Pulse Checks in Code Blues

Slides by Josiah Situmeang, Alex Ryden, Brian Locke

Pulse Checks in Code Blues

Learners will practice:

  1. Making a shock/no-shock call under uncertainty
  2. Preventing airway/procedure pauses
  3. Using EtCO2 and other signals when ROSC is uncertain

Code blue on E50

Compressions are ongoing when you arrive.

You establish yourself as code leader.

Prompt: You have 20 seconds before the next pulse check. What are the first things you consider?

Before the pause

  1. Confirm code status.
  2. Assign roles: meds, compressor, airway, recorder.

First pulse check

No palpable pulse

Rhythm strip during initial pulse check

Shock, no shock, or uncertain?

Fine VF vs asystole

If uncertain:

  1. Turn up gain.
  2. Check leads/connection.
  3. Voice your uncertainty.
  4. If it could be VF/pVT, shock (consider consequences of each error).
Coarse vs fine ventricular fibrillation
Coarse vs fine ventricular fibrillation

Second pulse check

No palpable pulse

CPR has resumed until the second pulse check. There is no palpable pulse and this rhythm:

Second pulse check with airway team asking for time

Airway team ready to intubate, asks for a moment before resuming compressions

Prompt: What is the rhythm now, and what do you do about the airway request?

Airway answer

Answer:

“Airway, keep working during compressions. We’ll give you the next planned pause only if you are ready.”

“If intubation will interrupt CPR, put in an LMA.”

Airway does not own the pause.

What really matters

During arrest, protect two things:

  1. Compression fraction
  2. Early defibrillation for shockable rhythm

Everything else has to fit around those.

Zoll feedback mode

Confirming ROSC can be hard

Use:

  1. EtCO2 trend or sudden rise
  2. Arterial line if present
  3. SpO2 pleth waveform if present
  4. Doppler if ready
  5. POCUS only if pre-positioned

When in doubt, continue compressions.

Do not forget EtCO2

EtCO2 waveform and values during resuscitation

Use EtCO2 to help detect ROSC

Use EtCO2 to monitor CPR quality, shock-type, and ROSC.

Third pulse check

EtCO2 rising to 36 mmHg

EtCO2 = 36 mmHg

“Possible ROSC. At the next check: rhythm, pulse, waveform. If not convincing, resume compressions.”

Think out loud

Try:

  • Do not forget EtCO2.
  • If unclear, resume compressions.

Summary

Confirm code status.

Do not miss fine VF.

Do not prolong pauses for procedures.

Use EtCO2 to monitor compressions and help detect ROSC.

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