Doppler during Code

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I have a burning question for my fellow nurses. Is the use of a doppler, for finding a pulse, acceptable practice during a code blue? The reason I ask is because I got into a debate with a "very seasoned" ICU nurse and we just do not agree. Every single time there is a code blue in the ICU nurses routinely grab the doppler and I could not be more opposed to it. If my patient coded and it took longer than 10 seconds to find a pulse because of using a doppler I would have a huge issue with that. When the ER doctor responds he says what I am thinking, "remove the doppler, it does not belong in a code". I was so happy to hear the doc tell the nurses that! I would appreciate any and all ideas. Thank you.

Should we follow ACLS guidelines or is it ok to deviate from the protocol? I was always under the impression that we have to follow ACLS guidelines because doing something else would be practicing medicine. We are only covered under ACLS guidelines therefore we are only allowed to do what the guidelines tell us to do unless of course a physician is giving us orders otherwise. So that tells me I cannot make any clinical decision using a doppler. For example, if I was to find a pulse with a doppler, but not a palpable pulse, could I consider the patient resuscitated and stop the code? Of course doctors can make that call but can a nurse?

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Thank you for the interesting article and maybe we will see changes in ACLS protocols because of studies like this.

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Specializes in ICU.

We do use a doppler in our codes in my ICU and I find them VERY helpful. That said, the doppler doesn't replace good ol' feeling for a pulse, it only enhances it. We don't delay any part of the ACLS protocol for not having a doppler present. We typically will feel for a pulse, start the code per ACLS, and while we're in our first two minutes of compressions someone goes and grabs the code doppler, which is stored at the nurses station in a dedicated spot. While compressions are going we apply the doppler to the femoral artery- you can clearly hear the blood flow with compressions. Then when we pause for pulse check it's very clear to hear whether there is a pulse or not. We still do check a carotid (and typically a fem) pulse on the other side, but it makes things way faster and more accurate in the pulse check to clearly hear whether there is a pulse or not and to assess how strong the pulse is.

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Specializes in Critical Care.
Should we follow ACLS guidelines or is it ok to deviate from the protocol? I was always under the impression that we have to follow ACLS guidelines because doing something else would be practicing medicine. We are only covered under ACLS guidelines therefore we are only allowed to do what the guidelines tell us to do unless of course a physician is giving us orders otherwise. So that tells me I cannot make any clinical decision using a doppler. For example, if I was to find a pulse with a doppler, but not a palpable pulse, could I consider the patient resuscitated and stop the code? Of course doctors can make that call but can a nurse?

ACLS doesn't limit assessment of ROSC to a palpable pulse assessment, and actually the purpose of using the term ROSC to take the focus off the sole use of palpable pulses, ACLS protocol specifically lists other ways of assessing ROSC such as capnography and obtaining an arterial waveform, so you're not going against ACLS by using more accurate methods of determining the presences of a pulse.

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Specializes in Hematology-oncology.
ACLS doesn't limit assessment of ROSC to a palpable pulse assessment, and actually the purpose of using the term ROSC to take the focus off the sole use of palpable pulses, ACLS protocol specifically lists other ways of assessing ROSC such as capnography and obtaining an arterial waveform, so you're not going against ACLS by using more accurate methods of determining the presences of a pulse.

Capnography sounds like such a great tool in a code. During my ACLS last year, our instructor said that they are starting to use capnography more, and it is a good indicator of when a compressor is fatigued, and a switch needs to occur. Then there is the bump that occurs with ROSC. Have you seen it work well in actual practice MunroRN?

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Specializes in many.
It's long been known that palpating pulses during a code is unreliable and can cause excessive delays in pulse checks and can lead the cessation of CPR when no pulse has actually returned. When used properly, the use of a Doppler or even better a bedside ultrasound can reduce time spent unnecessarily off the chest, and avoid the potential for a false finding of a pulse.

That sounds like a quote that could be referenced. Do you have one to share?

