac Care guidelines for their cardiac arrest management at all levels. AHA's guidelines is very wishy washy about the 2 minutes of CPR in an unwitnessed arrest or an arrest without bystander CPR. The AHA guidelines themselves mostly discuss doing CPR (compressions and ventilations) while preparing the AED, not necessarily delaying the AED for compressions. 




> When VF is present for more than a few minutes, the myocardium is depleted of oxygen and metabolic substrates. A brief period of chest compressions can deliver oxygen and energy substrates, increasing the likelihood that a shock may terminate VF (defibrillation) and a perfusing rhythm will return (ie, ROSC).18
> When an out-of-hospital cardiac arrest is not witnessed by EMS personnel, EMS may initiate CPR while checking the ECG rhythm and preparing for defibrillation. There is insufficient evidence to determine if 1
> 
> 
> ...



http://circ.ahajournals.org/cgi/content/full/122/18_suppl_3/S706


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## RanchoEMT (May 12, 2011)

reaper said:


> So you are relying on a pulse ox to check a pulse? Rather then reaching down and checking for one?



This is a cheap point, not relevant to the topic being discussed and i feel it, an attempt at distraction and belittlement to divert away the original discussion. That of the numerical and systematic priorities within Assessment/Treatment. I know it. You know it.
So Do answer please, *Do You Think It was Bad to Check the Presence of a Pulse Prior to Setting Up a BVM and Ventilating?*

Or have we just become against ourselves, attempting to out best one another, regardless of topic, because of a minor point that was overlooked or understated within previous posts...

To answer your question, No more than a medic is who charts the pulse he/she see' on his/her Monitor.  We need to count our cookies and walk away from this with "You have your methods with Reasoning, and I the same."


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## Hellsbells (May 12, 2011)

As far as RanchoEMT's treatment goes, I think, overall, it is sound. I'm sure that no amount of bagging with a BVM in the 30secs on arrival would have "saved" this pt. 

However, Using the pusle ox to obtain an initial pulse is not the best clinical method in my opinion. There are a lot of pitfalls with this technique, particularly in pts with circulatory collapse. Personally, I find it is difficult to obtain an accurate pulse rate on pts who have poor cirulation to their extremities. 

On initial assessment, it would have been completely acceptable to palpate the carotid for 3-5sec and determine if the pt has a pulse, and if it seems fast or slow. 

But, I agree the point is off topic. To the original question- I think its typical of multiple choice exams- to not nessesarily test the students knowledge of the subject, but instead their comprehension of the question itself. In my experience some of these exams don't even have a right answer, but instead you must select the least "wrong" answer.


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## JPINFV (May 12, 2011)

Hellsbells said:


> However, Using the pusle ox to obtain an initial pulse is not the best clinical method in my opinion. There are a lot of pitfalls with this technique, particularly in pts with circulatory collapse. Personally, I find it is difficult to obtain an accurate pulse rate on pts who have poor cirulation to their extremities.


The biggest problem with using a pulse ox to get a pulse is what now are you using to ensure that you are getting a good reading?


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## RanchoEMT (May 12, 2011)

JPINFV said:


> The biggest problem with using a pulse ox to get a pulse is what now are you using to ensure that you are getting a good reading?



That's true, and I think it probably be too late in my story to ensure anyone I checked for a palpable radial or carotid pulse as if to solidify my story so I won’t hit this topic.  But advantage wise for a patient that is circling, having an immediate Pulse (like a monitor) is nice.  Obviously this was an “Oh :censored::censored::censored::censored:! Call Help Case” But being able to know if and exactly when changes occur without the 15/30 sec. needed to assess exact pulse ranges and time in-between assessing is nice. Especially had I assessed her at 52 bpm manually, set up a BVM and not been able to watch her trend immediately into arrest with the pulse ox.
The Obsolute Correct Answer is obviously, assess for a Pulse manually before trusting anything electronic as it’s not that hard to wait 15/30 sec. to assess a pulse. That’s what everybody is looking for here…. Does everybody? …..mmmm they should but probably not. I’m well awear of how cheap and misleading a $20 pulse ox can be.  I’ll try and improve myself on the next assessment. But again, a side note.


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