# CPR or Defibrillation First - Witnessed Arrest



## 18G (Jul 16, 2013)

Had a minor dispute about what the proper action is on a witnessed arrest this evening so wanted to seek opinions. 

The scenario is: transporting a patient and patient arrests. What do you do first treatment wise? Shock or CPR?

I informed my preceptee that she should shock immediately. An EMT told me that was wrong and that you're supposed to do CPR first even though its witnessed. I strongly disagree. 

This is why I disagree. 

Defibrillation is the definitive treatment for cardiac arrest. The AHA says to start CPR while the defibrillator is retrieved. Well if ya got one six inches away from ya doesnt that qualify as defibrillator being retrieved and that you should use it immediately???? 

I understand the theory behind CPR first as an attempt to perfuse the myocytes so that they respond more favorably to the shock. But the research states that no solid evidence supports or refutes CPR before defibrillation. But what is known is that immediate defibrillation works. 

My thinking is this patient just coded and they aren't real hypoxic yet so why not shock them first and then start CPR? By starting CPR first we are delaying a crucial treatment.  

What do others think?


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## Aprz (Jul 16, 2013)

The current standard is if it's witnessed to defibrillate immediately, but if it's not witnessed or long down time, there is little research to support whether doing a cycle of CPR (2 minutes) or defibrillating immediately is better. They recommend that you do CPR while getting the defibrillator ready, but nothing about whether you actually need to delay defibrillation to complete the full 2 minutes.



> CPR Before Defibrillation
> During treatment of VF/pulseless VT healthcare providers must ensure that coordination between CPR and shock delivery is efficient. When VF is present for more than a few minutes, the myocardium is depleted of oxygen and metabolic substrates. A brief period of chest compressions can deliver oxygen and energy substrates and “unload” the volume-overloaded right ventricle, increasing the likelihood that a perfusing rhythm will return after shock delivery.141
> 
> Performing CPR while a defibrillator is readied for use is strongly recommended for all patients in cardiac arrest (Class I, LOE B). Analyses of VF waveform characteristics predictive of shock success have documented that the shorter the time interval between the last chest compression and shock delivery, the more likely the shock will be successful.141 A reduction of even a few seconds in the interval from pausing compressions to shock delivery can increase the probability of shock success.142
> ...


Source: http://circ.ahajournals.org/content/122/18_suppl_3/S729.full#sec-32

https://www.youtube.com/watch?v=riUAFkV7HCU

^Clearly can see right ventricular fluid overload. *Edit* Cannot get the Youtube thing to work. Just click the link to see.

In a short amount of time, I don't imagine that would happen.

I actually did read something though, I believe I saw it on ems12lead Facebook group Prehospital 12-lead ECG, that recommended doing 2 minutes of CPR first regardless of if it was witnessed. The research showed that the mortality rate was higher if it was witnessed and defibrillation was attempted first without chest compressions. At this time, I cannot find the article, but I will be browsing for it so I can post it here.

Another thing I can think about is what TomB said about shocking a patient into asystole.



TomB said:


> Yes, if the pre-shock coronary perfusion pressure is less than 15 mm Hg you will almost always shock the rhythm into asystole. This is why it's extremely important to perform comrpessions while the capacitor is charging and minimize the peri-shock pause. The pre-shock pause is more important that the post-shock pause but both are important.


Source: http://www.emtlife.com/showthread.php?p=483742#post483742

I'm not how fast the coronary perfusion pressure drops when trying to ready the defibrillator, but I think that could be another thing that would make somebody FOR doing chest compressions prior to defibrillation even if witnessed.

I will update this post when I find that article I am talking about.

*Edit* I cannot find the article after browsing the Facebook group page several time. I am positive it exists somewheres, but I can't find it. :[ Maybe Christopher or TomB will drop by?


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## DrParasite (Jul 16, 2013)

http://www.biomedcentral.com/1741-7015/8/52

http://www.theheart.org/article/1122241.do

http://www.uofmhealth.org/news/1708chest-compressions


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## mycrofft (Jul 16, 2013)

*Roger this*



Aprz said:


> The current standard is if it's witnessed to defibrillate immediately, but if it's not witnessed or long down time, there is little research to support whether doing a cycle of CPR (2 minutes) or defibrillating immediately is better. They recommend that you do CPR while getting the defibrillator ready, but nothing about whether you actually need to delay defibrillation to complete the full 2 minutes.
> 
> 
> Source: http://circ.ahajournals.org/content/122/18_suppl_3/S729.full#sec-32
> ...




