# Why is this answer right?



## jerellem (Feb 2, 2010)

This is a question off of a study guide for nremt-b.  Also, when can you do CPR on a child with a pulse?

10. Your patient is a 10 year old girl who was pulled unconscious from a pool. Lifeguards have been performing assisted ventilations on her with high flow O2 for about 15 minutes. She is not breathing on her own or perfusing adequately and has a pulse rate of 55 bpm. What would be the proper course of action? 



Your Answer: Attach the AED and analyze

Incorrect



Correct Answer is: Initiate chest compressions at 100 per minute



Other answers:

Increase the O2 flow rate to super high flow or 20 lpm

None of the above



Rationale: The newest AHA guidelines specify that a child who is not perfusing adequately, despite respiratory assistance, should receive chest compressions at 100 per minute.


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## Veneficus (Feb 2, 2010)

jerellem said:


> This is a question off of a study guide for nremt-b.  Also, when can you do CPR on a child with a pulse?
> 
> 10. Your patient is a 10 year old girl who was pulled unconscious from a pool. Lifeguards have been performing assisted ventilations on her with high flow O2 for about 15 minutes. She is not breathing on her own or perfusing adequately and has a *pulse rate of 55 bpm*. What would be the proper course of action?
> 
> ...




works for me


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## jerellem (Feb 2, 2010)

Ok, so when is CPR allowed on an adult or child WITH a pulse? And could your heart not beat at 55bpm in V-Fib?


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## JPINFV (Feb 2, 2010)

No... you will not have a pulse in v-fib.


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## medicdan (Feb 2, 2010)

Children with a pulse under 60bpm are not properly perfusing the brain... so compressions are warranted. Go back to your CPR textbook for clarification.


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## MMiz (Feb 2, 2010)

emt.dan said:


> Children with a pulse under 60bpm are not properly perfusing the brain... so compressions are warranted. Go back to your CPR textbook for clarification.


At what point, if ever, would you assess for a rhythm?


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## Veneficus (Feb 2, 2010)

MMiz said:


> At what point, if ever, would you assess for a rhythm?



Are you asking when you would use an AED or hook up a monitor?

the former... after 2 minutes of CPR you would reassess.

If the later... as soon as somebody had a free hand.


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## MMiz (Feb 2, 2010)

Well... this is awkward.  I misread the prompt.  Yep, I agree.  Missed the small detail regarding the pulse rate.  Small details will get ya.


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## jerellem (Feb 2, 2010)

Veneficus said:


> Are you asking when you would use an AED or hook up a monitor?
> 
> the former... after 2 minutes of CPR you would reassess.
> 
> If the later... as soon as somebody had a free hand.



Rephrase for me please


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## Veneficus (Feb 2, 2010)

jerellem said:


> Rephrase for me please



upon completion of 2 minutes of CPR on this patient. Check breathing, Check pulse, If pulse still <60 continue CPR, if no pulse, continue CPR stoppoing only to aplly the AED.

If you have a manual monior defib. I would hook it up as soon as was practical without interrupting CPR.


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## Velosprocket (Feb 2, 2010)

I would think the patient being wet might have something to do with the answer too.


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## Akulahawk (Feb 2, 2010)

Children are more rate dependent than adults are for maintaining cardiac output, and therefore, perfusion. The child in question may have a number of issues. She might be cold (hypothermic) and perhaps she's being inadequately oxygenated. Of the answers given, the more correct action is begin CPR to increase her cardiac output.


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## trevor1189 (Feb 2, 2010)

Velosprocket said:


> I would think the patient being wet might have something to do with the answer too.



Shouldn't, water on a Pt. should not deter AED use, wipe excess water from Pt. and proceed as normal.


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## Shishkabob (Feb 2, 2010)

Not adequate perfusion and low HR means correct the HR, which for peds tends to mean oxygen and compressions.


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## Velosprocket (Feb 2, 2010)

trevor1189 said:


> Shouldn't, water on a Pt. should not deter AED use, wipe excess water from Pt. and proceed as normal.



I was thinking more about the puddle of water the patient might be in.  Sorry, my earlier response wasn't very clear.  I'm interested in what might happen, if you use the AED on a patient in the rain, or kneeling in water.  I can't seem to find a concrete answer.

http://www.redcross.org/www-files/Documents/pdf/Preparedness/AED_FAQs.pdf

Q. Is it safe to use AEDs around water? 
A. Generally, the victim should not be in a puddle of water, nor should the rescuer be kneeling in a puddle of water when operating an AED.  AEDs can be used in a variety of environments including rain and snow.  Always use common sense when using an AED and follow the manufacturer’s recommendations.


