Question about CPR

[usafmedic45]

Hmm... That is interesting. I may have to do a little research on that. Although, I live in a fairly urban area, so we never have transports over 20 minutes. Thanks for the info. It is always neat to see how other systems do things.

Look for "termination of field resuscitation". It should be standard practice. There is nothing that the hospital can do for most paitents that we can't do in the field and besides, they will be long since brain damaged or brain dead before we get them there even if we have only a 20 minute transport time.

 

[mycrofft]

Sunyata, about "why" people keep at it/delay transport...

Other than USAF's reply, the real answer is "Single Combat with Mr. Death".

Someone asked about ventilationless CPR? That's all I hear about anymore. I take the instructor update on the 27th for ARC and have read the AHA notes, but the diff is primarily that some folks who would not do bystander CPR if they have to liplock some panhandler might do it if they don't have to apply the "kiss of life", and it might help.

 

[usafmedic45]

"Single Combat with Mr. Death".

Actually, it's more like "small unit tactics against Mr. Death", but I'll give you the point anyhow. I've worked a code more or less by myself for about 10 minutes (with a bystander doing CPR while I intubated, got an IV started, pushed drugs and worked the defib) and I'm glad that's not a common thing. It was one of the most stressful things I've done.

 

[attnondeck]

On a follow up note, we(BLS crew) were picking up out of a snf transporting code2 to the ER for ALOC(Not BLS by any means in San Bernardino County). I began to assess the patient while partner was talking to the nurse about an unsigned DNR down the hallway...
Patient is Pale, unresponsive, breathing at about 2 breaths a minute, has a pulse of 52 according to my little $20 Finger Oxy Sat. I look at the Saturation, 80....60....40...30...nada. Pulse is now gone, not breathing and as I look up the patient is yellow. (this event was approx. 30 seconds) Patient Codes, we put the AED on immediately (no shock advised) and start CPR. About 30 mins. go by, by now fire and an ALS ambulance are now on-scene working her. They push Epi/Atropine (i think) and we get a pulse back. Loaded her, and she died at the hospital.

This happened last night, although the patient inevitably died, this was my first witnessed arrest and CPR go around, I was very impressed that with the addition of drugs we were able to restore a pulse for a short time… Anywho, Just wanted to spill my story, still kinda excited about it.

and why weren't you bagging her/her at resp. of 2?????

 

[RanchoEMT]

and why weren't you bagging her/her at resp. of 2?????

Walk in Room (at 0 seconds)
Pt. Codes (at 30 Seconds)

Are you implying i should have
A.)Bagged a person at 2 times a minute while their coding?
or
B.) Assess her, including figuring out that she's breathing at about 2 times a minute, setup a bag and start bag'n her at 2 times a minute in a 30 second time frame...Before she coded???

MY ANSWER to either: Should be Obvious.

 

[reaper]

Walk in Room (at 0 seconds)
Pt. Codes (at 30 Seconds)

Are you implying i should have
A.)Bagged a person at 2 times a minute while their coding?
or
B.) Assess her, including figuring out that she's breathing at about 2 times a minute, setup a bag and start bag'n her at 2 times a minute in a 30 second time frame...Before she coded???

MY ANSWER to either: Should be Obvious.

Answer is "C"

Walk in room. Assess Pt and see that they are breathing 2 times a minute. Obtain BVM, Drop OPA and assist ventilations. All in under 30 seconds!

It takes no more then a second or two to assess a pt and see that they are in distress. Shouldnt take 10-15 seconds to obtain and assemble BVM. 2 seconds to obatin OPA. 5 seconds to drop OPA. 2 seconds to start ventilations.

Have to be quick with decision making. It can costs lives. Do not wait for a SPO2 to tell you she needs assistance. You may be new and it takes time to get to that point, but learn all you can from it.

 

[mycrofft]

You mean like, "Why is my patient grey?".

If the pulse ox isn't working, you know we can't eval people!

USAF, I hear you, but my thinking about "Single Combat" etc is more on the line of BLS/lower capacity ALS target fixation than being forced into the Alamo. I've seen instances where a transportable pt who could have been loaded, tx enroute then delivered, were treated on scene past the point of immediate threat where they could be moved to the vehicle, and there you sit in a drift of torn wrappers, used sharps from failed IV attempts, and etc with a straight-lined pt, or having to be bailed out by a firetruck load of huskies who can just physically haul and run for the ambulance, where the pt is most likely going to expire anyway.

