Checking BP during codes

[cloosh10]

Hey guys had a question for you that came up during a code.

Recently I was helping out in a code and someone yelled 'can we check her blood pressure?' during CPR. An ICU RN that was there then retorted 'why would we check a BP during a code?'. I think that RN was implying that there is no pulse hence no blood pressure. However, during CPR that patient should have cardiac output (if the compressions are good) and checking a BP would be useful. Additionally, hypotension is one of the "H"s we think about leading to cardiac arrest.

It got me interested as I have now seen tons of codes and people often cycle blood pressures (especially if the code is on the floor). I haven't found any good information on what the utility is/data on checking blood pressures during CPR.

I wanted to see what you all thought about this and if you guys had any more information about this.

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[deleted171991]

Hey guys had a question for you that came up during a code.

Recently I was helping out in a code and someone yelled 'can we check her blood pressure?' during CPR. An ICU RN that was there then retorted 'why would we check a BP during a code?'. I think that RN was implying that there is no pulse hence no blood pressure. However, during CPR that patient should have cardiac output (if the compressions are good) and checking a BP would be useful. Additionally, hypotension is one of the "H"s we think about leading to cardiac arrest.

It got me interested as I have now seen tons of codes and people often cycle blood pressures (especially if the code is on the floor). I haven't found any good information on what the utility is/data on checking blood pressures during CPR.

I wanted to see what you all thought about this and if you guys had any more information about this.

No pulse, no BP check; you need an A-line. I am not sure how reliable the Korotkoff method is during CPR. Use EtCO2 if you need an estimate of cardiac output (it should be a standard monitor in your ICU - it's 2016). And hypotension is NOT one of the H's.

 

[cloosh10]

No pulse, no BP check; you need an A-line. I am not sure how reliable the Korotkoff method is during CPR. Use EtCO2 if you need an estimate of cardiac output (it should be a standard monitor in your ICU - it's 2016). And hypotension is NOT one of the H's.

Thanks! I meant hypovolemia, my bad!

 

[deleted171991]

http://lifeinthefastlane.com/ccc/capnography-in-cardiac-arrest/

 

[SurfingDoctor]

Central pulse check.

Capnography is good (as above) but only works if you have an intubated patient (which I can't speak for ACLS, but is not part of a PALS algorithm in CPR). Likewise, an arterial line gives you a good impression of the effectiveness of chest compressions, but it only helps if it was there to begin with. People have tried pulse oximeters with limited success (https://www.ncbi.nlm.nih.gov/pubmed/8214462).

 

[psychbender]

Central pulse check.

Capnography is good (as above) but only works if you have an intubated patient (which I can't speak for ACLS, but is not part of a PALS algorithm in CPR). Likewise, an arterial line gives you a good impression of the effectiveness of chest compressions, but it only helps if it was there to begin with.

?? You could just put one in (ETT or art line) during the code.

 

[deleted171991]

By the time one wonders whether CPR is effective, one should have an ETT in place.

 

[lymphocyte]

By the time one wonders whether CPR is effective, one should have an ETT in place.

I think one should always wonder if CPR is effective. In terms of "bang for your buck," early and effective chest compression is perhaps the most meaningful intervention available. The question is, "how does one know if chest compression is effective"? Capnography is a good tool (whether from a ETT or *sometimes* a LMA, depending), as is an art line, but both take time to establish, especially on the wards.

So what to do in the meantime? Two things:

1. Ultrasound. Look for cardiac output, pump/tank/pipes, prognosticate, swing it down to pop in a femoral art line--useful on so many levels. Of note, the REASON trial was just published, and the evidence is mounting to integrate US into even ACLS, the most cookie-cutter of resuscitation algorithms.

2. Utterly flawless technique. No excuses. It's not like it's hard to practice, yet the literature shows we're often not as good as we think: poor timing, unnecessary delay, inadequate depth, "leaning"--which impedes recoil/cardiac filling--, etc. This really needs to be beaten into every medical student and intern. In the first few minutes, forget about sexy interventions, just focus on doing the basics exceptionally well.

http://www.ultrasoundpodcast.com/20...echo-reason-trial-with-romolo-gaspari-foamed/

Gaspari R, Weekes A, Adhikari S, et al. Emergency department point-of-care ultrasound in out-of-hospital and in-ED cardiac arrest. Resuscitation. 2016;109:33-39.