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## themooingdawg (Feb 3, 2010)

AED is already out of the question because the patient has a pulse, AED is only used on patients with no pulse whatsoever. You dont want to shock a living patient now do you, you might mess up the electrical activity in the heart and might even send the person into cardiac arrest


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## Velosprocket (Feb 3, 2010)

themooingdawg said:


> AED is already out of the question because the patient has a pulse, AED is only used on patients with no pulse whatsoever. You dont want to shock a living patient now do you, you might mess up the electrical activity in the heart and might even send the person into cardiac arrest



That's true, you do not want to shock a live patient.  I hijacked the original question with my own AED questions.


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## MrBrown (Feb 3, 2010)

Are these Guidelines 2005 or the new, newest ones coming out at the end of the year?


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## mycrofft (Feb 3, 2010)

*OK, think and imagine. (By the way I don't disagree with ther answer)*


AED: If you can't rapidly haul a ten year old to the lawn, or onto a spineboard as an insulator, you are a wimp (like me). Many AED"s can be used as a monittor also, can't they? The zap is not foreordained. Which leads to:

RATE: everyone seems (to me) to think you need a monitor for rate determination. Well, maybe; if the 55/min is irregular maybe a lot of activity is not making it to the ventricles or they are getting it but not firing. An irregular or weak 55 is a lot worse than a regular strong 55, especially if the pulse is readily palpated and confirmed at two locations. What is your pt's color, too?

SECONDARY CONSIDERATIONS: kids chill off faster than adults, especially if hauled out wet, but not enough to elicit mammalian diving reflex. Watch for gooseflesh, distal pallor and/or rubor. Also, if on dry concrete in the sun, get a thermal insulator like a towel between them and the deck to avoid an unintended painful stimulus (2nd deg burns, for instance).

TERMINOLOGY: odd use by the test authors for the concept "assisted respirations" when the pt is not spontaneously respiring. We called that "artificial respiration" in the good old days.


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## NJFLGHTMDC (Feb 3, 2010)

Your rational of Zapping a patient into cardiac arrest, will not happen with  an AED, as they only shock "the two shockable rhythms" You are correct in saying it's out of question because they have a pulse


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## Aidey (Feb 3, 2010)

NJFLGHTMDC said:


> Your rational of Zapping a patient into cardiac arrest, will not happen with  an AED, as they only shock "the two shockable rhythms" You are correct in saying it's out of question because they have a pulse



I wouldn't be so sure on that. A while ago a BLS agency around here arrived first on a chest pain pt who had a history of SVT. The pt looked like crap so they hooked her up to their AED thinking "well, can't just stand here and do nothing". The AED indicated they shock, so they did. Pt improved. The only thing the doc could figure was that they cardioverted her with the AED. 


Back on topic, the current peds vs adult designation is lack of puberty correct? With how early some girls develop, she could potentially be treated as an adult couldn't she?


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## Shishkabob (Feb 3, 2010)

Guess it really depends on protocols. 

The protocols we had to learn for my internship were, once you put "teen" on the age, you treat as an adult, that way you dont worrya bout what is and is not puberty for someone.  12 is ped, 13 is adult.


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## Aidey (Feb 3, 2010)

I was thinking for ACLS vs PALS and where AHA makes the designation. I will have to pull out my book and look.


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## ivanh3 (Feb 10, 2010)

This question is one of those pick the best answer questions even though in a scenario or real call the best answer here would be wrong. The question itself is straight forward:

Respiratory arrest s/p submerssion in 10 year old child with a heart rate of 55.

Universal precautions/scene safety (part of which is making sure you are not in any water if the need for defib arises).

The best answer is compressions, but real deal would be A: check/clear airway B: two rescue breaths (aka positive pressure, high flow is useless here: patient not breathing per question info) C: check pulse (it is there but too slow) start compressions.

Go for two minutes. Now AHA says wait 2 minutes for AED "scan", but consider: this is two person CPR, there will opportunies during the two minutes to apply the pads. After the two minutes hit the anaylyze button. Follow AED instructions.