 

[RanchoEMT]

a somewhat delayed response. sorry...

-Let's Get This Out of the Way, Because I'm tired of reading about it...

Do not wait for a SPO2 to tell you she needs assistance.

My Pulse Ox tells me her pulse, instantly, without the need to count for 15/30 sec. (For those who are counting to 30...) Her saturation level is obviously inadequate, indicative of her skin signs "Skins Don't Lie" as she was "Pale", I know this. My efforts in putting on a Pulse Ox to a women that is blue serves more purpose than I think I'm being given credit for. Moving On...

Let’s Review…

I began to assess the patient while partner was talking to the nurse about an unsigned DNR down the hallway...
Patient is Pale, unresponsive, breathing at about 2 breaths a minute, has a pulse of 52 according to my little $20 Finger Oxy Sat. I look at the Saturation, 80....60....40...30...nada. Pulse is now gone, not breathing and as I look up the patient is yellow. (this event was approx. 30 seconds) Patient Codes, we put the AED on immediately (no shock advised) and start CPR.

Answer is "C"
Walk in room. Assess Pt and see that they are breathing 2 times a minute. Obtain BVM, Drop OPA and assist ventilations. All in under 30 seconds!
It takes no more then a second or two to assess a pt and see that they are in distress. Shouldnt take 10-15 seconds to obtain and assemble BVM. 2 seconds to obatin OPA. 5 seconds to drop OPA. 2 seconds to start ventilations.

I think jumping to conclusions and declaring this a “respiratory case” is a little premature with regards to assessment. A patient can be in cardiac arrest and have Agonal Respirations of about 2 per minute, But one who grabs a BVM without checking a pulse is going to be less conversant to this.
http://en.wikipedia.org/wiki/Agonal_respiration
http://www.youtube.com/watch?v=CBMxH4xtE8w

The Big Picture that I have apparently failed to convey is that regardless if it was 30 sec. or Mr. Reaper’s 24, this patient’s pulse dropped off before a BVM could be established.

After establishing that the patient was breathing at about 2 times a minute, I immediately check for a Pulse with the Pulse Ox...

has a pulse of 52 according to my little $20 Finger Oxy Sat.

It reads "52". AS MY HEAD IS DOWN AND MY EYES ARE STILL ON THE PULSE OX LOOKING AT THE PULSE No more than a second later the saturation drops from 80 to 60 to 40 to 30..... And she becomes pulse-less. Almost No time spent assessing Pulse... National Registry teaches what??? Assess for 10 seconds??? My assessment of her pulse was less than that. While assessing the pulse she quite literally lost her pulse, secondary was the pulse Ox findings(80,60,40,30) which everybody seems to be stuck on for some reason.


The impression that I’m getting is that you think it was wrong of me to assess the presence of a pulse with a person who is breathing at a rate of 2 times per minute and time wasted in doing this could have been spent in setting up a BVM for ventilations. I don’t agree with this rationale. Obviously, seconds later she coded, had I set up the BVM while she coded and had been ventilating her without the pulse check I would have only effectively been providing CPR without compressions….(Bagging a Pulseless Patient) What is your Logic here?

and why weren't you bagging her/her at resp. of 2?????

To Answer the Original Question, That's Why. Because I needed to assess the presence of a pulse to see if she was in cardiac arrest, and Behold, while assessing her pulse, she coded. Indicating an immediate new treatment, CPR.

 

[reaper]

So you are relying on a pulse ox to check a pulse? Rather then reaching down and checking for one?

 

[JPINFV]

At first I wasn't sure on this one. I put C but then I changed it to A. I remember reading that the quicker the AED is used the better.
In this case, would you do A. 2 mins of CPR then apply AED, B. 5 cycles of CPR with ventilation and then apply AED, or C. immediately apply AED and analyze?

I'll be the odd man out and argue that for testing purposes the answer is C. The NREMT exam explicitly states that they use American Heart Association Emergency Cardiac Care guidelines for their cardiac arrest management at all levels. AHA's guidelines is very wishy washy about the 2 minutes of CPR in an unwitnessed arrest or an arrest without bystander CPR. The AHA guidelines themselves mostly discuss doing CPR (compressions and ventilations) while preparing the AED, not necessarily delaying the AED for compressions.

