Running a code

[atlpump]

I recently has a situation where a man had an MI at the gym. I immediately jumped on his chest and pumped until the EMTs arrived. (portable defib at gym didn't work but that is another story)

While I was doing CPR I realized I didn't know when to stop when outside of the hospital. If you don't have a monitor to confirm sinus, is the return of spontaneous breathing the only reason to stop ? If you get a strong regular pulse is it appropriate to support breathing without compressions ? If for any reason the EMT cant get to where you are, is lack of brain stem reflexes sufficient to call it after a certain time ? If so what is a responsible amount of time to work on the person ?

Thanks

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[EDMD4LIFE]

I recently has a situation where a man had an MI at the gym. I immediately jumped on his chest and pumped until the EMTs arrived. (portable defib at gym didn't work but that is another story)

While I was doing CPR I realized I didn't know when to stop when outside of the hospital. If you don't have a monitor to confirm sinus, is the return of spontaneous breathing the only reason to stop ? If you get a strong regular pulse is it appropriate to support breathing without compressions ? If for any reason the EMT cant get to where you are, is lack of brain stem reflexes sufficient to call it after a certain time ? If so what is a responsible amount of time to work on the person ?

Thanks

Can you please identify your skill level? Are you a student...medic...resident....attending....lay person????

 

[atlpump]

PA comfortable running the code until an attending arrives.

 

[erdoc00]

There's a reason you pause every 2 minutes for pulse checks...

ROSC is predicated on circulation and has nothing to do with whether they are breathing or not. If you get a pulse back, hold c0mpressions and provide rescue breaths, but continue to make sure you have a pulse. No pulse = resume compressions/CPR.

As far as when to call it. For a witnessed arrest in any situation where an ambulance can be expected within 30 minutes, I'd continue (CPR + AED) until an ambulance arrived. I probably would not personally call a code in the field and would let either the medics or hospital call it after having the ability to push meds and use a monitor.

As far as if you're too far away from access (i.e. someone in a remote campground)... I'd probably do it for 30 minutes and call it based on lack of ROSC over that time. I probably wouldn't be putting cold water in anyone's ear, either, to confirm their death.

 

[EDMD4LIFE]

You don't need a monitor to confirm ROSC (Return of Spontaneous Circulation). You need to physically check for a pulse. A monitor may show you a rhythm of some sort or asystole. However, if you see a sinus rhythm on the monitor but can't feel a pulse, then you have PEA (Pulseless Electrical Activity) and should continue compressions and high quality CPR.

I agree with erdoc00 regarding supporting airway if needed after ROSC. I would suggest you continue CPR for as long as you and other helpful bystanders can until EMS arrives, then let them take over. I've personally witnessed a code that was worked in the field by medics for 56 minutes before patient had ROSC, and a couple of weeks later, she walked out of the hospital.

Not to be mean or offend you, but have you taken an ACLS course atlpump?

 

[The White Coat Investor]

I stop pumping when I have a pulse. I stop bagging when they're breathing adequately. I stop the code when the patient asks me what we're all doing (or last time, "Where's my luggage?")

 

[Birdstrike]

I stop pumping when I have a pulse. I stop bagging when they're breathing adequately. I stop the code when the patient asks me what we're all doing (or last time, "Where's my luggage?")

Exactly.

 

[EDMD4LIFE]

I stop pumping when I have a pulse. I stop bagging when they're breathing adequately. I stop the code when the patient asks me what we're all doing (or last time, "Where's my luggage?")

Yep, hit the nail on the head and simplified very nicely!

 

[link2swim06]

I think there are cases I would quit CPR without a monitor. First if you were camping and far away from anyone. Doing CPR for 2 hours isn't going to end in a good outcome. Also trans-oceanic flights definitely would have a stop time at some point regardless what the AED advises you.

 

[atlpump]

You don't need a monitor to confirm ROSC (Return of Spontaneous Circulation). You need to physically check for a pulse. A monitor may show you a rhythm of some sort or asystole. However, if you see a sinus rhythm on the monitor but can't feel a pulse, then you have PEA (Pulseless Electrical Activity) and should continue compressions and high quality CPR.

