Make certain the CPR and airway management are being done properly. When I started our protocol said to intubate immediately.  On arrival, I would turn my back on the code and take the two minutes it takes to get my intubation roll out, unzip everything, take everything out, open the packages, assemble everything and then finally approach the patient.  Now I watch the compressions and the ventilations.  If only one person is doing the bag valve mask (assuming we are not doing passive ventilations), I grab someone else to hold the seal while the other squeezes the bag.  Make certain they are not hyperventilating.  Try using a period ambu bag instead of an adult.  Make certain a properly seized oral pharyngeal or nasal pharyngeal airway is in place and that the airway is held open.  

Watch the CPR.  Are the hands positioned properly.  Are they compression to an adequate depth and at the proper rate.

Since compressions are what matters most, make certain your team is doing them properly.  You are the coach.  You are in...

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You can’t work an arrest if you don’t have space to do effective CPR. I often come into a bedroom where responders are trying to work a code, and I will flips beds up on their sides, clear out couches, or if the patient is wedged in the bathroom, haul them out into the hallway, stopping so there is an open door in line with their chest.  Ideally you need room on both sides of the patient’s chest for compressors and room at the top for the airway management and space for your supplies.  Make use of your help.  In this age of stay and play for cardiac arrest, if you are going to be there for awhile, make certain you have the best conditions for an effective resuscitation.  

Stay Tuned for next cardiac Arrest Pearl # 4 CPR Coach

Charge your defibrillator before looking at the rhythm. Whether you and your partner are the first person at the patient’s side or first responders or laypeople are already doing CPR on your arrival, initiate and/or keep CPR going while you apply your pads.  Then with CPR still continuing, charge the defibrillator.  Only then stop CPR to look at the rhythm.  VFIB or VT, shock!

If its not a shockable rhythm, simply dump the charge by pushing the speed dial button.

Make certain to tell the compressors you will not shock them as you charge.  When you order them to stop so you can see the rhythm, you want your gun loaded.  If you were a hunter and had a deer in your sights, you would want a bullet in your rifle, not to have to stop and load.  This should be the process all through the code.  Charge while CPR is in progress.  At the 1 minute fifty second mark, charge so that at two minutes when you see VF or VT, you can shock, instead of starting another ten seconds of CPR before being able to fire.

Limit...

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Cardiac Arrest.  Pearl #1  Recognize cardiac arrest.

This sounds obvious, but it is not always so.  Early cardiac arrest can present like a seizure or syncope.  The patient’s eyes may be open and they may have agonal breathing.  Get the pads on!  Too many times I have shown up on scene to see first responders tell me the patient just had a seizure or they are breathing, and everyone is standing around.  I admit when I first started, I didn’t always instantly recognize what was going on.  When I was precepting, we had a patient with chest pain who all of a sudden he started seizing.  I reached for the valium (our benzo at the time).  My preceptor shook his head.  “Look at your monitor,” he said.  VF. 

Get the pads on!  Even if the patient snaps out of it before you can act, always get them on the monitor.  Be vigilant.  Several times early in my career I have had witnesses tell me the patient had stopped breathing and needed CPR before coming around.  Those reports did not seem consistent with the alert, talking...

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Paramedics all take ACLS every two years, and we all have roughly similar protocols. We all know that the key to resuscitation is high quality CPR and early defibrillation. I love this graph I found on Rogue Medic‘s blog a number of years ago.

This graph is the answer to the test. We read about the latest gizmos and approaches over the years – everything from high- dose epinephrine, the ResQPOD, CPR machines, double sequential defibrillation to the latest head up CPR, but despite their early promises, few innovations make a difference beyond the basics. Those basics will likely always be good CPR and early defibrillation.

What I will offer in a series of posts is not a new way of doing CPR or a new device, just some pearls that I have learned to include in my resuscitations over the years that work for me.

Pearl #1  Recognizing Cardiac Arrest