Medical Response?

[firedupnursing70]

OK,

Just a general nursing questions. I was attending a training for basic EMT's that a Para medic was protoring. Here is the scenario; A patient found down at the scene 24 yr male patient with head trauma, unconscious, lying supine on the floor, with decordicate posturing, cheyne stokes breathing, Oxygen Saturation 88%, HR 28, thats all the vitals you have. You have an AED, EMT basic bag, 911 is called. No drugs or transcutaneous pacing available. You do have oral adjuncts, 02 and bag valve mask. My questions is would you start CPR with this scenario? I said yes. He said no, not with a palpable pulse!

[MunoRN, RN]

Where was the pulse taken? According to Trauma life support guidelines, a palpable radial pulse suggests an SBP of greater than 80, although there are studies that say it's only reliable indicator of a systolic greater than 70.

[AnnieOaklyRN, BSN, RN, EMT-P]

No you would not start CPR on an adult with a pulse. That being said what do you think might be cause his bradycardia? They want you to think about the CAUSE of the bradycardia and how you might fix it with what you have.

Cheynes stokes respirations are shallow ans irregular, which is why your patient is hypoxic ans hypoxia also causes dilation of the cerebral vessels which can increase ICP. so you have two causes of the bradycardia , hypoxia and increased ICP, both of which can be much improved by starting manual ventilations with oxygen and a BVM. that is what they want you to do.

[AnnieOaklyRN, BSN, RN, EMT-P]

I guess I missed having O2 on scene.

This is a very weird scenario.

You would never hook a person up to an AED whi has a pulse!

There is nothing weird about the scenario, it is actually a realistic possibility. Ventilations would improve the hr.

This is why when nurses tell me they want to bridge right to being a paramedic I say dont do ir

[AnnieOaklyRN, BSN, RN, EMT-P]

How about: Hook him up to O2 and let the AED decide if shocks or CPR is warranted?

Also the AED does not decide if CPR is needed, they only verbalize a pre programmed algorithm.

[AnnieOaklyRN, BSN, RN, EMT-P]

Review Cushing's triad. You likely have a widened pulse pressure in this scenario although that information isn't given.

You and everyone else here are reading to koch into this scenario. They want the person to start basic ventilations with oxygen using a BVM, which will improve the heart rate. No BP Needed to realize you need that

[AnnieOaklyRN, BSN, RN, EMT-P]

You don't have a blood pressure though. So you don't know what the MAP is. You don't do compressions with a heart rate. The heart is still pumping. The EMTs will probably intubate because with decorticate posturing, your GCS is less than 8.

With a rate if 28, I'm guessing they will also get some atropine as well.

But no compressions.

I guess I'm confused as this is an EMT class but it's just the lay person on the scene?

EMT basics do not intubate and you would not give a bradycardia head injured hypoxic patient atropine as you would not fix the underlying problem

Airway and breathing folks!

[Guest219794]

OK,

Just a general nursing questions. I was attending a training for basic EMT's that a Para medic was protoring. Here is the scenario; A patient found down at the scene 24 yr male patient with head trauma, unconscious, lying supine on the floor, with decordicate posturing, cheyne stokes breathing, Oxygen Saturation 88%, HR 28, thats all the vitals you have. You have an AED, EMT basic bag, 911 is called. No drugs or transcutaneous pacing available. You do have oral adjuncts, 02 and bag valve mask. My questions is would you start CPR with this scenario? I said yes. He said no, not with a palpable pulse!

This isn't really a nursing question, more of an EMT question. As it happens, given the supplies available, the answer is the same.

Airway. Is this patient able to safely manage their own airway? Do they have a gag reflex? Assuming the answer is "no" to both, an oral airway is indicated.

Breathing. Is it adequate? SPO2 88%. Supplemental oxygen would be your first intervention.

If an oral airway and supplemental O2 did not bring SPO2 up, I suppose there could be an argument for pressure support with a BVM, but in a basic EMT class, probably not the move. The elevated RR is there for a physiologic reason, and trying to to increase tidal volume with a breath every 2 seconds is going to be hard to do safely. (increased intrathoracic pressure, gastric distension.)