For lay CPR she is an adult (>8 years), for pros she is a ped (unless she had secondary sex charactaristics)

Even if we didn't know the mechanism (H's and T's) this is a ped, odds are crazy high she needs proper O2 delivery.


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## JPINFV (Feb 10, 2010)

NJFLGHTMDC said:


> Your rational of Zapping a patient into cardiac arrest, will not happen with  an AED, as they only shock "the two shockable rhythms" You are correct in saying it's out of question because they have a pulse



Not 100% accurate. Provided there's operator error with analyzing a patient with a pulse, why wouldn't an AED advise and allow a shock in a patient in v-tach with pulse? Also, to clarify, v-tach with pulse is the only possible scenario I can see short of artifact causing a misread.


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## Veneficus (Feb 10, 2010)

JPINFV said:


> Not 100% accurate. Provided there's operator error with analyzing a patient with a pulse, why wouldn't an AED advise and allow a shock in a patient in v-tach with pulse? Also, to clarify, v-tach with pulse is the only possible scenario I can see short of artifact causing a misread.



I was under the impression an AED only shocked Fib. 

I am not an expert on AEDs though


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## JPINFV (Feb 10, 2010)

ivanh3 said:


> Go for two minutes. Now AHA says wait 2 minutes for AED "scan", but consider: this is two person CPR, there will opportunies during the two minutes to apply the pads. After the two minutes hit the anaylyze button. Follow AED instructions.



No... AHA does not say that because there is no reason to attach an AED to someone with a pulse.

Pediatric BLS flowchart... too large for an image link:
http://circ.ahajournals.org/content/vol112/24_suppl/images/large/23FF2.jpeg



> Pulse Check (for Healthcare Providers) (Box 5)
> If you are a healthcare provider, you should try to palpate a pulse (brachial in an infant and carotid or femoral in a child). Take no more than 10 seconds. Studies show that healthcare providers87–93 as well as lay rescuers94–96 are unable to reliably detect a pulse and at times will think a pulse is present when there is no pulse. For this reason, if you do not definitely feel a pulse (eg, there is no pulse or you are not sure you feel a pulse) within 10 seconds, proceed with chest compressions.
> 
> If despite oxygenation and ventilation the pulse is <60 beats per minute (bpm) and there are signs of poor perfusion (ie, pallor, cyanosis), begin chest compressions. Profound bradycardia in the presence of poor perfusion is an indication for chest compressions because an inadequate heart rate with poor perfusion indicates that cardiac arrest is imminent. Cardiac output in infancy and childhood largely depends on heart rate. No scientific data has identified an absolute heart rate at which chest compressions should be initiated; the recommendation to provide cardiac compression for a heart rate <60 bpm with signs of poor perfusion is based on ease of teaching and skills retention. For additional information see "Bradycardia" in Part 12: "Pediatric Advanced Life Support."



http://circ.ahajournals.org/cgi/content/full/112/24_suppl/IV-156


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## Melclin (Feb 10, 2010)

JPINFV said:


> http://circ.ahajournals.org/cgi/content/full/112/24_suppl/IV-156



I'd be very interested to see how this:



> No scientific data has identified an absolute heart rate at which chest compressions should be initiated; the recommendation to provide cardiac compression for a heart rate <60 bpm with signs of poor perfusion is based on ease of teaching and skills retention.



...idea has affected our guidelines. *We are to start performing compressions on a brady kiddy with a pulse when the pulse rate drops bellow 40*, but I have to say, I think it should be higher. I wonder what the arguments are for those setting it higher and those lower.


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## JPINFV (Feb 10, 2010)

Based off of the Cirulation article alone, it looks like it should be based on symptomatic hypotension more than any single number. Unfortunately, if you don't provide a number, then you won't have a lot of "professional rescuers" providing the intervention.


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## ivanh3 (Feb 11, 2010)

JPINFV said:


> No... AHA does not say that because there is no reason to attach an AED to someone with a pulse.



I will meet you partway and say I wouldn't necessarily turn it on, but there is no way I would initiate CPR with compressions on someone and not apply the pads and be ready.  From the AHA material you quoted: bradycardia w/ evidence of poor perfusion=imminent arrest. Don't forget that in the scenario the child is already in respiratory arrest. Those are very compelling reasons to attach an AED. There would be no way to defend not having the AED attached and after your 10 second pulse check you found no pulse.


