Assessing an Unresponsive Pt

Remi said:
Pulse rate and quality gives you good info, sure. I'm just not sure how standard a practice it actually is to assess it right away on every patient encounter. Most of the patients I transported when I did ground were standing by the curb waiting with their suitcase in hand when we pulled up.....I rarely had any concerns about their hemodynamic status.
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Someone standing at the curb is going to be perfusing reasonably well. That doesn't mean that you shouldn't take note of skin signs or do a quick pulse check early on. It's amazing what you can get out of a quick introduction with a handshake...
 
Remi said:
Pulse rate and quality gives you good info, sure. I'm just not sure how standard a practice it actually is to assess it right away on every patient encounter. Most of the patients I transported when I did ground were standing by the curb waiting with their suitcase in hand when we pulled up.....I rarely had any concerns about their hemodynamic status.
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I probably would change my approach when presented with that. I don't really deal with that where I am though, suppose that's part of working in a rural area.

If someone is unresponsive I would hope that someone would be trying to find some sort of pulse right away, to get back to the OP...
 
The original question/issue was about an unconscious patient, not one standing on the curb with positive suitcase sign. My previous comments were generally along the lines of a patient that is unconscious... That still being said, at some point I'm usually able to do a pulse check early on in the encounter. I'd get a little worried about the positive suitcase patient that's got a pulse rate in the 160's and has been standing there for a few minutes and should have recovered from any exertion. I wouldn't necessarily know that the pulse rate is that high unless I did a quick check.
 
Cast eyeballs, say hi, shake hands, feel a radial. That's my initial assessment.
 
Brandon O said:
Cast eyeballs, say hi, shake hands, feel a radial. That's my initial assessment.
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And in the process you learn a lot about the patient's immediate situation... in about 3 seconds.
 
After you get the general impression that your patient is unresponsive you should immediately switch from ABC to CAB and check a pulse, if a pulse is found then you go back to airway, breathing and circulation and if no pulse is found you correct the circulation before going back to airway.

-Student
 
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Alpiner said:
After you get the general impression that your patient is unresponsive you should immediately switch from ABC to CAB and check a pulse, if a pulse is found then you go back to airway, breathing and circulation and if no pulse is found you correct the circulation before going back to airway.

-Student
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wait, what?

This is why people fail the NREMT. It's soooooo damn confusing.
 
Gurby said:
Note that a patient can be in cardiac arrest but still breathing. Always check for a pulse RIGHT AWAY in any unresponsive patient:

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Take a close look at her initial ECG morphology—awesome example of long QT syndrome triggering a Torsades event.
 
This video blew me away. Because grabbing a "quick" and accurate pulse during an active seizure can be a fairly difficult endeavor, as is the opportunity to hook up leads without introducing placement errors. I have worked seizure pts. ranging from almost still and rigid to literally kicking items off the shelves in a grocery store.

Now that I have actually seen time correlation with patient deterioration and the accompanying strip, I'm convinced that unless it is virtually impossible to obtain some sort of circulation through this patient-she is in full arrest and needs to be treated as such. This-obviously- may be extremely difficult depending on the magnitude and type of seizure.

I guess the most important questions for me are: Is this strip typical of most seizures? And If O2 admin is possible, is it as critical as circulating what is available? Wouldn't mind a little guidance on this one.
 
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BigBad said:
You do realize that is an EEG right?
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Ahhhh, good eye! Too bad they didn't put a few more leads on to get an EKG and have it display at the bottom - that would have been interesting to see. Still a pretty interesting video.
 
BigBad said:
You do realize that is an EEG right?
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Gurby said:
Ahhhh, good eye! Too bad they didn't put a few more leads on to get an EKG and have it display at the bottom - that would have been interesting to see. Still a pretty interesting video.
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The bottom most line is an EKG. You can see it written on there. All other lines are from the EEG.
 
Alpiner said:
After you get the general impression that your patient is unresponsive you should immediately switch from ABC to CAB and check a pulse, if a pulse is found then you go back to airway, breathing and circulation and if no pulse is found you correct the circulation before going back to airway.

-Student
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DEmedic said:
wait, what?

