What do you use to guage CPR adequacy?

[HERBIE1]

Herbie, I think you need a bigger rig. I will admit that I have not reviewed the original article or the sources cited in it. Lack of evidence is not the same thing as evidence against. If you don't have an ideal test you have to accept the next best thing. I agree with Mobey, maybe the OP had good intent by bringing up this thread but the way it was carried out was very condescending.

Yeah doc, more room would be nice- I can't tell you how many times the heart lung bypass machine gets in the way. It simply takes up too much room.

I'm all for technology when appropriate but prehospital, I think sometimes we rely too heavily on what a machine or electronic device tells us. Look at the patient- simple assessments can tell us so much- skin parameters, lungs, V/S, cap refill- all can paint a better overall picture and are fast and easy to obtain. It's akin to one of the first things we are taught in cardiology- when the "machine" tells you the patient is in V-fib but they are awake and talking to you, your first treatment is checking leads and not grabbing for the paddles.

I see it in many of my students- they are so infatuated with their new skills that they sometimes forget about the basics, but I think we've all been there. For one "nonbeliever", he was so anxious to intubate, that he didn't even realize that our cardiac arrest had a ROSC and was waking up.

[mobey]

We use ETCO2 (sometimes works sometimes not), combined with a visual depth and speed check from the call leader, Along with switching out compressors every 5 min.

NONE of these things have been PROVEN effective in a code situation, but we work with what we have.

As a side note (and attempt at hijacking) the autopulse dude came to give us a salespitch, and tried to use me as the patient.

Turns out, me at 6'3, ***Lbs (Very slim) am too narrow chested for the machine.

Lying flat with this thing wrapped around me, there was about a quarter inch of space between the ram and my chest. Just something to keep in mind when you stick this thing on a skinny frail old man (like I will be).

[Jwade]

Et al...

First, I was not trying to start a flame war by any means. However, I do not like people who state something as FACT and then cannot back it up with proven scientific evidence.

I was always taught from DAY one in EMT BASIC school way back in 1992 that checking a femoral pulse was pointless.

1. Cardiac Output is 20% at best of normal

2. Finding Femoral Pulses in people is a difficult task many times even with Normal Cardiac Output.

The reason I started this thread stemmed from a discussion / debate with an M.D. as I was teaching an ACLS course. A second reason I started the thread was having just finished an MBA program and having spent way too many hours looking at various HEMS / EMS statistics I was curious as to what the majority of responses would be, and from what background and education. (I.E. Street Paramedic, Flight Paramedic, EMT, Nurse, etc.....) I am more interested in the statistics.

After pulling up the various studies which show femoral pulses during CPR = Retrograde Flow this physician has since changed his lectures to include this info to students.

So, I am just curious as to what you guys do and WHY? Do you do it because that is what " we have always done" or " this is what i was taught" or do you alter your practice based on current literature?

Also, I was not limiting the discussion to PRE-Hospital, I see many nurses checking femoral pulses in the ER during codes. I completely understand if you are limited in what you carry on the RIG due to medical direction and so forth. As a Flight Paramedic, we pretty much have every toy at our disposal, and waveform ETCo2 is used extensively in many different aspects of our patient care, especially when we are running on a vent.

Anyways, I apologize if I offended anyone, it was not my intention. Also, Where did I make an assumption? I simply stated " ONE " must have a good working knowledge of A & P, I did NOT single any individual person out.

Look forward to your continued responses.

Respectfully,

JW

PS. MOBEY, What are you using for ETCo2? EasyCap or Waveform? There is a HUGE difference.

Edited September 20, 2009 by Jwade

[mobey]

We use the EtCo2 module on our LP12.

[cosgrojo]

Unfortunately Jwade, you have narrowed possible responses to your question by instituting your "qualifying" guidelines. Anybody who is a CPR instructor who went through the 2005 update process and actually read through the materials that you posted knows the answer to your questions. But since this is apparently the only answer that is acceptable for a response, what do you want? Anecdotal evidence is all anybody could possibly have for any other techniques or procedures.

Since the AHA sets the standards for the most part, and national protocols are (eventually) adapted from their research, no other answer could be backed with proper scientific data and statistics that you are requiring. I agree with ERdoc's original post. Maybe it would have been a less contentious conversation if you just posted the material you wanted to discuss, and enquire if we did it different in our respective neck of the woods.

I'm not suggesting that you were trying to pick a fight or be condescending, just that when you narrow the answer to only what you were going to post, there is not a lot of directions the conversation can go. BTW, the majority of quality posters on this site are just as against posting without backing or some form of research... but there is room here for everybody.

[Jwade]

Cosgrojo,

Points taken!

So, let me try to simplify what I was asking.

1. Do you use Femoral Pulse checks to gauge CPR adequacy?

2. If " YES" please provide your rationale and literature.

3. If " NO" please explain your procedure and why.

4. What is your background and education.

5. Do you actually spend time reading and understanding current research literature?

Again, Sorry for the confusion, I was not trying to flame anybody.

I ask these questions because it is my experience having worked from the streets of Detroit to flying the friendly skies, when I ask a provider " WHY" he or she usually will say either, " that is what I was taught" or "that is the way we have always done it".

Respectfully,

JW

[DwayneEMTP]

I don't use femoral pulses. I use depth of compression as the only indication.

Could you explain 'retrograde blood flow?'

I understand the concept in the abstract, as in retrograde depolarization, but as one that likes to believe he as at least a feeble grasp of anatomy and physiology, I can't seem to develop a clear concept for creating significant 'backwards' blood flow.

Thanks.

Dwayne

[HERBIE1]

Cosgrojo,

Points taken!