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## JPINFV (Feb 12, 2010)

Still, on the list of things to do on a bradycardic ped with CPR in progress, applying the pads is pretty far down the list. Activating paramedics and transporting definitely being above it. Sure, go ahead and throw them on provided that it's not delaying transport since you're most likely going to need them. However applying them to someone with a pulse is a far cry from analyzing a patient with a pulse. Similarly, respiratory arrest is not an indication for an AED. 

Let me ask you a question. You arrive as a paramedic as the first on scene. Is your first response to apply pads just in case you need them, or is it the bajillion other things that might actually be immediately useful? Do you charge your manual defib just so that when the patient does go into arrest you only have to hit one button to deliver a defibrillation?


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## wyoskibum (Feb 12, 2010)

ivanh3 said:


> I will meet you partway and say I wouldn't necessarily turn it on, but there is no way I would initiate CPR with compressions on someone and not apply the pads and be ready.  From the AHA material you quoted: bradycardia w/ evidence of poor perfusion=imminent arrest. Don't forget that in the scenario the child is already in respiratory arrest. Those are very compelling reasons to attach an AED. There would be no way to defend not having the AED attached and after your 10 second pulse check you found no pulse.



Instead of preparing for cardiac arrest by applying an AED, why not try and prevent the Cardiac Arrest?  As a Paramedic, you have a bradycardic patient who is not perfusion well,  what can you do to improve HR and perfusion??


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## ivanh3 (Feb 12, 2010)

JPINFV said:


> Still, on the list of things to do on a bradycardic ped with CPR in progress, applying the pads is pretty far down the list. Activating paramedics and transporting definitely being above it. Sure, go ahead and throw them on provided that it's not delaying transport since you're most likely going to need them. However applying them to someone with a pulse is a far cry from analyzing a patient with a pulse. Similarly, respiratory arrest is not an indication for an AED.
> 
> Let me ask you a question. You arrive as a paramedic as the first on scene. Is your first response to apply pads just in case you need them, or is it the bajillion other things that might actually be immediately useful? Do you charge your manual defib just so that when the patient does go into arrest you only have to hit one button to deliver a defibrillation?


A respiratory arrest by itself with evidence of adequate perfusion might not be a reason for hooking up an AED, but a respiratory arrest with compressions (i.e. imminent cardiac arrest), whether there is a pulse or not, is a different story. Applying an AED will not delay anything. It can be done during the first two minutes of CPR without interrupting the compressions or decreasing their quality. I have seen this often. Again, there should be no delay of transport, or anything else for that matter. 

As far as what is immediately useful, consider that in a cardiac arrest there are really only two interventions that have been shown to make a difference on patient outcomes: quality CPR and early defibrillation. IVs, medications, and intubation (when airway can be maintained with proper BVM technique) have not been demonstrated to improve outcomes in terms of patients leaving the hospital. So while there are indeed other tasks which must be done, I must triage the order of those tasks. In this case the order is simple because a) this is an intervention that has been scientifically demonstrated to affect patient outcomes and b) it actually delays nothing.

So as a paramedic my first response would be to assess, begin CPR, and in this case connect the AED. Now my hope would be that with good CPR and positive pressure ventilation there will be an improvement in status (this is not uncommon in pediatric cases), and that I would not need the AED/cardiac monitor, but that is a big chance to take. And no, I don't charge a defib unless a shock is called for. For me that is a safety consideration, and modern devices charge much quicker than they used to. 

Would you be wrong if you did not apply the AED because there is a pulse (albeit slow and under threat of cardiac arrest)? I guess not, but again what happens when that 2 minute mark comes up and there is no pulse? There is a dramatic decrease in AED effectiveness for each minute that elapses.


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## ivanh3 (Feb 12, 2010)

wyoskibum said:


> Instead of preparing for cardiac arrest by applying an AED, why not try and prevent the Cardiac Arrest?  As a Paramedic, you have a bradycardic patient who is not perfusion well,  what can you do to improve HR and perfusion??


I can do both measures without decreasing from either's effectiveness. *What is most likely to help this patient will be the positive pressure ventilation which would happen during CPR.* Applying the pads in anticipation of cardiac arrest does not detract from the intervention that might improve the bradycardia, but what it does do is to prepare me for possible (if not highly likely cardiac arrest). In this scenario the patient does not have just simple bradycardia. There is already respiratory arrest. This has to increase the chance of cardiac arrest.


