# Capillary refill - not indicative of perfusion in adults, right?



## rickd3x (Sep 13, 2012)

I'm a student at the University of Miami and I recently joined the university's CERT team after realizing getting a job as an EMT in the city wasn't going to happen. I've debating whether or not to stay in the group, because I could pretty easily obtain a leadership role, but there are some pretty strange things we were taught in the basic training class (I still had to attend). The CERT lectures were created by Miami-Dade Fire Recuse/OEM so I was surprised to see cap refill as the only method of assessing perfusion in a patient (including adults) despite the fact that locations of major arteries were stressed so they could be used to help stop bleeding when direct pressure and elevation fails. I was taught that cap refill was only accurate in children, and even then, a distal pulse gives you a better idea of how well the patient is being perfused. I was also shocked to see their protocol for securing a patient to a backboard, securing the head before the body, which I think could possibly lead to c spine injury if the patient seizes or somehow gets violently moved before the upper body is secured. Just wanted to get some people's opinion on this...

Thanks!


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## socalmedic (Sep 13, 2012)

rickd3x said:


> I'm a student at the University of Miami and I recently joined the university's CERT team after realizing getting a job as an EMT in the city wasn't going to happen. I've debating whether or not to stay in the group, because I could pretty easily obtain a leadership role, but there are some pretty strange things we were taught in the basic training class (I still had to attend). The CERT lectures were created by Miami-Dade Fire Recuse/OEM so I was surprised to see cap refill as the only method of assessing perfusion in a patient (including adults) despite the fact that locations of major arteries were stressed so they could be used to help stop bleeding when direct pressure and elevation fails. I was taught that cap refill was only accurate in children, and even then, a distal pulse gives you a better idea of how well the patient is being perfused. I was also shocked to see their protocol for securing a patient to a backboard, securing the head before the body, which I think could possibly lead to c spine injury if the patient seizes or somehow gets violently moved before the upper body is secured. Just wanted to get some people's opinion on this...
> 
> Thanks!



Cert is taught for lowest common denominator (fart smellers and nose pickers) to understand. everything is made incredibly simple so that years from now when "the Big One" comes people trained today will remember what to do. this is not necessarily a bad thing, I have seen EMTs who cant take a pulse. everyone can see a cap refill. I can tell you if they aren't perfusing the cap refill will be affected, even adults. I am on a USAR RTF and teach CERT from time to time I can tell you that they, and you, will be a great commodity when needed. an army of people to triage and tell me who needs the most help.


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## NYMedic828 (Sep 13, 2012)

> I'm a student at the University of Miami and I recently joined the university's CERT team after realizing getting a job as an EMT in the city wasn't going to happen. I've debating whether or not to stay in the group, because I could pretty easily obtain a leadership role, but there are some pretty strange things we were taught in the basic training class (I still had to attend). The CERT lectures were created by Miami-Dade Fire Recuse/OEM so I was surprised to see *cap refill as the only method of assessing perfusion in a patient* (including adults) despite the fact that locations of major arteries were stressed so they could be used to help stop bleeding when direct pressure and elevation fails. I was taught that cap refill was only accurate in children, and even then, a distal pulse gives you a better idea of how well the patient is being perfused. I was also shocked to see their protocol for securing a patient to a backboard, securing the head before the body, which I think could possibly lead to c spine injury if the patient seizes or somehow gets violently moved before the upper body is secured. Just wanted to get some people's opinion on this...
> 
> Thanks!



Odds are their teaching are out of date for starters and they also probably don't carry much to use a basis for gauging patient condition. They come up with the things they can do solely with their hands and implement it how they can. 

Cap refill is no longer viewed as an adequate gauge of perfusion, this is correct. A distal pulse and overall skin color is the way to go but at the same time, if a patient isn't perfusing cap refill is certainly still affected. It just isn't the best indicator/early sign of hypoperfusion.