Circulation. Present, or absent? There is no indication for either a nurse or EMT to do compressions on this patient.

When looking at airway and breathing, there is some judgement involved as to whether or not the patient's own response is adequate.

When evaluating circulation, it is a simple yes/no question.

[Wuzzie]

Breathing. Is it adequate? SPO2 88%. Supplemental oxygen would be your first intervention.

If an oral airway and supplemental O2 did not bring SPO2 up, I suppose there could be an argument for pressure support with a BVM, but in a basic EMT class, probably not the move. The elevated RR is there for a physiologic reason, and trying to to increase tidal volume with a breath every 2 seconds is going to be hard to do safely. (increased intrathoracic pressure, gastric distension.)

The presence of Cheyne-Stokes respirations with a concomitant saturation of less than 90% would trigger me to provide respiratory assistance via BVM. The goal would not be pressure support but to achieve a more normal respiratory pattern. The apneic period associated with C-S respirations would continue to cause periods of de-saturation with supplemental oxygen alone which should be avoided. It should be noted that hyperventilation also should be absolutely avoided in the first 24 hours after TBI to avoid ischemia so great care must be taking in how you provide the BVM breaths. They should be at a normal rate with enough volume to adequately move the chest but not excessively. This is no small feat when your adrenaline is pumping and with a posturing patient.

[JKL33]

You and everyone else here are reading to koch into this scenario. They want the person to start basic ventilations with oxygen using a BVM, which will improve the heart rate. No BP Needed to realize you need that

I didn't think I was reading too much into it. The OP was concerned about hypotension. I wasn't saying he needed a b/p or should prioritize getting one. I just think it's important to look at the larger context in so that, as a novice, one can see that chest compressions or atropine (as mentioned elsewhere) are not the answer - but the answer is to do the only thing that can be done in a setting of compromised cerebral perfusion. I believe that if you read about cushing's triad you will see that making sure the airway is open and oxygenating the patient is exactly what is suggested in the OP's scenario/setting. It's the only major thing that can be done to assist this scenario of increased icp and maximize opportunity for brain oxygenation. A second benefit of understanding the larger scenario is so that the OP could understand that, although airway/oxygenation is one of the only thing that can be done to mitigate the situation and attempt to get oxygen to the brain, it isn't going to be a quick fix-all for anything.

I asked him to read about a topic that would've led to the right answer - which is the same as yours.

This is headed toward a pending herniation scenario.

Edit: TL/DR: I did not ask him to prioritize obtaining a blood pressure. I directed him toward the same information you touched on in post #13.

[bgxyrnf, MSN, RN]

Practically speaking, decorticate posturing and Cheyne-Stokes means this person is toast... especially in a setting that lacks ACLS interventions.

What this dude needs is (a) transcutaneous pacing, (b) intubation, © narcan, (d) a blood sugar check, and (e) a stat head CT. {the narcan is simply to cover my bases since I have no information as to the cause of the head trauma}

EMS could provide a-d and getting them there is the HIGHEST priority. Next would be airway and ventilatory support.

CPR is not indicated in a bradycardic adult with pulses... though I'd have someone find the femoral pulse and keep their hand on it.

Again, though, the initial presentation indicates a grim prognosis regardless of what you do... by the time the trauma progresses to the point of posturing and C-S respirations, the EVD and/or crani that's certain to follow within minutes of arrival at a trauma center are too little, too late.

To your original question, though: No, CPR is not indicated.

[Wuzzie]

Practically speaking, decorticate posturing and Cheyne-Stokes means this person is toast... especially in a setting that lacks ACLS interventions.

Well, yes that's true so really this is purely academic but it's still fun to discuss.

[ione.karnes]

Airway, breathing, and circulation. ABC's come first. An airway must be established and maintained using the oral airway. Then the breathing assessment reveals Cheyne Stokes warranting O2 and BVM. Heart failure frequently occurs secondary to inadequate O2 levels. If the pulse doesn't increase with a rise in blood O2 level then it is unlikely that chest compressions would help. Monitor the carotid pulse (not femoral). These vitals and signs are representative of a probable brain herniation and survival is unlikely.