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Specializes in many.
We do use a doppler in our codes in my ICU and I find them VERY helpful. That said, the doppler doesn't replace good ol' feeling for a pulse, it only enhances it. We don't delay any part of the ACLS protocol for not having a doppler present. We typically will feel for a pulse, start the code per ACLS, and while we're in our first two minutes of compressions someone goes and grabs the code doppler, which is stored at the nurses station in a dedicated spot. While compressions are going we apply the doppler to the femoral artery- you can clearly hear the blood flow with compressions. Then when we pause for pulse check it's very clear to hear whether there is a pulse or not. We still do check a carotid (and typically a fem) pulse on the other side, but it makes things way faster and more accurate in the pulse check to clearly hear whether there is a pulse or not and to assess how strong the pulse is.

This sounds like a good way to be certain of a) strong enough compressions b)actual blood flow in the vessel (as opposed to a hemorrhage somewhere)

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Specializes in Emergency.

Practice in the field (yes, paramedic stuff but still useful) is that if we have any question of the possibility of spontaneous circulation a person NOT engaged in current resuscitation efforts takes the doppler, finds the femoral pulse WHILE compressions are occurring and stays on that site. When compressions are stopped for whatever reason, that person will know if the whooshing continues without compressions. It also verifies effective compressions. That's what we do and it is pretty useful.

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Specializes in Emergency.
Capnography sounds like such a great tool in a code. During my ACLS last year, our instructor said that they are starting to use capnography more, and it is a good indicator of when a compressor is fatigued, and a switch needs to occur. Then there is the bump that occurs with ROSC. Have you seen it work well in actual practice MunroRN?

Capnography is an amazing tool! On many codes we will see the capnography reading in the 20's or so then suddenly jump to 65 (or some random high number). That is the point you check for ROSC.

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Specializes in Critical Care.
That sounds like a quote that could be referenced. Do you have one to share?

Responders to a patient in arrest incorrectly assessed pulses by palpation 22% of the time, potentially leading to withholding CPR in 14% of the cases: Reliability of pulse palpation by healthcare personnel to diagnose paediatric cardiac arrest. - PubMed - NCBI

Reliability of pulse palpation by healthcare personnel to diagnose paediatric cardiac arrest. - PubMed - NCBI

The 3-point pulse check, cardiac arrest & patient safety: An ALS myth or best practice? | The resuscitation panopticon

Assar, D., Chamberlain, D.A., et al. (1998). A rationale for staged teaching of basic life support. Resuscitation. 39.137-143.

Getting back to the OP's question, the lack of reliability of pulse palpation in an code situation is also why the AHA no longer utilizes palpated pulses as a decision point.

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I second what a lot of nurses on here have said--nothing tops a manual pulse check when initiating CPR. After that we'll get a doppler to do femoral checks during CPR within the ten second window. A second use for doppler is our ERMD will typically confirm cardiac death and pronounce patient's after doing a doppler on femoral to ensure no cardiac activity. He/She will also do cardiac US occasionally, depending on the situation, to ensure no cardiac activity before pronouncing.

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Legally you should always stick with established protocol. Always think to yourself how would this look in court? Time wasted running for the doppler can be a real monkey bar for the right lawyer in court. "So nurse Jenkins you ran for the doppler and that took you an additional one minute of time, is that in the ACLS protocol?"

Nurse Jenkins: "Ah, well...no but that other nurse is mean and rude to me if I don't do that."

Lawyer: "There is no law against being mean and rude Nurse Jenkins, we are here today because my client suffered a major brain trauma due to LACK OF OXYGEN during cardiac arrest while under YOUR CARE."

Lawyer: "We have experts here to testify that the additional minute or so of time that you took to run over and get the doppler, put it on the client and WAIT to see if there was a valuable pulse, in fact wasted the time my client needed to receive viable CPR as set by the national standards under ACLS protocol".

Nurse Jenkins: "Oh, well I see where this is going, I'm going to quit nursing today and go work in the potato field. Thank you your honor".

DONE DEAL. Lawyers can be like tigers. Never forget the tiger in the corner.

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