I agree with erdoc00 regarding supporting airway if needed after ROSC. I would suggest you continue CPR for as long as you and other helpful bystanders can until EMS arrives, then let them take over. I've personally witnessed a code that was worked in the field by medics for 56 minutes before patient had ROSC, and a couple of weeks later, she walked out of the hospital.

Not to be mean or offend you, but have you taken an ACLS course atlpump?

Ill bet you are a joy to work with.

 

[atlpump]

Thank you. All the constructive comments are very much appreciated.

 

[Boatswain2PA]

PA comfortable running the code until an attending arrives.

Not trying to be rude, but you asked a question about a very simple, basic concept....one that anyone who can find themselves running a code should have a deep understanding of.

The goal of CPR is perfusion. If patient is perfusing, then stop. Until then, keep going until you are ready to call it.

 

[atlpump]

Not trying to be rude, but you asked a question about a very simple, basic concept....one that anyone who can find themselves running a code should have a deep understanding of.

The goal of CPR is perfusion. If patient is perfusing, then stop. Until then, keep going until you are ready to call it.

I glad I was able to give the opportunity to make you feel impressed with yourself.

 

[deuist]

I glad I was able to give the opportunity to make you feel impressed with yourself.

Now now, no reason to get your feelings all hurt. You told us that you are comfortable running codes, then asked questions that make us wonder how comfortable you really are. We all have our own levels of ignorance. If an oncologist tried to tell me something about chemotherapy, I wouldn't take it as an offense.

 

[SouthSideSteve]

While I was doing CPR I realized I didn't know when to stop when outside of the hospital. If you don't have a monitor to confirm sinus, is the return of spontaneous breathing the only reason to stop ? If you get a strong regular pulse is it appropriate to support breathing without compressions ?

Thanks

All of those questions can be answered by taking a BLS class...

 

[EDMD4LIFE]

Ill bet you are a joy to work with.

Hey. You asked a question, you got your constructive feedback. My saves and the people I run them with DO find me a joy to work with. Based on your fumbling question, apparent knowledge gaps (to say the least) and your responses to logical feedback, I truly hope that you are not given the autonomy to run a code on your own. Ever.

Nice troll post, by the way.

 

[atlpump]

Wow, now this has really gone off the shamefully unprofessional deep end.
Doing chest compressions on a gym floor between a pair of tread mills, on a man who just grabbed his chest
and collapesed while a malfunctioning AED beeps uselessly and the EMT seems like it is taking forever
is NOT the same thing as running a code. Being clear on what to do when you are camping in a remote spot is
a question of first aid and is a different skill set than knowing how to read a strip and what drugs to push.

ERdoc00 gave useful, professional information. The rest of have embarassed themselves although I doubt
they realize it.

 

[Druggernaut]

Wow, now this has really gone off the shamefully unprofessional deep end.
Doing chest compressions on a gym floor between a pair of tread mills, on a man who just grabbed his chest
and collapesed while a malfunctioning AED beeps uselessly and the EMT seems like it is taking forever
is NOT the same thing as running a code. Being clear on what to do when you are camping in a remote spot is
a question of first aid and is a different skill set than knowing how to read a strip and what drugs to push.

ERdoc00 gave useful, professional information. The rest of have embarassed themselves although I doubt
they realize it.

It's kind a different skill set, I guess: one's BLS, one's ACLS. But if you're calling the ACLS shots, you should have a good handle on the BLS. These were pretty much BLS 101 questions, which the greenhorn 4-credits at the technical college EMT-Basic ought to be able to handle, much less an ED PA "comfortable running a code."

I don't think anyone was out of line until you became unnecessarily catty with EDMD4LIFE, which justifiably opened the floodgates.

 

[WilcoWorld]

Damnit I can't resist...if someone doesn't realize he's embarrassed, can he actually be embarrassed?

 

[deleted432032]

Damnit I can't resist...if someone doesn't realize he's embarrassed, can he actually be embarrassed?

Yes, Yes they can.

I think!

Maybe not.

What was the question?

 

[atlpump]

Fair enough, I worded the question badly.

