# Pulse-check after AED-shock?



## coyotejack (May 18, 2011)

Who can solve this question that is being kicked back and forth at my station:

The proceedure states that immediately after giving a shock using an AED, the responder should begin another 5 cycles of chest compressions.

Question:  If the purpose of the shock is to allow the heart to "reset" itself to sinus-rhythm, shouldn't there be a check for an appropriate pulse be made before returning to compressions that may be unnecessary (and harmful)?

Thanks,

CoyoteJack


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## ArcticKat (May 18, 2011)

No because it's a waste of time.  The study which resulted in the change of the AHA guidelines determined that doing CPR on a beating heart will not result in a detrimental effect and will in fact assist the newly restarted heart in increasing cardiac output prior to the AED reassessing the patient.   The AED is designed to detect if the rhythm is a shockable one.  If there is a pulse then the AED would detect the organised electrical activity and recommend "No Shock Advised, Check Patient"  

In essence, it was determined that doing CPR on a heart that is just getting itself started again has a better patient outcome.


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## coyotejack (May 18, 2011)

ArcticKat said:


> No because it's a waste of time.  The study which resulted in the change of the AHA guidelines determined that doing CPR on a beating heart will not result in a detrimental effect and will in fact assist the newly restarted heart in increasing cardiac output prior to the AED reassessing the patient.   The AED is designed to detect if the rhythm is a shockable one.  If there is a pulse then the AED would detect the organised electrical activity and recommend "No Shock Advised, Check Patient"
> 
> In essence, it was determined that doing CPR on a heart that is just getting itself started again has a better patient outcome.



Thanks ArcticKat,

CoyoteJack


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## systemet (May 18, 2011)

ArcticKat said:


> In essence, it was determined that doing CPR on a heart that is just getting itself started again has a better patient outcome.



Just wondering --- was that actually shown?  

I mean, I understand the logic that if a small percentage of people with perfusing rhythms get two minutes of CPR, that probably won't harm them, it might be better than doing pulse checks and no CPR on a bunch of people with perfusing rhythms.  But has anyone actually shown this practice improves real outcomes?


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## BEorP (May 18, 2011)

systemet said:


> Just wondering --- was that actually shown?
> 
> I mean, I understand the logic that if a small percentage of people with perfusing rhythms get two minutes of CPR, that probably won't harm them, it might be better than doing pulse checks and no CPR on a bunch of people with perfusing rhythms.  But has anyone actually shown this practice improves real outcomes?



From the 2010 Guidelines:
"After shock delivery, the rescuer should not delay resumption of chest compressions to recheck the rhythm or pulse. After about 5 cycles of CPR (about 2 minutes, although this time is not firm), ideally ending with compressions, the AED should then analyze the cardiac rhythm and deliver another shock if indicated (Class I, LOE B). If a nonshockable rhythm is detected, the AED should instruct the rescuer to resume CPR immediately, beginning with chest compressions (Class I, LOE B)."

Class I is the highest class of recommendation and Level of Evidence B means that this is based on "Data derived from a single randomized trial, or non-randomized studies".


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## mycrofft (May 18, 2011)

*I give it three iterations then maybe they'll change their minds...again.*

Pulse-taking is falling out of fashion, especially with bystander level training, but elsewhere too. Laypersons often can't detect a pulse, literally, on themselves.

Since the current fashion is to pack every fraction of a second with productive compressions and recoils, if the compressions are now described as "harmless" to a beating heart, then snapping right back to compressions is in line with that algorithm.

Personally, I think it reflects the fact that, while AED gives you the best chance of survival, in most cases it will NOT make you sit up then drive yourself home, just restore a bioelectrical rythmn initially needing mechanical overpacing (CPR) to send blood to brain, coronary arteries, etc. until things get back to kilter (usually with drugs too), or the pt is pronounced dead ( still the most frequent outcome).  I tell my students to just dive back into compressions as quick as the machine says to, have hands poised but don't lean on the pt.


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## ArcticKat (May 18, 2011)

Consider this, what is the current BLS procedure to treat an unconcious choking adult?


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## mycrofft (May 18, 2011)

*Well, ARC bystander CPR says go to chest compressions.*

Doesn't the "B" in BLS stand for "Bystander"?


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## JPINFV (May 18, 2011)

ArcticKat said:


> Consider this, what is the current BLS procedure to treat an unconcious choking adult?


