# Dispatched for an unknown



## spfoster719 (Jul 4, 2015)

I was presented with a scenario the other day while talking amongst peers. Need some input.

The pt is down with a HR of 10, agonal resp. What is your treatment? Unknown down time.


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## Flying (Jul 4, 2015)

CPR


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## NomadicMedic (Jul 4, 2015)

CPR and attempt TCP, intubation. IO and ACLS drugs.

Then most likely, measure for box.


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## Ewok Jerky (Jul 4, 2015)

CPR duh. Boring, next!


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## DesertMedic66 (Jul 4, 2015)

DEmedic said:


> CPR and attempt TCP, intubation. IO and ACLS drugs.
> 
> Then most likely, measure for box.


Exactly this. Except we don't carry tape measures in the ambulance so that is something the ED will do.


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## RedAirplane (Jul 4, 2015)

CPR with a pulse?

I thought you only do that for newborns with HR<60?


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## DesertMedic66 (Jul 4, 2015)

RedAirplane said:


> CPR with a pulse?
> 
> I thought you only do that for newborns with HR<60?


1 beat every 6 seconds is no where near enough to sustain life, let alone a decent blood pressure. Meds or electricity should help this patient but both of those take a little bit of time to set up compared to compressions.


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## NomadicMedic (Jul 4, 2015)

A HR of 10 isn't comparable with life. At least for very long.


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## ERDoc (Jul 4, 2015)

Do you think a heart rate of 10 is compatible with life?  Do you think you are going to adequately perfuse the important things?

EDIT: Wow, we were all replying at the same time with pretty much the same advice,lol.


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## RedAirplane (Jul 5, 2015)

I'm not saying that I think he's in great shape...

I just wasn't sure about whether it's recommended to do CPR.


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## DesertMedic66 (Jul 5, 2015)

RedAirplane said:


> I'm not saying that I think he's in great shape...
> 
> I just wasn't sure about whether it's recommended to do CPR.


What are your other options to get his system to pump blood to his organs?

If you have no other options aside from transport, do you want to have his organs not receiving blood for the transport time?


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## RedAirplane (Jul 5, 2015)

DesertMedic66 said:


> What are your other options to get his system to pump blood to his organs?
> 
> If you have no other options aside from transport, do you want to have his organs not receiving blood for the transport time?



That makes sense.

But on the other hand, if someone is choking but moving any air at all, you are not supposed to do anything because you may make it worse. I'm not sure if it's like that or not.

Dogmatically I'd fall back on CPR=pulseless except newborns, but this case is making me think a little.


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## DesertMedic66 (Jul 5, 2015)

RedAirplane said:


> That makes sense.
> 
> But on the other hand, if someone is choking but moving any air at all, you are not supposed to do anything because you may make it worse. I'm not sure if it's like that or not.
> 
> Dogmatically I'd fall back on CPR=pulseless except newborns, but this case is making me think a little.


If they are moving air in and out hopefully they should be able to cough to remove the object. Coughing works much better than upward thrusts do.


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## Tigger (Jul 5, 2015)

RedAirplane said:


> That makes sense.
> 
> But on the other hand, if someone is choking but moving any air at all, you are not supposed to do anything because you may make it worse. I'm not sure if it's like that or not.
> 
> Dogmatically I'd fall back on CPR=pulseless except newborns, but this case is making me think a little.


Apples and oranges. 

You have to perfuse the body. Doing nothing is not the answer here. Critical thinking, not just algorithms. 

Also, you're not likely to be able to palpate a rate of 10.


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## NomadicMedic (Jul 5, 2015)

This patient isn't breathing effectively and probably doesn't have an appreciable pulse.

This patient isn't technically in arrest, but is peri-arrest, and really in the prehospital world, it doesn't matter. CPR is 100% indicated, at least while TCP is being attempted. An advanced airway and ACLS drugs would come shortly after, but CPR first.

(If TCP captures and a pulse and BP can be measured, then you can stop CPR.)


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## RedAirplane (Jul 5, 2015)

Tigger said:


> Apples and oranges.
> 
> You have to perfuse the body. Doing nothing is not the answer here. Critical thinking, not just algorithms.
> 
> Also, you're not likely to be able to palpate a rate of 10.



In a world of apples and oranges, I prefer to think of myself as a mango. 

More seriously, makes sense. Especially because you'd feel at most one pulse in your 5-10 second pulse check, which I'm sure would quality as "if you are not sure whether you felt a pulse, begin CPR."


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## RedAirplane (Jul 5, 2015)

Would this be an unusual presentation of an "almost" cardiac arrest? 

The "guideline" pathway I was taught (which I know is not always the case) is something like this.
1. Choking
2. Unconscious, not breathing, with a pulse
3. Heart goes into VT then VF

Or, you have a cardiac issue and the heart may have PVCs first then VT/VF.

Is it common to get the Hollywood-esque "beeps getting further apart until asystole"?


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## Ewok Jerky (Jul 5, 2015)

Sure, its called bradycardia>unstable bradycardia>asystole.

Typical Hx would include OD of certain meds, can you imagine what classes?


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## RedAirplane (Jul 5, 2015)

Opiates? Alcohol? Central nervous system depressants?


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## RedAirplane (Jul 5, 2015)

Or would those cause BP down but pulse to shoot up like in shock?


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## Ewok Jerky (Jul 5, 2015)

Those are all good bets to cause unstable bradycardia, but I imagine at the moment of arrest those Pts would more likely go into VT/VF, not the "beep..beep......beep...........beeeeeeeeep" you asked about. Think unintentional OD.


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## Ewok Jerky (Jul 5, 2015)

RedAirplane said:


> Or would those cause BP down but pulse to shoot up like in shock?


CNS depressants, like opiates EtOH and barbituates, will cause both a drop in HR and BP, as well as RR.


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## RedAirplane (Jul 5, 2015)

Ewok Jerky said:


> Those are all good bets to cause unstable bradycardia, but I imagine at the moment of arrest those Pts would more likely go into VT/VF, not the "beep..beep......beep...........beeeeeeeeep" you asked about. Think unintentional OD.



Sleeping pills? Tylenol? Cardiac Meds?


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## NomadicMedic (Jul 5, 2015)

Who knows? The OP didn't provide much more that "mostly dead".


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