Now back to information, Ive read through every termination of resuscitation guideline I can find. I cant find one that covers a witnessed arrest with no meds, shocks or rhythm strips.

If anyone knows of one that covers these circumstances in an area where EMS cannot be reached, I would like to read it.

Please stay on topic.

 

[Boatswain2PA]

When they start perfusing on their own, or you are too tired to continue.

 

[SouthSideSteve]

Fair enough, I worded the question badly.

Now back to information, Ive read through every termination of resuscitation guideline I can find. I cant find one that covers a witnessed arrest with no meds, shocks or rhythm strips.

Why are you so hung up on a rhythm strip? Do they have a pulse? If so they are perfusing and you can stop compressions. If not, keep going.

You don't need a monitor to tell you if someone has a perfusing rhythm.

This is a elementary protocol that nurses and emts are able to follow. It doesn't require a high level of thought.

 

[Birdstrike]

If there's no pulse, do compressions. If there is a pulse, stop. As a general rule, awake patients will have a pulse. Awake adults don't need chest compressions no matter what your monitor says. (You might see a flat line with improper leads or placement).

After 20-30 minutes without a pulse, in a non-hypothermic patient, return of meaningful spontaneous circulation or meaningful brain function is exceedingly rare. It's rare after much less than that, but most people feel pretty comfortable calling a code, if truly pulseless after 20-30 minutes of downtime. (Keep in mind, a lot of people have no clue how to truly check for pulselessness, especially in obese patients). Time from arrest to hospital arrival, or time to EMS arrival, eats into a good portion of that to begin with. Generally, if there's nothing defibrillatable, the vast majority of the time you're going to be calling time-of-death at some point, regardless of cause or initial rhythm.

Most often, people call codes too late, as opposed to early. Though you do hear of these sporadic cases where some "cadaver" wakes up in the morgue or body bag after being pronounced, because someone did a sloppy job of pronouncing. Based on how this thread has gone, my best advise is: When in doubt, just keep pumping until someone more comfortable with arrest situations comes into play.

 

[TooMuchResearch]

If there's no pulse, do compressions. If there is a pulse, stop. As a general rule, awake patients will have a pulse. Awake adults don't need chest compressions no matter what your monitor says. (You might see a flat line with improper leads or placement).

After 20-30 minutes without a pulse, in a non-hypothermic patient, return of meaningful spontaneous circulation or meaningful brain function is exceedingly rare. It's rare after much less than that, but most people feel pretty comfortable calling a code, if truly pulseless after 20-30 minutes of downtime. (Keep in mind, a lot of people have no clue how to truly check for pulselessness, especially in obese patients). Time from arrest to hospital arrival, or time to EMS arrival, eats into a good portion of that to begin with. Generally, if there's nothing defibrillatable, the vast majority of the time you're going to be calling time-of-death at some point, regardless of cause or initial rhythm.

Most often, people call codes too late, as opposed to early. Though you do hear of these sporadic cases where some "cadaver" wakes up in the morgue or body bag after being pronounced, because someone did a sloppy job of pronouncing. Based on how this thread has gone, my best advise is: When in doubt, just keep pumping until someone more comfortable with arrest situations comes into play.

There is a growing number of case reports of good neurologic outcomes after 20+ minutes (I know cases of 60+ minutes) of good CPR. There was a paper on this within the last 1-2 years...can't remember which journal, title, or authors.

Shockable rhythms should go to the cath lab (if you have one) before quitting, but that takes a lot of Interventional Cards buy in.

Edit:

Matos et al. Duration of CPR and Illness Category Impact Survival and Neurologic Outcomes for In-Hospital Pediatric Cardiac Arrests. Circulation, Jan. 21, 2013

Zachary D Goldberger, Paul S Chan, Robert A Berg, Steven L Kronick, Colin R Cooke, Mingrui Lu, Mousumi Banerjee, Rodney A Hayward, Harlan M Krumholz, Brahmajee K Nallamothu. Duration of resuscitation efforts and survival after in-hospital cardiac arrest: an observational study. The Lancet, 2012; 380 (9852): 1473 DOI: 10.1016/S0140-6736(12)60862-9

The second reference is the paper I was thinking about.