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## wyoskibum (Feb 12, 2010)

*What if..... AED isn't always the answer*



ivanh3 said:


> I can do both measures without decreasing from either's effectiveness. *What is most likely to help this patient will be the positive pressure ventilation which would happen during CPR.* Applying the pads in anticipation of cardiac arrest does not detract from the intervention that might improve the bradycardia, but what it does do is to prepare me for possible (if not highly likely cardiac arrest). In this scenario the patient does not have just simple bradycardia. There is already respiratory arrest. This has to increase the chance of cardiac arrest.



I think the OP question was answered and the discussion had progressed from there.  An AED is contraindicated on a patient with a pulse.  The original scenario doesn't address anything beyond that.  So what are we really going to be able to do for this patient?

The patient is in Respiratory arrest, bradycardic with poor perfusion.  If the heart stops, what is the likely rhythm?  VFib/VTach or more likely it would be PEA?

A - airway? At the very least an OPA, perhaps consider ETT.
B - pt is in respiratory arrest, pt being ventillated.
C - circulation, poor, compression to help perfusion.  IV? might be a good idea before there is no pulse.

As an ALS provider I would forget about the AED.  Do you apply your leads/PAD's for the manual monitor/defibrillator?  Sure!  Perhaps the patient is a candidate for pacing.  At the very least see what rhythm there is.  Baseline vitals?  What is the BP?  What is the temp?  Is the pt hypothermic?

There are a lot of variables that are unknown in this scenario, but it does make interesting discussion.


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## ivanh3 (Feb 12, 2010)

wyoskibum said:


> I think the OP question was answered and the discussion had progressed from there.  An AED is contraindicated on a patient with a pulse.  The original scenario doesn't address anything beyond that.  So what are we really going to be able to do for this patient?
> 
> The patient is in Respiratory arrest, bradycardic with poor perfusion.  If the heart stops, what is the likely rhythm?  VFib/VTach or more likely it would be PEA?
> 
> ...



I agree the question has progressed from the OP, and it is interesting. This is how learning takes place. Not flaming anyone here, but I would have to respond by asking where is the science behind your response? Pediatric bradycardia is more likely to respond to proper O2 than any IV medication. If you are getting proper chest rise/fall with a BVM then a tube at the expense of compressions is not warranted at least initially.  I am not sure about what you mean by the AED being contraindicated. There is no contraindication. If you apply the pads for the manual then why not the AED (in the absence of a manual one)? If you are doing compressions you are essentially working an arrest. From the AHA:

_During cardiac arrest, basic CPR and early defibrillation are of primary importance, and drug administration is of secondary importance. Few drugs used in the treatment of cardiac arrest are supported by strong evidence._

My route would be to treat this an arrest/imminent arrest with high quality CPR/AED. At the same time I am treating my bradycardia by BVM and compressions.


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## wyoskibum (Feb 12, 2010)

ivanh3 said:


> I agree the question has progressed from the OP, and it is interesting. This is how learning takes place. Not flaming anyone here, but I would have to respond by asking where is the science behind your response? Pediatric bradycardia is more likely to respond to proper O2 than any IV medication. If you are getting proper chest rise/fall with a BVM then a tube at the expense of compressions is not warranted at least initially.  I am not sure about what you mean by the AED being contraindicated. There is no contraindication. If you apply the pads for the manual then why not the AED (in the absence of a manual one)? If you are doing compressions you are essentially working an arrest. From the AHA:
> 
> _During cardiac arrest, basic CPR and early defibrillation are of primary importance, and drug administration is of secondary importance. Few drugs used in the treatment of cardiac arrest are supported by strong evidence._
> 
> My route would be to treat this an arrest/imminent arrest with high quality CPR/AED. At the same time I am treating my bradycardia by BVM and compressions.



There are so many what if's in this scenario.  I don't disagree with that pt needs good CPR and ventilation.   Your argument for applying the AED Pads is to be ready for cardiac arrest.  You can use the same argument as reason to gain IV access.    

In my experience, it is more likely that this sort of patient will go from bradycardia to asystole or PEA.  What good is an AED then?    

My point is that if you have a monitor/defibrillator, apply that and forget the AED.  At least with the limb leads you can try to determine what rhythm does the pt have.

As for the AED being contraindicated, most AED protocols:

Indication: Unresponsive and without a pulse (signs of circulation for lay rescuer)
Contraindications: a pulse

Just my opinion.


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