# Pulse rate and chest compressions



## JNASTY (Mar 21, 2014)

If a patient has a slow pulse rate and is breathing and conscious would u start compressions? ( pulse is 40 bpm) I know CPR says they they need to be pulse less but I was doing some training and was told that if a Pt has a pulse of 50 bpm or less to start compressions. Now I'm a little confused, should this only be done on an unconscious Pt? 

Can anyone clarify this at all for me a little bit? Thanks


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## NomadicMedic (Mar 21, 2014)

Now, stop and read what you wrote. A person who's BREATHING and CONSCIOUS. Does that person need CPR?
What are the indications for CPR?

They may (stress on MAY) eventually need CPR, but conscious with a HR of 50 can be normal, or if the patient is "sick", may require pharmacological or electrical intervention. 

A marathon runner or a patient on beta blockade might always have a HR in the 50s and be perfectly happy.


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## chaz90 (Mar 21, 2014)

Perhaps you're thinking of infants? Compressions and ventilations are indicated in infants when their HR is <60. This is profoundly bradycardic for that patient population and considered to have a low enough cardiac output to need intervention.


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## JNASTY (Mar 21, 2014)

I understand if the Pt is conscious then CPR is not needed, but let's say the Pt is UNconsciouse HR is 50 bpm and starts to fall to 40 bpm, and Resp are 12 would you want to start compressions for the Pt? let's say you were called to the scene by his wife because he was not feeling well, he was conscious when you fist arrived but is getting worse.

Maybe what I'm asking is, is there a min HR that you would want to start compressions for someone who's condition is getting worse?


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## captinfocker (Mar 21, 2014)

TREAT THE PT NOT THE NUMBERS, my hr is 40-50 sitting here typing this and if you started compressions on me well it might not end well for you.

as for your question, if they are getting worse that quickly I would have called for als if available and or started transporting to the closest hospital. So no there isn't a magic number. My rule of thumb unless they are unconscious and pulse-less they don't get compressions.


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## STXmedic (Mar 21, 2014)

Please do not fall into the "Treat the patient, not the monitor" crap. We have tools for a reason. If they were so useless, we wouldn't have them. Look at the entire picture, not just one or the other.

OP, DE and Chaz answered your question. Newborns get compressions below 60bpm, typically refractory to oxygen. Adults get compressions when their heart is not pumping. If it's pumping, albeit it slowly, they do not get compressions. If you're BLS, either get ALS en route or load and go if you have a symptomatic, bradycardic patient.


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## chaz90 (Mar 21, 2014)

JNASTY said:


> I understand if the Pt is conscious then CPR is not needed, but let's say the Pt is UNconsciouse HR is 50 bpm and starts to fall to 40 bpm, and Resp are 12 would you want to start compressions for the Pt? let's say you were called to the scene by his wife because he was not feeling well, he was conscious when you fist arrived but is getting worse.
> 
> Maybe what I'm asking is, is there a min HR that you would want to start compressions for someone who's condition is getting worse?



No.

There is precisely one HR that needs compressions in the adult population. 0.

I can't stress this enough, and it's one of the most basic and fundamental concepts in medicine. Pulseless people who are only merely dead and not yet profoundly so get chest compressions, and those who have any kind of detectable pulse at the carotid artery do not. If your patient's pulse rate is 30 with a BP of 50 systolic, you still don't do compressions. As discussed, best have ALS coming and/or be moving at a rapid (yet safe) rate to the nearest ED at that point. If the patient becomes pulseless (clearly a big risk at that point) start CPR.

If you only read one word of my reply, let it be the first one of my post. Clear enough?


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## JNASTY (Mar 21, 2014)

I understand the answer that you gave ,Chaz, the reason I asked the question is I was practicing Pt assessments with a Paramedic and I'm only an EMT, he gave me the scenario and the Pt HR was falling but I didn't start CPR because there still was a pulse. After I completed the assessment he came back to me and said I should have started compressions if the hr was falling that low.  This is why I asked to get others opinion. Maybe it's just a Paramedic thing they do?


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## DesertMedic66 (Mar 21, 2014)

JNASTY said:


> I understand the answer that you gave ,Chaz, the reason I asked the question is I was practicing Pt assessments with a Paramedic and I'm only an EMT, he gave me the scenario and the Pt HR was falling but I didn't start CPR because there still was a pulse. After I completed the assessment he came back to me and said I should have started compressions if the hr was falling that low.  This is why I asked to get others opinion. Maybe it's just a Paramedic thing they do?



Negative. Paramedics can administer medications and/or pace the patient to get the HR up. Compressions on adults are only for a HR of 0 (excluding PEA).


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## STXmedic (Mar 21, 2014)

If that's exactly what he said and there was no misunderstanding, your paramedic needs to go back to school.


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## chaz90 (Mar 21, 2014)

DesertEMT66 said:


> Compressions on adults are only for a HR of 0 (excluding PEA).