 

[Birdstrike]

There is a growing number of case reports of good neurologic outcomes after 20+ minutes (I know cases of 60+ minutes) of good CPR. There was a paper on this within the last 1-2 years...can't remember which journal, title, or authors.

Shockable rhythms should go to the cath lab (if you have one) before quitting, but that takes a lot of Interventional Cards buy in.

Edit:

Matos et al. Duration of CPR and Illness Category Impact Survival and Neurologic Outcomes for In-Hospital Pediatric Cardiac Arrests. Circulation, Jan. 21, 2013

Zachary D Goldberger, Paul S Chan, Robert A Berg, Steven L Kronick, Colin R Cooke, Mingrui Lu, Mousumi Banerjee, Rodney A Hayward, Harlan M Krumholz, Brahmajee K Nallamothu. Duration of resuscitation efforts and survival after in-hospital cardiac arrest: an observational study. The Lancet, 2012; 380 (9852): 1473 DOI: 10.1016/S0140-6736(12)60862-9

The second reference is the paper I was thinking about.

I forgot to mention: Kids. Everyone goes longer in kids.

So are you going to run every code > 60 minutes based on those papers?

 

[Arcan57]

I forgot to mention: Kids. Everyone goes longer in kids.

So are you going to run every code > 60 minutes based on those papers?

So far I have an n=2 for patients I've coded for 60+ minutes that came back neuro intact. For me the distinction is downtime prior to CPR initiation. Both of the codes I've gotten back have been witnessed arrests (by me) in the hospital where I knew there had been constant, quality chest compressions. Witnessed in-hospital cardiac arrest is a different beast then what gets brought into us from the field. With the exception of the septic shock ICU player maxed out on 3 pressors who's BP goes away, I will stay and play on in-hospital arrests until I hit a couple rounds of asystole or they come back. With that being said, my average code length is probably less than 10 min because EMS brings us 40-60 min downtimes with persistent asystole despite double digit rounds of epi.

 

[Birdstrike]

So far I have an n=2 for patients I've coded for 60+ minutes that came back neuro intact. For me the distinction is downtime prior to CPR initiation. Both of the codes I've gotten back have been witnessed arrests (by me) in the hospital where I knew there had been constant, quality chest compressions. Witnessed in-hospital cardiac arrest is a different beast then what gets brought into us from the field. With the exception of the septic shock ICU player maxed out on 3 pressors who's BP goes away, I will stay and play on in-hospital arrests until I hit a couple rounds of asystole or they come back. With that being said, my average code length is probably less than 10 min because EMS brings us 40-60 min downtimes with persistent asystole despite double digit rounds of epi.

Right. Most of this is anecdote and case reports. Near impossible to get level I data on this stuff. Your protocol is as good as anyone's for that reason.

 

[TooMuchResearch]

I forgot to mention: Kids. Everyone goes longer in kids.

So are you going to run every code > 60 minutes based on those papers?

Haha, you know that's not the case. Apply clinical judgment liberally (i.e. not going to win with the metastatic cancer patient or 95 year old), knowing that if they get good CPR in a hurry, you have a chance.

 

[atlpump]

Bird, research and arcan, thank you very much for the discussion.

If any of you found yourself in the everglades and you had to stop, what evidence would you report to the coroner when you got back to town. Its easy to get to a place where it can take many hours to get back.

 

[emd123]

, research and arcan, thank you very much for the

 

[TooMuchResearch]

Bird, research and arcan, thank you very much for the discussion.

If any of you found yourself in the everglades and you had to stop, what evidence would you report to the coroner when you got back to town. Its easy to get to a place where it can take many hours to get back.

"I pushed on the chest until my arms and own chest stopped working due to fatigue, then I stopped."

Doing compressions by yourself with no defibrillator is not ideal, and no one would fault you for quitting once exhausted.

 

[AlmostAnMD]

One person giving compressions for 40 minutes without a break or partner to trade off with wouldn't be giving very quality compressions by the end of that time, anyway....I'm a strong guy with decent stamina and five minutes of compressions on a trauma patient left me winded!