Furthermore, pressure points are no longer the go to next step. The old way is "DEPT", direct pressure, elevate, pressure point, tourniquet. When that was implemented the mindset was that applying a tourniquet instantly means the patient is going to lose their limb distal to the site of application which is completely false. You can go quite some time with a tourniquet applied and still return the limb to full perfusion post surgical intervention. That said, the current practice is direct pressure, pressure dressing, tourniquet. 

Great thing about a tourniquet is it usually able to control the bleeding and its able to be made out of just about anything around you in a pinch. (clothing, shoe laces etc)

As far as securing the head first, that is backwards but at the same time, it doesn't matter. Long boards are stupid. The entire procedure of putting someone in a collar and on a longboard is an EMS thing that never ceases to remain ridiculous. But, alas, the head first is technically incorrect and we are still required to board people. So that should be changed...


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## Handsome Robb (Sep 13, 2012)

CERT is generally activated for large scale disasters, correct? Which would put you in an MCI/Triage type scenario.

"30, 2, can do" RR <30, Cap Refill <2 sec, A&O. 

Like everyone else said, it's taught for the lowest common denominator to be able to remember in a stressful situation.


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## Meursault (Sep 13, 2012)

There are probably instructors around here that will have more info, but for now, here's what occurs to me.


rickd3x said:


> The CERT lectures were created by Miami-Dade Fire Recuse/OEM so I was surprised to see cap refill as the only method of assessing perfusion in a patient (including adults) despite the fact that locations of major arteries were stressed so they could be used to help stop bleeding when direct pressure and elevation fails. I was taught that cap refill was only accurate in children, and even then, a distal pulse gives you a better idea of how well the patient is being perfused.


Bear in mind that CERT is intended to be activated in disasters. Let's compare this to the START and SALT guidelines, both designed for people who find radial pulses every day. START and SALT use only presence/absence of peripheral pulse, and in SALT, only after sorting patients. The AHA is also moving away from pulse checks for non-ACLS rescuers because they've found them unreliable and time-consuming. The emphasis here is on rapid triage and avoiding tunnel vision. CERT team members aren't supposed to be conducting medical assessment; they're extra bodies usable to speed up triage by finding the most critical patients.



rickd3x said:


> I was also shocked to see their protocol for securing a patient to a backboard, securing the head before the body, which I think could possibly lead to c spine injury if the patient seizes or somehow gets violently moved before the upper body is secured.


And how often is that likely to happen? It's pretty clear that long spine boards are useful for patient movement and might be helpful in clinically suspected spinal injury, but are mildly harmful otherwise. How prevalent will nonfatal c-spine injuries be in most disasters? What role does spinal "immobilization" serve in an incident large enough to require CERT activation? If you're moving a victim, does it matter if their head or feet get secured first? Does your team even stock long boards?


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## Handsome Robb (Sep 13, 2012)

One thing I'll add about radial pulses is they aren't necessarily a great indicator of perfusion status either. 

Had a septic dude the other day with a pressure of 68/40 with radial pulses, albeit they were very weak. That's a MAP of 49 and change. That man was not perfusing well.


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## DrankTheKoolaid (Sep 13, 2012)

You are correct with your assessment of the poor backboard instruction.  Someone mentioned that it was not important if was "the head or the feet" that is secured first.  Nothing could EVER be further from the truth.  And teaching that to laypeople is even worse the telling a provider that, since the layperson may actually think it is alright to do that.  

The head is never secured before the "body" as your initial post implies.  Are you sure of your wording here, as in you first secure the head and then the rest of the body?  If the person needs to vomit, or joe layperson in his/her excited hurry drops his or her side of the backboard during some movement and ONLY the head is secured, what do you think will happen to that patient....................

If thats the case bring it up to the CERT leader and tell them to fix the protocol typo, as it really has to be a typo as it would be a epic stupidity fail to actually put out a protocol stating that.


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## Medic496 (Sep 13, 2012)

Capillary refill is one simple indicator.  It is good to have as an assesment tool, but you need to look at the whole picture and see where that sign is relevant.  Is poor capillary refill and indicator of anything of concern in hypothermia?  Not really, it should be expected in mild and above hypothermia.


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