I wouldn't even add the PEA caveat here since we're going off of palpable pulse rather than electrical HR. That's obviously why HR of ~200 doesn't matter for pulseless V-Tach either. 

This isn't directed at you either Desert, as I know exactly what you meant. More adding clarification for the OP.


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## chaz90 (Mar 21, 2014)

JNASTY said:


> I understand the answer that you gave ,Chaz, the reason I asked the question is I was practicing Pt assessments with a Paramedic and I'm only an EMT, he gave me the scenario and the Pt HR was falling but I didn't start CPR because there still was a pulse. After I completed the assessment he came back to me and said I should have started compressions if the hr was falling that low.  This is why I asked to get others opinion. Maybe it's just a Paramedic thing they do?



Said paramedic was mistaken if you understood him correctly. There's no special paramedic or even doctor magic that makes them able to do compressions on a patient with a pulse.


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## DesertMedic66 (Mar 21, 2014)

chaz90 said:


> I wouldn't even add the PEA caveat here since we're going off of palpable pulse rather than electrical HR. That's obviously why HR of ~200 doesn't matter for pulseless V-Tach either.
> 
> This isn't directed at you either Desert, as I know exactly what you meant. More adding clarification for the OP.



I was lazy and didn't want to specify palpable pulse or electrical HR lol


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## Christopher (Mar 21, 2014)

JNASTY said:


> I understand the answer that you gave ,Chaz, the reason I asked the question is I was practicing Pt assessments with a Paramedic and I'm only an EMT, he gave me the scenario and the Pt HR was falling but I didn't start CPR because there still was a pulse. After I completed the assessment he came back to me and said I should have started compressions if the hr was falling that low.  This is why I asked to get others opinion. Maybe it's just a Paramedic thing they do?



Paramedics are an odd bunch, I'll give you that. But no, if you can still palpate a pulse their intrinsic cardiac output is better than your CPR.

(I've always been dubious about pediatric CPR due to HR below 60 and why we wouldn't supplement the HR through more effective means...but that's a question for another day.)


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## Medic Tim (Mar 21, 2014)

Only time I can think of where I would do compressions with a pulse ( on an adult) is post rosc . We continues compressions for 2 minutes..... Unless they ask is to stop.


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## mycrofft (Mar 21, 2014)

disregard.


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## mycrofft (Mar 21, 2014)

Medic Tim said:


> Only time I can think of where I would do compressions with a pulse ( on an adult) is post rosc . We continues compressions for 2 minutes..... Unless they ask is to stop.



Bet that asking thing is about, uh, 100%


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## Medic Tim (Mar 21, 2014)

I have had a few witnessed arrests where we did a defib and no CPR and they were right back talking to us. I have had others where we worked them a few rounds and got pulses back but they remained unconscious. They didn't complain.


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## mycrofft (Mar 21, 2014)

Medic Tim said:


> I have had a few witnessed arrests where we did a defib and no CPR and they were right back talking to us. I have had others where we worked them a few rounds and got pulses back but they remained unconscious. They didn't complain.



HA I bet. We had a guy in Lincoln who would say "Here I go" and go unconscious with no palpable pulse. Actually saw it at the ER once. Doc said "Stand by", and about one minute later the guy was back. NO idea what that was about, but bystanders had called 911 a few times on him.


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## Akulahawk (Mar 21, 2014)

Basically, if an adult is conscious and alert... there's no need to do CPR on them. Their cardiac output (while possibly in the drain) is high enough to keep the brain going for now. Someone who is unconscious but still has a pulse may not have sufficient cardiac output to do that... but if you can feel a pulse, that patient's cardiac output is still likely to be higher than you doing chest compressions. 

As a Paramedic, if my patient has such a low HR that they're unconscious/non-responsive, there are things I can do about that. As an EMT, I'm going to do one of two things: find a way to get ALS to the patient very quickly or get the patient to ALS very quickly. In the meantime, I'm going to at least provide some oxygen, ensure as open an airway as I can mange, and ventilate if necessary.


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## JNASTY (Mar 21, 2014)

Thanks for the input everyone.


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## Handsome Robb (Mar 21, 2014)

STXmedic said:


> If that's exactly what he said and there was no misunderstanding, your paramedic needs to go back to school.



bahaha :lol: :rofl:

The only time I've seen an adult with pulses get compressions is when the only way we could get a pulse was by doppler, it was under 10 BPM and unobtainable BP. He was refractory to every other intervention so we started chest compressions, push dose pressors, a drip or 6 and then he went to the cath lab where he later died. 

This was in-hopsital though, not prehospital. My thought was hold the CPR do do everything else but the ERP who I respect had a good explanation as to his reasoning.