I believe in a prior post it was cited that it takes about fifteen compressions to reestablish haemodynamic pressure if CPR is halted. One might add, that means losing CPR-effective circulation over the time for fifteen compressions, plus the downtime which precipitated the catch-up. It also presumes that you CAN "catch-up".

Trouble with "shock first" is an AED would not shock most conditions where the very promptly administered shock could make a difference (electrocution, atrial fib related hypotension, unknown etc). Different if you are using a manual defib, but is it in protocols? 

How about have electrodes in place for every patient suspected of needed enroute jolts? Tap the "CHARGE" switch or button, start CPR, when the light is green switch to "shock", then CPR until proven unnecessary (pt threatens to sue).


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## 18G (Jul 16, 2013)

Thanks for the links and feedback. I appreciate it.


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## Christopher (Jul 16, 2013)

18G said:


> Had a minor dispute about what the proper action is on a witnessed arrest this evening so wanted to seek opinions.
> 
> The scenario is: transporting a patient and patient arrests. What do you do first treatment wise? Shock or CPR?
> 
> ...



Nothing says you can't instruct your partner to pull over, lean patient back, put on pads, press charge (or press charge then put on pads, depends if your cardiac monitor will allow it), begin compressions, and press shock once charged...but to do two full minutes?

Primary VF responds very well to immediate defibrillation.


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## Mariemt (Jul 16, 2013)

I believe you can shock if it is witnessed and can shock immediately . However,  most cases people do not have a d fib right there so they are taught 5 rounds of CPR first. The CPR first is to prime the heart obviously. Why prime a primed heart? 
Why would an EMT be arguing with their medic? I would say what I thought was correct and drop it. Let them research it


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## VFlutter (Jul 16, 2013)

Do CPR long enough to charge the defib then shock. Personally, if I can get the pads on and shock with in ~45 sec I will just skip the CPR and save the patient the trauma. Coronary perfusion pressure wouldn't drop instantly (I don't think)

During various procedures (central line placement, cardiac Caths, etc) which frequently cause VT/VF we will have defib pads on and ready. If they sustain a lethal rhythm we charge and shock without CPR and the vast majority convert. If the first shock doesn't work we start CPR.  


For what it's worth I also saw a Precordial thump work once :beerchug:


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## mycrofft (Jul 16, 2013)

" For what it's worth I also saw a Precordial thump work once ".

Just to be a curmudgeon, prove it. 

Better yet, start a thread, see if others have also.


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## TomB (Jul 17, 2013)

ROC PRIMED showed no significant difference between shocking right away versus shocking after a prescribed interval of CPR. However, compressions were almost certainly being performed while setting up the defib and charging the capacitor.

From: http://www.nhlbi.nih.gov/news/press-releases/supplement/questions-and-answers-roc-primed.html

"The preliminary results of the study indicate that a small amount of CPR (30-90 seconds) is just as effective as a longer period of CPR (approximately three minutes) before EMS providers analyze heart rhythm to determine the need for defibrillation when performing CPR. The method of analyzing heart rhythm after 30-90 seconds of CPR is just as beneficial as performing CPR for up to three minutes before analyzing heart rhythm. Both methods are in widespread use depending on the common practice of individual organizations."

We've measured this in-house and there was huge variability from shift-to-shift and crew to crew. Our top performers were shocking within about 1 minute from announcing "at patient". Since the correct compression rate is 100/min. you ought to be able to deliver about 100 compressions while the monitor is turned on, the pads are unwrapped, the cable is connected, the pads are attached to the chest, an energy level is selected, and the capacitor is charged.


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## jefftherealmccoy (Jul 17, 2013)

mycrofft said:


> " For what it's worth I also saw a Precordial thump work once ".
> 
> Just to be a curmudgeon, prove it.
> 
> Better yet, start a thread, see if others have also.



Seen it. 

Why not just start CPR while monitor is hooked up?  Most of the time our cycles aren't 2 exactly two minutes anyways.  If the monitor's hooked up, patches on, I say shock 'em.  Seen the cath lab do it plenty of times.


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## mycrofft (Jul 18, 2013)

Remember I'm the guy who has said multiple times most CPR survivors didn't need it in the first place.h34r:


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## treckker (Jul 26, 2013)

Analyze and pop them, and if that dosent work compress. I feel that of you waited to pop the pt you could go into asystoly. If you do get ROSC then start going down your list of causes and correct them due to the pt may go back into that bad arrythmia.


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## HeatStroke (Jul 26, 2013)

ACLS says witnessed arrests get defibrillated immediately


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## mycrofft (Jul 27, 2013)

ACLS can use something more potent than an AED or defibrillator-only, too. Just saying.