Price S, Uddin S, Quinn T. Echocardiography in cardiac arrest. Curr Opin Crit Care. 2010;16(3):211-215.

 

[deleted171991]

Since we are on the subject of ETTs, the worst and most frequent mistake I see is hyperventilating the patient, thus killing cardiac output. Almost every time I am near an arrest, the RT is squeezing that ambu bag at least 15 times/minute (when 6 are more than enough). They just don't get that the lungs are like cushions sitting between the spine/thoracic cage and the heart, and every inflation decreases the efficiency of cardiac massage. Who cares that the blood gets super-oxygenated if it doesn't circulate?

 

[BigRedBeta]

which I can't speak for ACLS, but is not part of a PALS algorithm in CPR

Actually, consideration of an advanced airway is part of the PALS algorithms for both VT/VF and Asystole/PEA. Not a requirement by any means and I've been in plenty of codes where you get ROSC and then place the ETT
http://circ.ahajournals.org/content/122/18_suppl_3/S876.figures-only

Totally agree with the need for constant assessment of chest compressions and overbagging, though in our pediatric patients, people are usually chugging away at 30 breaths a minute if not more

 

[deleted547339]

Since we are on the subject of ETTs, the worst and most frequent mistake I see is hyperventilating the patient, thus killing cardiac output. Almost every time I am near an arrest, the RT is squeezing that ambu bag at least 15 times/minute (when 6 are more than enough). They just don't get that the lungs are like cushions sitting between the spine/thoracic cage and the heart, and every inflation decreases the efficiency of cardiac massage. Who cares that the blood gets super-oxygenated if it doesn't circulate?

15 bpm? Try 50, then we're in the ballpark.

 

[deleted171991]

15 bpm? Try 50, then we're in the ballpark.

That also happens, when they are "compensating for the metabolic acidosis".

 

[SurfingDoctor]

Actually, consideration of an advanced airway is part of the PALS algorithms for both VT/VF and Asystole/PEA. Not a requirement by any means and I've been in plenty of codes where you get ROSC and then place the ETT
http://circ.ahajournals.org/content/122/18_suppl_3/S876.figures-only

Totally agree with the need for constant assessment of chest compressions and overbagging, though in our pediatric patients, people are usually chugging away at 30 breaths a minute if not more

Yes. I meant requirement (but I didn't type that clearly), but it is always done when someone has the ability to place an ETT. I can't say I've been in a code that didn't have an ETT (or trach) by the end of a code.

 

[engineeredout]

The latest Zoll defibrillator models have the ability to do both ETCO2 as well as dynamic feedback of CPR rate and depth of compressions. It also allows for visualization of the underlying rhythm below compressions without actually stopping compressions

http://www.zoll.com/medical-technology/cpr/cpr-dashboard/

http://www.zoll.com/medical-products/defibrillator-electrodes/onestep/

http://www.zoll.com/medical-technology/cpr/see-thru-cpr/

Got to play around with this stuff during an in-service because were supposed to be getting these soon. Out of all the technology that comes out that appears to be fancy junk, this actually seems like it could go a long way to improving our performances in cardiac arrest.

Another cool feature available is this:

Imagine putting these in the radiology department or outpatient facilities connected to your hospital. All someone has to do is attach the pads and it functions like a traditional AED. Once advanced providers arrive it can be switched into the conventional/manual mode.

I sware Zoll doesn't pay me (unfortionately). Just find this really neat and has potential to improve outcomes

 

[Siggy]

Imagine putting these in the radiology department or outpatient facilities connected to your hospital. All someone has to do is attach the pads and it functions like a traditional AED. Once advanced providers arrive it can be switched into the conventional/manual mode.

I sware Zoll doesn't pay me (unfortionately). Just find this really neat and has potential to improve outcomes

Umm, that's already a pretty standard feature. My hospital uses Phillips Heartstream XL and you move the dial clockwise from off to go to monitor/defib and counterclockwise from off to enter AED mode.

 

[engineeredout]

Umm, that's already a pretty standard feature. My hospital uses Phillips Heartstream XL and you move the dial clockwise from off to go to monitor/defib and counterclockwise from off to enter AED mode.