This is why people fail the NREMT. It's soooooo damn confusing.
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This is correct in a real life situation right? I check responsiveness and check for a pulse. If I don't find a pulse, I go straight into CPR. If I do find a pulse, I manually open the airway (adjunct and suction maybe), check the approximate rate and quality of breathing, and then check the approximate rate and quality of the carotid pulse? Then move into the secondary? Seems to play out fine in my mind.
 
benasack2000 said:
This is correct in a real life situation right? I check responsiveness and check for a pulse. If I don't find a pulse, I go straight into CPR. If I do find a pulse, I manually open the airway (adjunct and suction maybe), check the approximate rate and quality of breathing, and then check the approximate rate and quality of the carotid pulse? Then move into the secondary? Seems to play out fine in my mind.
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Yep.
 
Alpiner said:
After you get the general impression that your patient is unresponsive you should immediately switch from ABC to CAB and check a pulse, if a pulse is found then you go back to airway, breathing and circulation and if no pulse is found you correct the circulation before going back to airway.
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Unresponsive patients get (A)BC during assessment, CAB during treatment. People get confused about that one. You don't switch to CAB until you have checked for responsiveness, checked for breathing, and checked for pulse and are actually treating the patient.

Adult BLS sequence from 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science, Part 5: Adult Basic Life Support
  • Step 1A: Verify Unresponsive
  • (Lay rescuers Activate 911)
  • Step 1B: check for absence of breathing or agonal breathing. Do not "look, listen, and feel", anymore. This can be done while verifying patient is unresponsive; indeed it is often lumped into the first step. Do not open airway - this is done before rescue breathing.
  • Step 2: healthcare providers activate 911 unless drowning/choking, get AED if nearby or send someone to fetch AED
  • Step 3: health care providers check for carotid pulse, 10 seconds max. Lay people skip this step.
  • If you found pulse, then you switch to rescue breathing and rechecking pulse every 2 minutes
  • Step 4A: 30 Chest compressions
  • Step 4B: open airway and give two breaths
  • Step 4C: repeat until AED arrives and is ready
  • Step 5: AED arrives. Note that you can interrupt steps 4A and 4B if the AED arrives.
  • Step 6: check for shockable rhythm
  • Step 7: if shock advised , adminster shock followed by 2 minutes CPR
  • Step 8: otherwise (no shock advised), give 2 minutes CPR
  • If not already done, activate 911 (drowning/choking)
  • repeat step 6
Numbers are the steps numbers in the flowchart on figure 2. A, B, C added when multiple sequencial steps from narrative are included in one box on flowchart.

National Registry of EMT's Implementation of 2010 AHA Guidelines for CPR and Emergency Cardiovascular Care also says assess breathing before pulse.
 
I didnt wanna make a new thread, but I just have a question that needs clarifying:

When assessing an unresponsive trauma patient, I was told that I have to use the radial pulses to assess circulation due to determining if systolic bp is at least 90. However, I was taught in every unresponsive pt, you assess carotid for circulation. Any insights?
 
patzyboi said:
I didnt wanna make a new thread, but I just have a question that needs clarifying:

When assessing an unresponsive trauma patient, I was told that I have to use the radial pulses to assess circulation due to determining if systolic bp is at least 90. However, I was taught in every unresponsive pt, you assess carotid for circulation. Any insights?
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At my college we teach to check both radial and carotid at the same time.

The 90, 80, 70 that is taught widely is not true in the slightest. You can very easily have a patient with a SBP of 80 and still have radial pulses.
 
I am an EMT from Ireland and I hope you don't mind me taking part in this thread as I find it interesting seeing how it's done outside Ireland. Over here we are thought to check radial and carotid on ALL unresponsive PT and adopt the CAB approach for BLS. ABC applies to all patients and this is what confuses our guys as to which to use and when. In general upon assessing a PT as an EMT we are trained to check for presence/absence of a pulse by palpating the carotid and the radial. We take not of the rythm and quality at this point. In the secondary survay I am looking for the rate also.

There has been a bit of discussion on whether to check pulse on all patients. It's personally something I do for 99.9% of PT where appropriate as it can tell a lot about whats happening under the hood if you like.
 
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