# No shock advised, now what?



## BigDEMT

you arrive at a scene of a "man down"

Pt. is not responsive, apnic and you could find no pulse.
You start compressions  while your partner sets up the AED. you let the AED diagnose and it says "No shock advise"

what's next?

resume compressions? check pulse? how long?


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## NomadicMedic

CPR for another 2 minutes. Analyze again.


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## Jim37F

Push hard, push fast...


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## chaz90

Assuming this is for the BLS level, as above x2. 

/Close thread/


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## STXmedic

BigDEMT said:


> you arrive at a scene of a "man down"
> 
> Pt. is not responsive, apnic and you could find no pulse.
> You start compressions  while your partner sets up the AED. you let the AED diagnose and it says "No shock advise"
> 
> what's next?


Consider field termination.


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## BigDEMT

The reason I'm asking is my classmate and I had an argument if should you check for pulse before you resume compressions (his opinion) or you resume compressions for 2 min (5 cycles) and then re-assess (my vote).

other than the textbook answer I'm interested to find out what would you do in the field (BLS level)


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## cprted

After the initial pulse check, BLS only performs pulse checks again if there are signs of life.  If you wanted, you could assess pulses while the AED is analyzing.  But delaying chest compressions to check for a pulse after a no-shock without any other signs of life, not good practice.  You'll notice both box 7 and 8 below state "resume CPR immediately." 

Finding a pt in arrest, with unknown down time and no bystander CPR, the odds of a single two-minute cycle of chest compressions achieving ROSC are pretty much nill.


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## DesertMedic66

Slam that energy drink and protein shake because it's going to be a workout for you guys/gals.


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## Tigger

Hands over the chest while the AED is doing it's thing and then right back to compressions as soon as that eery "it is now safe to touch the patient" is heard.


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## ShearFish

Make them ribs mushy. 

Odd question, does anyone else have the monitor with the female voice that screams, "Deeper" or "Faster" if you are doing compressions wrong? I find it hard to stifle a laugh every time I hear that. Or maybe I'm just that twisted.


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## PotatoMedic

ShearFish said:


> Make them ribs mushy.
> 
> Odd question, does anyone else have the monitor with the female voice that screams, "Deeper" or "Faster" if you are doing compressions wrong? I find it hard to stifle a laugh every time I hear that. Or maybe I'm just that twisted.


All I can imagine now is someone with CPR pads on their pelvis...


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## Brandon O

The confusion here may be that some sources suggest, if you've been working the code (not the initial shock like this) and get a "no shock advised," you should check the pulse because you might've got a rhythm back with the last shock. But what I teach and what's most consistent with the guidelines (and data) is to keep pushing and shocking until there's some kind of overt signs of life or reperfusion (I would accept pinking of the skin). Otherwise in an asystole arrest you're going to be stopping for pulse checks every 2 minutes, which is absolutely not okay.


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## JPINFV

Brandon O said:


> The confusion here may be that some sources suggest, if you've been working the code (not the initial shock like this) and get a "no shock advised," you should check the pulse because you might've got a rhythm back with the last shock. But what I teach and what's most consistent with the guidelines (and data) is to keep pushing and shocking until there's some kind of overt signs of life or reperfusion (I would accept pinking of the skin). Otherwise in an asystole arrest you're going to be stopping for pulse checks every 2 minutes, which is absolutely not okay.


 If they're BLS (or ortho sx), they might not know if it's asystole.


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## Brandon O

Well, exactly. Although if you did find no pulse and it was No Shock Advised I suppose you could play odds.


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## Sunburn

You won't get pinking of the skin if it's 2 am and 5 degrees outside. 2 min intervals are there for a reason and you should definitely stick to them.


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## RedAirplane

If I recall correctly, checking pulse instead of resuming compressions is critical fail criteria.


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## JPINFV

Brandon O said:


> Well, exactly. Although if you did find no pulse and it was No Shock Advised I suppose you could play odds.


...PEA...

...also if the patient reaches asystole, then it really doesn't matter much since asystole is a relatively stable rhythm.


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## Brandon O

All rather moot unless the BLS crew is sitting around placing bets on the rhythm...

Actually, I shouldn't say that, I suppose you could argue a PEA rhythm might provide additional motivation to search for correctable causes. But I'm insane and even I would be a little skeptical of a Basic huddling on the floor trying to diagnose PEA by heart tones or something. Get dat history instead.


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## Gurby

Calling for ALS should be something that happens pretty shortly after you get on scene.



BigDEMT said:


> The reason I'm asking is my classmate and I had an argument if should you check for pulse before you resume compressions (his opinion) or you resume compressions for 2 min (5 cycles) and then re-assess (my vote).
> 
> other than the textbook answer I'm interested to find out what would you do in the field (BLS level)



You are right here - jump right back into compressions.  If you do get pulses back after a shock and their heart is now beating, a bit more CPR isn't going to hurt them - in fact, it might even help.  The protocol in my state for symptomatic bradycardia in peds is to do CPR if their heart rate is under 60 - just as an example of how you don't need to worry about doing CPR on a beating heart.


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## JeffT

http://emtlife.com/threads/shockable-rhythms.13976/


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## joshrunkle35

BigDEMT said:


> The reason I'm asking is my classmate and I had an argument if should you check for pulse before you resume compressions (his opinion) or you resume compressions for 2 min (5 cycles) and then re-assess (my vote).
> 
> other than the textbook answer I'm interested to find out what would you do in the field (BLS level)



Always immediately resume CPR.


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## squirrel15

As Jim Jeffries so eloquently puts it, push, push, blow, blow


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## Accelerator

You resume compressions immediately. Even the most well orchestrated synchronous cpr will leave breaks to throw in a quick pulse check. You should do it when possible. Always treat the patient not the monitor. Doubly so for an AED.


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