Oh well excuseeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeee me Dr. Fancy Pants

 

[andrek82]

The latest Zoll defibrillator models have the ability to do both ETCO2 as well as dynamic feedback of CPR rate and depth of compressions. It also allows for visualization of the underlying rhythm below compressions without actually stopping compressions

http://www.zoll.com/medical-technology/cpr/cpr-dashboard/

http://www.zoll.com/medical-products/defibrillator-electrodes/onestep/

http://www.zoll.com/medical-technology/cpr/see-thru-cpr/

Got to play around with this stuff during an in-service because were supposed to be getting these soon. Out of all the technology that comes out that appears to be fancy junk, this actually seems like it could go a long way to improving our performances in cardiac arrest.

Another cool feature available is this:

Imagine putting these in the radiology department or outpatient facilities connected to your hospital. All someone has to do is attach the pads and it functions like a traditional AED. Once advanced providers arrive it can be switched into the conventional/manual mode.

I sware Zoll doesn't pay me (unfortionately). Just find this really neat and has potential to improve outcomes

Does this cardiovert? It's missing a few buttons and displays that I'm used to.

 

[lymphocyte]

The latest Zoll defibrillator models have the ability to do both ETCO2 as well as dynamic feedback of CPR rate and depth of compressions. It also allows for visualization of the underlying rhythm below compressions without actually stopping compressions

http://www.zoll.com/medical-technology/cpr/cpr-dashboard/

http://www.zoll.com/medical-products/defibrillator-electrodes/onestep/

http://www.zoll.com/medical-technology/cpr/see-thru-cpr/

Got to play around with this stuff during an in-service because were supposed to be getting these soon. Out of all the technology that comes out that appears to be fancy junk, this actually seems like it could go a long way to improving our performances in cardiac arrest.

That actually looks pretty neat. Have you used one during a code? I'm curious how well all those features perform in a non-ideal setting, like the depth of compression sensor or the "see-thu" filter.

 

[engineeredout]

Does this cardiovert? It's missing a few buttons and displays that I'm used to.

As soon as you hit that button that says "Manual Mode" on the bottom left, all the usual buttons/options appear

That actually looks pretty neat. Have you used one during a code? I'm curious how well all those features perform in a non-ideal setting, like the depth of compression sensor or the "see-thu" filter.

No, not yet during a real code. It's being rolled out at my hospitals now. I'll post feedback when I get to use it.

 

[RNthenDoc]

That actually looks pretty neat. Have you used one during a code? I'm curious how well all those features perform in a non-ideal setting, like the depth of compression sensor or the "see-thu" filter.

Depth of compression sensor works reasonably well. It is goofy as all heck to hear a robot say "Faster." "Deeper." during a code but the fact that I've heard it means that it must have been warranted and/or helped.

See-thru sensor has not worked well for me, ever, but my n=low.

 

[engineeredout]

See-thru sensor has not worked well for me, ever, but my n=low.

Agreed now that I've used it for a while now. Always looks like a regular rhythm with CPR, but as soon as compressions stop its different.

 

[DoctwoB]

Can CPR be too effective? Had a patient with a pre-existing artline that coded and was getting pressures in the 250s/120 range from chest compressions. I was hesitant to alter proper ACLS technique based on a monitoring device that I'm not convinced works well in that scenario.

 

[Psai]

Can CPR be too effective? Had a patient with a pre-existing artline that coded and was getting pressures in the 250s/120 range from chest compressions. I was hesitant to alter proper ACLS technique based on a monitoring device that I'm not convinced works well in that scenario.

How much epi did they get

 

[GhostTree]

Or was the transducer on the floor?

 

[danibrittany]

CPR may or may not be useful at all times. Therefore, chest comprehension gives a clear picture of the reasons behind the cardiac arrest. Similarly, one can use Capnography but take precautions and time to determine the real cause behind it.

 

[engineeredout]

CPR may or may not be useful at all times. Therefore, chest comprehension gives a clear picture of the reasons behind the cardiac arrest. Similarly, one can use Capnography but take precautions and time to determine the real cause behind it.

Um what?

 

[CCM-MD]

CPR may or may not be useful at all times.

Agreed. Its not useful in someone with a pulse.