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Pulse-Check Decisions
The consequences of errors:
You defibrillate You don’t
They have VF or VT* 👍👍 👎👎👎👎👎👎👎👎
👎👎👎👎👎👎👎👎
They have PEA/Asystole 👎 👍👍
Therefore:
• You(r team) must identify actionable rhythms correctly
• When unsure, make the better error
Reality
(unknown)
Your
Decision
Scenarios
• Pulse check
• What do you do?
Scenarios
• Pulse check
• What do you do?
(VF can be easy)
(Or, hard)
Scenarios
• Pulse check
• What do you do?
Scenarios
• Pulse check
• What do you do? (Are you sure???)
Scenarios
• Pulse check
• What do you do? (Are you sure???)
(it’s asystole)
What can you do when you’re unsure?
• Make the better error
• Enroll help (the nurses are good)
• “Are we certain this is asystole?"
• Turn up the gain
What is the big picture?
1. If they don’t have a pulse, someone is
compressing the chest with high quality
CPR. NO significant breaks.
1. Minimize pauses to necessary position
changes, pulse checks, and a little wiggle
room to the Lucas or intubation (but only a
little)
2. Shock them if they have a shockable
rhythm
The rest (mostly*) not so important
What if the pulse is hard to feel?
10 second pause, total
Use doppler
Use EtCO2 to detect ROSC
You resume
compressions
You don’t
They Don’t Have ROSC 👍👍 👎👎👎👎👎👎👎👎
👎👎👎👎👎👎👎👎
They Do Have ROSC 👎 👍👍
When uncertain…
make the better error!
In cardiac arrest scenarios, what interventions have a known, well established
mortality benefit for in hospital cardiac arrest? (Select all that apply)
• Minimally interrupted CPR
• Sodium bicarb in acidemic patients
• LUCAS device compressions for patients undergoing more than 30 minutes of
CPR
• Defibrillation of Shockable Rhythms
• ECMO (E-CPR)
In cardiac arrest scenarios, what interventions have a known, well established
mortality benefit for in hospital cardiac arrest? (Select all that apply)
• Minimally interrupted CPR
• Sodium bicarb in acidemic patients
• LUCAS device compressions for patients undergoing more than 30 minutes of
CPR
• Defibrillation of Shockable Rhythms
• ECMO (E-CPR)
Summary: Pulse Check Decisions
• Codes are uncertain: if you might make an error, make the better one.
• DO NOT MISS FINE V. Fib
• Only allow, at most, a few seconds of CPR delay for Lucas / Intubation

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Pulse Check Decisions - RRT and Code Blue Workshop

  • 2. The consequences of errors: You defibrillate You don’t They have VF or VT* 👍👍 👎👎👎👎👎👎👎👎 👎👎👎👎👎👎👎👎 They have PEA/Asystole 👎 👍👍 Therefore: • You(r team) must identify actionable rhythms correctly • When unsure, make the better error Reality (unknown) Your Decision
  • 4. Scenarios • Pulse check • What do you do? (VF can be easy) (Or, hard)
  • 6. Scenarios • Pulse check • What do you do? (Are you sure???)
  • 7. Scenarios • Pulse check • What do you do? (Are you sure???) (it’s asystole)
  • 8. What can you do when you’re unsure? • Make the better error • Enroll help (the nurses are good) • “Are we certain this is asystole?" • Turn up the gain
  • 9. What is the big picture? 1. If they don’t have a pulse, someone is compressing the chest with high quality CPR. NO significant breaks. 1. Minimize pauses to necessary position changes, pulse checks, and a little wiggle room to the Lucas or intubation (but only a little) 2. Shock them if they have a shockable rhythm The rest (mostly*) not so important
  • 10. What if the pulse is hard to feel? 10 second pause, total Use doppler Use EtCO2 to detect ROSC You resume compressions You don’t They Don’t Have ROSC 👍👍 👎👎👎👎👎👎👎👎 👎👎👎👎👎👎👎👎 They Do Have ROSC 👎 👍👍 When uncertain… make the better error!
  • 11. In cardiac arrest scenarios, what interventions have a known, well established mortality benefit for in hospital cardiac arrest? (Select all that apply) • Minimally interrupted CPR • Sodium bicarb in acidemic patients • LUCAS device compressions for patients undergoing more than 30 minutes of CPR • Defibrillation of Shockable Rhythms • ECMO (E-CPR)
  • 12. In cardiac arrest scenarios, what interventions have a known, well established mortality benefit for in hospital cardiac arrest? (Select all that apply) • Minimally interrupted CPR • Sodium bicarb in acidemic patients • LUCAS device compressions for patients undergoing more than 30 minutes of CPR • Defibrillation of Shockable Rhythms • ECMO (E-CPR)
  • 13. Summary: Pulse Check Decisions • Codes are uncertain: if you might make an error, make the better one. • DO NOT MISS FINE V. Fib • Only allow, at most, a few seconds of CPR delay for Lucas / Intubation

Editor's Notes

  1. * The same is true for other rhythms e.g. complete heart block or Afib vs NSR, but answers aren’t needed as fast and consequences aren’t severe.
  2. Do not miss fine V Fib. This is harder than you think Have someone bring the tele strip to all RRTs or code that occur when someone is monitored People who code on monitored units generally don’t go straight to Asystole Change change size of waveform on machine. Hopefully will have zoll with us on hand to show
  3. The point is – if you got one of those right and one of those wrong, you much prefer the error where you shock asystole… because who cares?
  4. Survival from witnessed ventricular fibrillation (VF) decreases by 10–12% for every minute defibrillation is delayed [3, 4], but when CPR is provided the decline in survival is only 3-4% per minute Utilize code team members – 1 to check pulse and 1 to monitor tele/zoll monitor Spend only 10 seconds checking for a pulse to minimize interruptions in CPR You don’t want house md at your code. Don’t try to diagnose lupus in a code. The rest is whatever (people will be fired up about all sorts of things, but they don't matter). It’s a bonus if you figure out why they coded, but it’s a small, small minority where the etiology is not blindingly obvious but is also easily reversible. LUCAS: institution policies vary, but Negative RCT in OHCA - DOI:https://doi.org/10.1016/S0140-6736(14)61886-9 Negative retrospective data in IHCA - https://doi.org/10.1016/j.resuscitation.2024.110142 The only time it may be important is ECMO/long resusc with procedure. IF pause in compression is more than a few seconds, USE YOUR CRED HERE.