So, let me try to simplify what I was asking.

1. Do you use Femoral Pulse checks to gauge CPR adequacy?

2. If " YES" please provide your rationale and literature.

3. If " NO" please explain your procedure and why.

4. What is your background and education.

5. Do you actually spend time reading and understanding current research literature?

Again, Sorry for the confusion, I was not trying to flame anybody.

I ask these questions because it is my experience having worked from the streets of Detroit to flying the friendly skies, when I ask a provider " WHY" he or she usually will say either, " that is what I was taught" or "that is the way we have always done it".

Respectfully,

JW

The issues I have here are with femoral pulse check and "CPR adequacy". If you define this "adequacy" as simply a ROSC or oxygenation, then stats and studies would be appropriate. Prehospitally, if you are looking to see if the compressions being done are effectively-as in depth and rate, then anecdotal evidence is essentially all you can expect. I am well aware about the efficiency of CPR, but again, I look at this from a practical standpoint. In a code room in an ER(with respiratory techs, docs, students, nurses, etc- it's pretty crowded. People are pushing meds from peripheral IV ports, doing ventilations, checking BP's, doing compressions- all on the upper half of the patient. Thus, the least crowded location is the lower half of the patient, thus the femoral area is a good place to verify compressions. Same with prehospital- it gets pretty crowded in the back of a rig.

I tend to take a pragmatic approach to prehospital care. We improvise, adapt, and do what needs to be done since much of what we see and do is not in the books or any table of stats. Learning the skills in this business is the easy part- knowing the proper place to apply them takes time.

I'll leave the discussion relating to a in-hospital, critical care setting to someone else.

As for background- 30 years in EMS. Worked in ER's and level 1 trauma centers for 15 years. Volunteered, did disaster assessment, special events,

Worked as a preceptor, management, administration. Masters degree, teach university level classes, teach EMT's and paramedics. All star credentials- nope, but adequate to make a few observations.

[chbare]

I don't use femoral pulses. I use depth of compression as the only indication.

Could you explain 'retrograde blood flow?'

I understand the concept in the abstract, as in retrograde depolarization, but as one that likes to believe he as at least a feeble grasp of anatomy and physiology, I can't seem to develop a clear concept for creating significant 'backwards' blood flow.

Thanks.

Dwayne

It is essentially blood flowing in the opposite direction. In this case, he is talking about blood essentially flowing away from the heart in the venous system as a potential explanation for the presence of femoral pulsatile sensations during CPR. I agree, there exists no conclusive evidence to my knowledge that says the presence of pulses during compressions means much of anything. I have never relied on pulses during CPR unless we had a rhythm change and were assessing for ROSC. Even then, waveform capnography can be quite helpful for detecting the presence of ROSC.

However, we really do not understand what is occurring hemodynamically during CPR. I have pasted an abstract of a small but relatively new study that finds the presence of both anterograde and retrograde circulation components during CPR. In addition, some people suspect that the heart is nothing more than a conduit for blood and that circulation occurs as a result of intra-thoracic pressure gradient changes.

"Direction of blood flow from the left ventricle during cardiopulmonary resuscitation in humans-its implications for mechanism of blood flow.

Clinical Investigation

American Heart Journal. 156(6):1222e1-1222e7, December 2008.

Kim, Hyun MD a; Hwang, Sung Oh MD a; Lee, Christopher C. MD b; Lee, Kang Hyun MD a; Kim, Jang Young MD c; Yoo, Byung Su MD c; Lee, Seung Hwan MD c; Yoon, Jung Han MD c; Choe, Kyung Hoon MD c; Singer, Adam J. MD b

Abstract:

Background: Common mechanisms proposed to explain forward blood flow during cardiopulmonary resuscitation (CPR) include the cardiac and thoracic pumps. However, the exact role of the left ventricle in promoting forward blood flow during standard CPR in humans is mostly unknown. The aim of this study was to explore the role of the left ventricle in generating forward blood flow during standard CPR in humans by observing the direction of blood flow during CPR.

Methods: Ten patients with non-traumatic cardiac arrest were enrolled in this study. During CPR, contrast echocardiography with agitated saline was performed in the left ventricle and the aorta, and the direction of contrast flow was assessed using transesophageal echocardiography.

Results: On injecting the contrast in the aortic root, anterograde flow from the aorta during the compression phase was observed. No aortic regurgitation was present. Retrograde blood flow from the left ventricle into the left atrium as well as anterograde blood flow from the left ventricle into the aorta during the compression phase of CPR was observed in all cases. On injecting the contrast in the aortic root, anterograde flow from the aorta during the compression phase was observed. During each cycle of chest compression, the mitral valve closed during compression and opened during relaxation, and the aortic valve opened during compression and closed during relaxation.

Conclusions: Retrograde flow to the left atrium and forward blood flow onto the aorta on left ventricular contrast echocardiography during the compression phase suggests that extrinsic compression of the left ventricle by external chest compression acts as a pump in generating blood flow during standard CPR in humans.

© Mosby-Year Book Inc. 2008. All Rights Reserved."

Take care,

chbare.

[crotchitymedic1986]

If the patient walks out of the hospital, your efforts were adequate. Sounds crass, but CPR by EMS rarely matters as our response times are too long, and we are not involved enough in teaching community CPR so that the patient can get CPR when it matters.

Its like a Chef who blames his staff for his cooking failures, because they didnt buy the right ingredients. If it is that important, he/she should shop for themselves. If you are serious about saving cardiac arrest patients, you should begin by making the first link of the chain stronger. How many CPR Saturdays has your department had this year ? Teach community CPR so you do not have to do it.