Background: I’ve worked at a hospital as an orderly for a few years, and one of our duties is driving corpses to the morgue. Majority of our time, however, is spent on taking living patients to and from different wardunits and diagnostic procedures. Because some of these patients are in critical stages of an assortment of diseases we have had extensive CPR training. Whoop-de-doo, you think: CPR classes are given out like candy even outside of the hospital environment.
Here comes the reason for this thread. All around the hospital, you can see CPR (and first aid)posters on the walls.
The first obvious step is assessing whether the patient reacts. If yes, then you don’t need to proceed with mouth-to-mouth or checking their pulse, as they have spontaneous breathing and a heartbeat.
The next step, if they don’t respond, is to check whether they are breathing. If yes, then they do have a pulse. BUT according to the chart, you need to check for a pulse anyways. Why? In order to sustatin breathing, you must have a pulse. So isn’t it a bit frivolous? However, you can have a heartbeat but not be breathing, but that’s not the same thing.
I talked to a colleague (he is also the CPR-instructor) about this, and he said there are cases where a dead person can breath. I said, “Bullshit”. He claimed that he went to get a corpse once from the angiograph-lab and when he came there the dead patient was in fact breathing. According to the doctors there it was nothing to be worried about because s/he was clinically dead.
Now, I understand that in some cases bodies can spasm after death due to the high levels of lactic acids in the body tissues that cause muscles to contract. But my colleague made it sound like the corpse was actually breathing, not having spasms. What do you make of this?
And, is it really necessary to check for a pulse once you’ve established that the patient is infact breathing?
Just browsing through and saw something I could answer. To start off the person who told you that people can have some sort of spontaneous movement when they are ‘clinically dead’ that mimics a respiration is completely false. Involuntary muscle jerks… yes mimicing respirations… negative. I am a licensed paramedic in the state of texas and i also hold my ACLS-Instructor(advanced cardiac life support) and my instructor in cpr, btls, pals and phtls and all the other alphabet soups but thats irrelevant. To answer your question I think you were just misunderstanding what is to be performed. After you establish that they are not breathing you do not check for a pulse. Without going into particulars you adjust the airway and give 2 rescue breaths… after that step then you check to see if you had a spontaneous return of pulse from ventilating your patient. You are correct that your pt can have a pulse and not be breathing but no way can your patient be breathing with no pulse. The people who told you that should re-think what they are doing. I hope this answers your questions any more I will try and find you an answer.
I appreciate your response!
However, I was just curious as to why one must check for a pulse AFTER one has established that the pt has spontaneous breathing? It would be a given that if they were breathing that they would have a pulse.
That’s what started the whole argument between my colleague and myself.
I asked the on-call cardiologist about it, but they weren’t sure (or they didnt understand my question as it was a hurried dialogue).
You’re not checking for a pulse. You’re checking and evaluating the pulse. Maybe the HR is like 30, weak and irregular. That’s not necessarily a good thing, but it’s enough to make someone breath.
Checking for a pulse on an unconscious, breathing person may give you useful information that can direct additional action. It may not be useful to the first responder on the scene who has no AED or drugs, but the info can be of use to others. A pulse is only palpable above a certain blood pressure level (differs in different situations), so if you can’t feel the pulse of a person who is breathing it suggests that there is a cardiovascular problem, even though you wouldn’t do chest compressions as long as they were breathing on their own. A strong, regular pulse should be reassuring - as long as it stays that way. Rapid, slow, bounding, or irregular pulses can all help to narrow down your differential diagnosis and treatment plan. It’s also worth knowing if the pulse situation changes over time.
Very good points. I’ll keep those in mind.
Please correct me if I am wrong but from what i remember of my EMT days this would not be correct. IF you have no palpable pulses you will not be perfusing sufficently to sustain life for any significant amount of time, and they definitely will not be conscious. Airway and breathing can be fairly easily managed via intubation and bagging them so messing with ineffective or slow respirations is less of an issue than not performing CPR on a patient who is not circulating their blood effectively. If you have no pulses any gas exchange that is taking place is not leaving the lungs and the diaphram will not get blood flow to sustain itself, breathing stops. Breathing spontaneously and or having a palpable pulse does not in itself mean the heart rythym and respiratory rate/depth will sustain life.
Ok I believe now I understand your question. Remember that you can have a pulse and not be breathing. So with that understood, once you give your two rescue breaths you will check for a pulse to see if your rescue breathing has caused a spontaneous return of pulse (which could be with or without respirations). If after you give your 2 breaths the pt’s begins choking or just breathing then you know that there is a pulse and then roll them onto their side and all that good stuff. But there is an outside chance that just from your 2 rescue breaths you caused a spontaneous return of pulse and no breathing so you need to check that pulse. If there is no return of pulse then you begin your chest compressions. I hope this answered your question. As for the rest of the answers I am not really understanding the debate. So I will answer the best way I can. All EMT’s whether paramedic or EMT-basic are taught to ‘go back to the basics’. Your method of treatment is always ABC A- Airway B-Breathing C-Circulation. Check to see if an airway is patent, if so skip to breathing if not readjust using the different techniques. Next you assess their breathing (rate quality regularity) then you go onto to circulation (do they have a pulse if so what is the rate quality and regularity). If at any point in your ABC’s you find a problem you correct it. Having no pulse is last. Now this takes alot of schooling for EMT’s to understand so don’t feel confused. And then to throw in a huge loop to what you have been taught the American Heart Association just came out with new protocols contradicting everything but I will not go into that. So needless to say you all you care about (as a laye rescuer) is do they have a pulse if so then thats good you do not care about if its strong or weak or thready, none of that stuff. If they do not have a pulse then begin CPR. Yes you can have a pulse and just not be able to feel it you need special equipment called a DOPPLER to assess it. Bottomline if you cant feel it, it is not adequate and you need to begin CPR. And if a person does not have a palpable pulse it DOES NOT mean that it is necessarily a cardiac problem, there are many other types of shock that could be causing that problem. Again to go into particulars is a long lectured class. But any other questions feel free to ask.