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, increasing the likelihood that a shock may terminate VF (defibrillation) and a perfusing rhythm will return (ie, ROSC).18
When an out-of-hospital cardiac arrest is not witnessed by EMS personnel, EMS may initiate CPR while checking the ECG rhythm and preparing for defibrillation. There is insufficient evidence to determine if 1

to 3 minutes of CPR should be provided prior to defibrillation. CPR should be performed while a defibrillator is being readied (Class I, LOE B). One cycle of CPR consists of 30 compressions and 2 breaths. When compressions are delivered at a rate of about 100 per minute, 5 cycles of CPR should take roughly 2 minutes (range: about 1

to 3 minutes).
EMS system medical directors may consider implementing a protocol that allows EMS responders to provide CPR while preparing for defibrillation of patients found by EMS personnel to be in VF. In practice, however, CPR can be initiated while the AED is being readied.

http://circ.ahajournals.org/cgi/content/full/122/18_suppl_3/S706

 

[RanchoEMT]

So you are relying on a pulse ox to check a pulse? Rather then reaching down and checking for one?

This is a cheap point, not relevant to the topic being discussed and i feel it, an attempt at distraction and belittlement to divert away the original discussion. That of the numerical and systematic priorities within Assessment/Treatment. I know it. You know it.
So Do answer please, Do You Think It was Bad to Check the Presence of a Pulse Prior to Setting Up a BVM and Ventilating?

Or have we just become against ourselves, attempting to out best one another, regardless of topic, because of a minor point that was overlooked or understated within previous posts...

To answer your question, No more than a medic is who charts the pulse he/she see' on his/her Monitor. We need to count our cookies and walk away from this with "You have your methods with Reasoning, and I the same."

 

[Hellsbells]

As far as RanchoEMT's treatment goes, I think, overall, it is sound. I'm sure that no amount of bagging with a BVM in the 30secs on arrival would have "saved" this pt.

However, Using the pusle ox to obtain an initial pulse is not the best clinical method in my opinion. There are a lot of pitfalls with this technique, particularly in pts with circulatory collapse. Personally, I find it is difficult to obtain an accurate pulse rate on pts who have poor cirulation to their extremities.

On initial assessment, it would have been completely acceptable to palpate the carotid for 3-5sec and determine if the pt has a pulse, and if it seems fast or slow.

But, I agree the point is off topic. To the original question- I think its typical of multiple choice exams- to not nessesarily test the students knowledge of the subject, but instead their comprehension of the question itself. In my experience some of these exams don't even have a right answer, but instead you must select the least "wrong" answer.

 

[JPINFV]

However, Using the pusle ox to obtain an initial pulse is not the best clinical method in my opinion. There are a lot of pitfalls with this technique, particularly in pts with circulatory collapse. Personally, I find it is difficult to obtain an accurate pulse rate on pts who have poor cirulation to their extremities.

The biggest problem with using a pulse ox to get a pulse is what now are you using to ensure that you are getting a good reading?

 

[RanchoEMT]

The biggest problem with using a pulse ox to get a pulse is what now are you using to ensure that you are getting a good reading?

That's true, and I think it probably be too late in my story to ensure anyone I checked for a palpable radial or carotid pulse as if to solidify my story so I won’t hit this topic. But advantage wise for a patient that is circling, having an immediate Pulse (like a monitor) is nice. Obviously this was an “Oh :censored::censored::censored::censored:! Call Help Case” But being able to know if and exactly when changes occur without the 15/30 sec. needed to assess exact pulse ranges and time in-between assessing is nice. Especially had I assessed her at 52 bpm manually, set up a BVM and not been able to watch her trend immediately into arrest with the pulse ox.
The Obsolute Correct Answer is obviously, assess for a Pulse manually before trusting anything electronic as it’s not that hard to wait 15/30 sec. to assess a pulse. That’s what everybody is looking for here…. Does everybody? …..mmmm they should but probably not. I’m well awear of how cheap and misleading a $20 pulse ox can be. I’ll try and improve myself on the next assessment. But again, a side note.