...CPR, which makes perfect sense when you think about it...


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## coyotejack (May 18, 2011)

Thanks everyone; I got it.  

CoyoteJack


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## systemet (May 19, 2011)

BEorP said:


> From the 2010 Guidelines:
> "After shock delivery, the rescuer should not delay resumption of chest compressions to recheck the rhythm or pulse. After about 5 cycles of CPR (about 2 minutes, although this time is not firm), ideally ending with compressions, the AED should then analyze the cardiac rhythm and deliver another shock if indicated (Class I, LOE B). If a nonshockable rhythm is detected, the AED should instruct the rescuer to resume CPR immediately, beginning with chest compressions (Class I, LOE B)."
> 
> Class I is the highest class of recommendation and Level of Evidence B means that this is based on "Data derived from a single randomized trial, or non-randomized studies".



Well, that's embarrassing.   I guess I should have taken 5 seconds to just check the guidelines.  I find the study (or studies) and report back.


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## Blessed187 (May 20, 2011)

It's funny cause this same question came into play about two weeks ago when we did an AED skills test. Funny how it was the MEDIC student that instructed us stupid BLS providers to check pulses after first shock. Good luck to you OP! I am glad some people where able to be respectful and answer your question(s).


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## ClaymoreCharlie (May 20, 2011)

Not to get too off topic here but...

We also need to think about how proficient in "pulse locating" we aren't.


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## medtech421 (May 23, 2011)

Stop CPR after your patient says "ouch" the second time.  Compressions might become detrimental after that.


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## korvus (May 25, 2011)

I don't have an actual reference in front of me, but I recall hearing that even if a shock works, it's common to get several seconds of asystole before the heart starts up again, so even if you do a pulse check, you probably won't detect anything even if the shock "worked".  Add that to the previous comments about CPR not really hurting a beating heart, and emphasis on limiting breaks in compressions, and it all makes sense.


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## medtech421 (May 25, 2011)

korvus said:


> I don't have an actual reference in front of me, but I recall hearing that even if a shock works, it's common to get several seconds of asystole before the heart starts up again, so even if you do a pulse check, you probably won't detect anything even if the shock "worked".  Add that to the previous comments about CPR not really hurting a beating heart, and emphasis on limiting breaks in compressions, and it all makes sense.



I seem to remember in my last instructor update..they said even if a pulse is obtained, you should do compressions because there is a high chance it will stop after a minute or so..thereby causing reports of "we lost him a couple of times"


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## rogersam5 (May 29, 2011)

medtech421 said:


> Stop CPR after your patient says "ouch" the second time.  Compressions might become detrimental after that.



And not just detrimental to you... the Patient might get a little testy, particularly if you sohuldn't have started in the first place..


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## EMTswag (Jun 7, 2011)

I was always taught that the only reassessment of pulse was when ordered by ALS or an obvious return of circulation. I think the time saved by immediately returning to compressions in the event that they are still in a shockable rhythm outweigh the risks of compressions on someone that had returned to normal sinus.


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## TacEMT (Jul 8, 2011)

Just to confirm, after giving a shock with an AED, you immediately continues with CPR? No pulse check.
You keep going with chest compressions and ventilations (30:2) for 2 minutes. Then you check pulse, and if you get a pulse, check breathing. If you find a pulse, you assist with ventilations. If there is no pulse you continue with CPR.

And lets say the AED analyzes and give a no shock. Then you check pulse, and check breathing.

Is this correct?


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## Handsome Robb (Jul 8, 2011)

CPR with the patient hooked up to an AED is pretty simple as it tells you what to do. If a shock is advised, deliver the shock then continue compressions. No shock advised it'll tell you to "Check pulse. If no pulse present continue CPR" Pulse present? Support ventilations until adequate and monitor the pulse. Not present, continue compressions.

So yes, you are correct. The thought is, even if the shock restarts the heart, it still needs help circulating oxygenated blood right after it starts back up.


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## hippocratical (Jul 16, 2011)

I find it humorous that the guidelines have to point out: _"If the patient is not unconscious, do not start CPR". 
_
Imagine someone yelling at their Pt: _"Stop struggling! I'm trying to do chest compressions here!"_


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## Handsome Robb (Jul 16, 2011)

You should meet some of the security guards in Reno....


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