Oh and welcome to the boards, hope you like it here.
Yes, welcome indeed! Now just pay for your subscription so you can continue posting with interesting medical posts. I’m thinking of becoming either a paramedic or a nurse anesthesiologist, so i’m always looking for relevant threads on here.
now, you were talking about a contradicting loop thrown out by the AHA. What might that be? If it’s easier, just post a link and I’ll check up on it!
I’m curious too. The only differences I noticed in the new AHA curriculum is that compression to breaths ratios have changed (again), and that you now do compressions between shocks instead of three static shocks. What else is different?
Thank you all for the warm welcome. Here is the link for the new guidelines. American Heart Association | To be a relentless force for a world of longer, healthier lives. In a nut shell they put a lot of emphasis on compressions more than ventilations for a pt with an unknown down time. There reasoning for that is, to not get technical, that if your body is “dying” then you do not need your normal amount of oxygen you just need what you already have circulated. Hence the increase in the ratio to 30:2. There alot of other changes if you go in there and read up. Some of the other ones are they don’t like paramedics using the Endotracheal tube as a drug route. They would like us to go straight to IO (intraosseous) instead of ET, IV or EJ. The stacked shocks are new but we had already changed our protocols before hand to limit the stacked shocks. But basically they have changed alot of things that some old paramedics are finding hard to adjust to. Any medical questions feel free to ask I will answer them to the best of my ability if I dont have the answer I can sure find it fore you.
When assessing a head trauma patient, do you use the GCS or the RLAS system? Ultimately I’d like to know what the main differences between the two are (aside from the fact that they use a different numeric system).
Is the 30:2 compression-breath system becoming common practice in the US? Any chance that this will be adopted by other countries? I’m assuming that they have very good data to make the transition from the old system to this.
Well personally I don’t trust anything called the Rancho Los Amigos Scale but hey that’s me. No but honestly the RLAS is mainly used for long-term care for measuring pts activity after being in a medically defined coma. The Glasgow Coma Scale has its uses prehospital. All of my trauma pts that I transfer to the hospital get a GCS rating. It is very useful if used properly. If a good GCS is established early it can help the hospital in watching a trend and deterioration in the pts condition just like any other vital sign. But no I do not see a use for the RLAS prehospital at all. The 30:2 is the ‘standard of care’ now in the United States. Cypress Creek EMS are the ones who virtually pioneered it. They are located in my area and had researched this extensively before putting it into effect. That EMS agency has the greatest out of hospital survival rate of any EMS in the nation which is pretty impressive. The problem with International EMS systems are that they are night and day different from what we know in the U.S. We tend to treat pts more aggressively and have more advanced protocols for care. With that being said I must also say that many international EMS agencies use MD’s. But any time there is a competition US based EMS systems tend to dominate even over the docs (mainly Cypress Creek EMS).
Aah. Interesting. I’d just assumed that they used the RLAS in the pre-hospital environment as well.
Are american paramedics (and EMTs) trained to intubate a patient?
As an emergency doctor, who does this sort of thing most days, I’d point out:
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Parawhat is correct to emphasize airway than breathing than pulse (circulation); we all do. Drachillix is correct vis-a-vis prefusion.
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Dead people don’t breathe, but people with hypothermia, severe acidosis, apnea or brainstem damage can breathe very slowly and often seem dead.
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If you are breathing, you still need to check the pulse. There may be a dangerous rhythm in need of immediate tratement – unstable atrial fibrillation, ventricular taqchycardia, ventricular fibrillation, a slow pulse, no pulse (with or without “electrical activity” on the monitor), etc. This may help with diagnosis – heart or lung problems, poisoning, electrolyte problems, etc.
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The GCS is useful not since everyone will agree on the exact number, but to see how it changes. I don’t use RLAS. Paramedics are different “levels” and some of them can intubate.
Paramedics can intubate patients. From there, it depends. In most places EMT-Intermediates can intubate patients. EMT-Basics generally cannot intubate. Some places allow waivers for basics to intubate, some places allow them to use Combitubes or LMAs. It varies greatly by area.
St. Urho
Paramedic
Dr_Paprika
I understand what you wrote about checking the pulse after you’ve assured that the patient is breathing. But for the layman, checking the pulse would be irrelevant. I don’t think joe-shmoe can palpate the carotid artery and be able to establish whether or not the patient is tachycardic or has AF. However a paramedic ought to be able to distuingish between a weak/irregular pulse and a healthy one. Am I right in assuming this?
The pulse is checked after establishing that the patient has a good airway an is breathing. It is true that a paramedic can usually tell if the pulse is irregular or weak or strong. Most of us rely on heart monitors to get aqn electrical tracing of the heart to get a better picture.
As drachillix said, though, the purpose of breathing in CPR is to help supply oxygen, and the purpose of chest compressions, like the heart, is to help the oxygenated blood get to the tissues of the body which most need it. If there is breathing, but no pulse, the layman still needs to do chest compressions to allow the blood from the lungs to get to the brain, kidney, etc. If the breathing is poor, the patients needs oxygen, bagging, “mouth to mouth” breathing, in addition to the chest compressions. When oxygen levels are low, the blood goes to the major organs and the arteries going to the less important structures become constricted – so this process is automatic.