Should we of Initiated cpr earlier

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chickj0434

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So call came for a fall with altered mental status. Get on scene late 60 male laying on grass smelling of booze. Construction workers found him and said he was talking talking them but not making any sense.. Check pulse. Very faint pulse not sure about respirations. Seemed like agonal breathing. He would lift his head up and open his mouth. Felt cold so was outside for some time. We quickly put him on stretcher and started bagging him with npa and bvm and administered a narcan. Checked pulse again and had no pulse so initiated cpr and aed and sectioned. . Medics arrived on scene later. Beating myself up over if I should of started cpr immediately or not
 
You said he initially had a pulse. Why would you start compressions on a patient with a pulse?
 
The OP might be questioning if they actually did feel a pulse in the beginning. I've brought it up here before when talking about pacing http://emtlife.com/threads/antero-lateral-infarct-to-arrest.49241/post-705449. Like Desert said, if you felt a pulse, no CPR. If in doubt or no pulse, do CPR. I think people will doubt themselves, freeze or try to convince themselves that there might be a pulse, unsure of it, and not do CPR or delay it.
 
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"Very very faint pulse" kind of supports what Aprz is saying. You want to feel a pulse, so there may be a little unintentional bias in that direction. An analogy in an ALS setting would be "very very fine vfib."
 
chickj0434 said:
He would lift his head up and open his mouth.
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if he's lifting his head up, I'm thinking CPR might be contra-indicated... remember you should stop compressions after the patient says ouch... goes double if he has a pulse.
 
mgr22 said:
"Very very faint pulse" kind of supports what Aprz is saying. You want to feel a pulse, so there may be a little unintentional bias in that direction. An analogy in an ALS setting would be "very very fine vfib."
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Yea went back at the hospital and he did pass. Charge nurse said they were asking around who narcaned him and why. I said we did. Was that the wrong move. Could that have any negative impact at all. From my point of view we had a male altered not making sense. Weak pulse with atonal breaths. Bag full of medications and alcohol. Pupils were maybe pinpoint or regular honestly didn't get as good as a long as I would of liked to. So while bagging pt I decided to see of narcan would improve anything. Gave 1 dose
 
chickj0434 said:
Yea went back at the hospital and he did pass. Charge nurse said they were asking around who narcaned him and why. I said we did. Was that the wrong move. Could that have any negative impact at all. From my point of view we had a male altered not making sense. Weak pulse with atonal breaths. Bag full of medications and alcohol. Pupils were maybe pinpoint or regular honestly didn't get as good as a long as I would of liked to. So while bagging pt I decided to see of narcan would improve anything. Gave 1 dose
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The Narcan wasn't a bad idea. If he had taken narcotics plus certain other meds, his pupils may not have been constricted.
 
chickj0434 said:
Yea went back at the hospital and he did pass. Charge nurse said they were asking around who narcaned him and why. I said we did. Was that the wrong move. Could that have any negative impact at all. From my point of view we had a male altered not making sense. Weak pulse with atonal breaths. Bag full of medications and alcohol. Pupils were maybe pinpoint or regular honestly didn't get as good as a long as I would of liked to. So while bagging pt I decided to see of narcan would improve anything. Gave 1 dose
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Altered? Agonal breathing? Bag full of medications? Yes, to narcan.

Also, the charge nurse '...wants to ask why..." doesn't have to be taken as an accusation.
 
DrParasite said:
if he's lifting his head up, I'm thinking CPR might be contra-indicated... remember you should stop compressions after the patient says ouch... goes double if he has a pulse.
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Yea but he wasn't really responding to sternly rub. I believe he only slightly moved his head up two times and that was one of them. He didn't really have any real. Noticeable chest rise and fall.
 
You can do everything right and still lose. I know it's easier said than done, but don't dwell too much on it.
 

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chickj0434 said:
Yea but he wasn't really responding to sternly rub. I believe he only slightly moved his head up two times and that was one of them. He didn't really have any real. Noticeable chest rise and fall.
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Watch Bondi Beach Rescue. Agonal breathing.
 
 
Aprz said:
You can do everything right and still lose. I know it's easier said than done, but don't dwell too much on it.
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This is huge, and can’t be stressed enough most times.

I’ve recently even had a guy who was talking to me answering questions alert and oriented code infront of me and was declared at hospital. I recognized he coded with in milliseconds. Never got pulses back. Threw the kitchen sink at him and all, docs summed it up to a pe or massive mi, neither of which we could fix in the field and the er even attempted altepase(tpa)
 
Aprz said:
You can do everything right and still lose. I know it's easier said than done, but don't dwell too much on it.
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Corollaries to this are that bad outcomes don't mean you did something wrong and if someone doesn't understand something (ie an RN asking about narcan) it doesn't mean someone did something wrong. Two axioms that are useful to remember where a toxic nursing culture exists.
 
As charge nurse, I have to call the ME, call LifeNet, and deal with the local authorities regarding any deaths. A lot of times questions about prehospital care are simply to clarify these dealings. And then some questions are because some nurses are *****es ;)
 
E tank said:
Corollaries to this are that bad outcomes don't mean you did something wrong and if someone doesn't understand something (ie an RN asking about narcan) it doesn't mean someone did something wrong. Two axioms that are useful to remember where a toxic nursing culture exists.
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Or really anyplace that two distinct cultures interact.
 
Narcan seemed entirely correct. Honestly, everyone in the company i work at Does narcan on Every arrest indicated or not just to Rule out H's and T's. You seemed to have started CPR at the correct time, And shouldnt have started it earlier if he was moving his head etc thats a clear sign he still has a pulse and somewhat following commands (or not)
 
OP: don't beat yourself up too much about this. From what you describe, it all seems quite appropriate for the situation. This one just seemed to be an unwinnable fight.
 
While I agree with everyone else who has posted so far, one thing I would like to add is what can be learned from this? Every call, every patient, every scenario has a teachable moment if you're willing to look for it and learn from it.
 
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