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## VFlutter (Mar 21, 2014)

Percussion pace em' :rofl:

I actually did it once. It worked. No joke



Robb said:


> bahaha :lol: :rofl:
> 
> The only time I've seen an adult with pulses get compressions is when  the only way we could get a pulse was by doppler, it was under 10 BPM  and unobtainable BP. He was refractory to every other intervention so we  started chest compressions, push dose pressors, a drip or 6 and then he  went to the cath lab where he later died.
> 
> This was in-hopsital though, not prehospital. My thought was hold the  CPR do do everything else but the ERP who I respect had a good  explanation as to his reasoning.



Did they float a wire?


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## Handsome Robb (Mar 21, 2014)

Chase said:


> Percussion pace em' :rofl:
> 
> I actually did it once. It worked. No joke
> 
> ...




For a transvenous pacer? Not when I was there, this hospital at the time didn't have a super aggressive interventional cardiology program but they've got a new lead cardiologist and things are a lot different now.


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## VFlutter (Mar 21, 2014)

Robb said:


> For a transvenous pacer? Not when I was there, this hospital at the time didn't have a super aggressive interventional cardiology program but they've got a new lead cardiologist and things are a lot different now.



Yep. Any EMP or CCP should be able to do it. It is just like placing a central and floating a swan. No special skills required. I am all for early transvenous pacing. Definitive treatment.


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## Brandon O (Mar 21, 2014)

Chase said:


> Percussion pace em' :rofl:
> 
> I actually did it once. It worked. No joke



Really?

How do you know? Pulses?


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## Handsome Robb (Mar 21, 2014)

Chase said:


> Yep. Any EMP or CCP should be able to do it. It is just like placing a central and floating a swan. No special skills required. I am all for early transvenous pacing. Definitive treatment.




Knowing the changes that have been made in pretty sure he'd have gotten one now. He seemed like a good candidate for ECMO but I'm not sure if that hospital has the capabilities or not. 

I've always wondered about that call and if we'd have gone to the TC which has not capabilities if it would've had a different outcome. I watched him go from walky talky to basically dead over the course of 40 minutes. Nothing I did would work. Pretty helpless feeling I'm not going to lie.


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## VFlutter (Mar 21, 2014)

Brandon O said:


> Really?
> 
> How do you know? Pulses?



Art line. After a temporary pacer wire was pulled out of the pacemaker terminal and patient was in  Ventricular standstill. A couple hits on the chest corresponded with small tracings on the arterial waveform.


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## Handsome Robb (Mar 21, 2014)

Chase said:


> Art line. *After a temporary pacer box wire was pulled out and patient was in  Ventricular standstill.*



I can count how many patients I've paced on one hand. Every. Single. One. Someone at the hospital disconnected the limb leads, even after I repeatedly said "No one touch any of my monitor cables, no one touches them except me."

D/C the limb leads and the pacer goes kaput. So frustrating. Every time we were able to get capture back either on my monitor or swap to the ER's crash cart quickly, thank goodness.


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## Brandon O (Mar 21, 2014)

Chase said:


> Art line. After a temporary pacer wire was pulled out of the pacemaker terminal and patient was in  Ventricular standstill. A couple hits on the chest corresponded with small tracings on the arterial waveform.



Couldn't that be artifact from you whacking him?


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## VFlutter (Mar 21, 2014)

Brandon O said:


> Couldn't that be artifact from you whacking him?



Don't burst my bubble. :rofl: I wouldn't think a hit in the center of the chest would cause artifact in a radial art line. But it's possible, probably likely, it was artifact.


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## Brandon O (Mar 21, 2014)

I do hate to be a bubble burster... this kind of thing is just an old issue from the TCP pacing world. "Is it working?" "Eh... who knows."


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## Handsome Robb (Mar 21, 2014)

I'm not exactly sure I know what y'all are talking about


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## Rialaigh (Mar 22, 2014)

Ive started compressions on a post arrest patient who we had lost again and gotten back, watch him go from HR of 80 to brady 60-50-40 and we started compressions at about 30-40...dude was 5 seconds from coding, cardiac output was kaput, difference between waiting for him to code and starting then...probably close to 0..

lost story short, I have absolutely done compressions on adults with a pulse.


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## mycrofft (Mar 22, 2014)

You folks are spurring me to get a DNR tag to add to my two dog tags already.


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## Akulahawk (Mar 22, 2014)

mycrofft said:


> You folks are spurring me to get a DNR tag to add to my two dog tags already.


My gift to you will be boot-method of CPR. You're grumpy enough that you'll just spring back to life if I just threaten to use it on ya... because you'll probably try chasing me down the street! :rofl:


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## mycrofft (Mar 22, 2014)

Oh, the time-immemorial "precordial jump".


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## Brandon O (Mar 22, 2014)

Robb said:


> I'm not exactly sure I know what y'all are talking about



http://bja.oxfordjournals.org/content/98/4/429.full


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## ZachJCH (Mar 23, 2014)

Not on an adult but an infant is a different story.


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## Handsome Robb (Mar 23, 2014)

Brandon O said:


> http://bja.oxfordjournals.org/content/98/4/429.full




Thanks. 

Sorry I was being really lazy.


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