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## Wheel (Jul 27, 2013)

HeatStroke said:


> ACLS says witnessed arrests get defibrillated immediately



Yes, as soon as you can get the pads on them. CPR for 30 seconds while you get the pads on will only help though, and practically will be the most likely situation you'll face.


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## SandpitMedic (Jul 28, 2013)

Wheel said:


> Yes, as soon as you can get the pads on them. CPR for 30 seconds while you get the pads on will only help though, and practically will be the most likely situation you'll face.



This
+1

Follow the algorithm/protocol.


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## Carlos Danger (Jul 28, 2013)

Wheel said:


> *Yes, as soon as you can get the pads on them.* CPR for 30 seconds while you get the pads on will only help though, and practically will be the most likely situation you'll face.



Pads?

What ever happened to paddles?


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## treckker (Jul 28, 2013)

Halothane said:


> Pads?
> 
> What ever happened to paddles?



lol the hands of God lol..........the local rural ED still has paddles on their Lp9.....and I have seen them used by the old school ED doc


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## Wheel (Jul 28, 2013)

Halothane said:


> Pads?
> 
> What ever happened to paddles?



Oh we still have them. They are purely ornamental though.


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## usalsfyre (Jul 29, 2013)

Halothane said:


> Pads?
> 
> What ever happened to paddles?



30 pounds of pressure while leaning over a patient and trying not to slip off the chest you had just applied a lubricant to....ah the memories:unsure:


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## NomadicMedic (Jul 29, 2013)

I worked an arrest in Haiti a few years ago. I shocked the PT with an old LP10 that had paddles. When I turned around, there was a line of people waiting to so the next shock because they had never used paddles and wanted to try them. True story.


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## VFlutter (Jul 29, 2013)

DEmedic said:


> I worked an arrest in Haiti a few years ago. I shocked the PT with an old LP10 that had paddles. When I turned around, there was a line of people waiting to so the next shock because they had never used paddles and wanted to try them. True story.



Our transport monitors have paddles. Rarely we will have to shock while transporting off the floor. I have seen them used but have not done it myself yet. I had a patient code in the elevator and the PA had to pull a yoga move to use it.


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## Carlos Danger (Jul 29, 2013)

I learned on LP10's with paddles (one of our ambulances even had an old LP5) and used them for the first few years of my career. I've probably worked 50 or 100 arrests with paddles.

Obviously patches have advantages, but paddles have some as well. 

I still miss being able to do a "quick look"


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## NomadicMedic (Jul 29, 2013)

The first monitor I used was an LP5. I miss being able to split the monitor and defib.  I also miss the "quick look".


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## the_negro_puppy (Jul 29, 2013)

We check for rhythm and shock first (if applicable) on all arrests


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## BigBad (Jul 31, 2013)

This is why you are the paramedic  and he is an emt.   Even acls says you shock witnessed arrest.


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## Akulahawk (Aug 1, 2013)

Witnessed arrest? If you have a defib right there, slap the pads on or grab some paddles and spark 'em. One of the things I liked about the paddles is that you can charge them as you grab them. If not, you might consider doing a precordial thump because you can apply one almost instantly. An instructor of mine had a patient that kept going into VF, so he'd thump him and the rhythm would convert. Yes, that patient went into a witnessed arrest (and was converted out of VF) probably somewhere >10 times in one transport...


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## hogdweeb (Aug 5, 2013)

regardless if my defiv is 6 inches from me or not, until it is on and ready to go I would not have me or any other EMS standing around twidling their thumbs, especially if there are bystanders. I havent looked at my protocols to see what they say regarding witnessed arrest, we have maybe one or two arrests a year in my service area, but if they say shock first, I would still have capable EMS doing CPR until protocol says to shock... Have to check on my protocol tonight....


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## usalsfyre (Aug 5, 2013)

hogdweeb said:


> regardless if my defiv is 6 inches from me or not, until it is on and ready to go I would not have me or any other EMS standing around twidling their thumbs, especially if there are bystanders. I havent looked at my protocols to see what they say regarding witnessed arrest, we have maybe one or two arrests a year in my service area, but if they say shock first, I would still have capable EMS doing CPR until protocol says to shock... Have to check on my protocol tonight....



As a former poster used to say "when in doubt, punt on first down...."


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## PurpleCharli (Aug 5, 2013)

Witnessed arrest, our protocols are to defib as soon as it is ready.  So if this patient had fast patches on the and it was just a matter of flippin a switch then defib.  If you had not anticipated the arrest, and you had to get the defib ready then compressions until you were ready.


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