What would you do in this code?

[nursejackie821]

Looking for any experience with this and/or advice as to what you would do in this situation. We were in the middle of coding a patient last night that had a working arterial line (meaning that it read accurately, flushed, and had good blood return) prior to the code. After giving 3 rounds of epi and doing a rhythm check, the patient appeared to be in a sinus rhythm, but we were unable to palpate a pulse. HOWEVER, the a-line reading on the monitor was showing a pulsatile waveform and a systolic blood pressure in the 200's (with compressions stopped, obviously). We continued on the code this way for 20 minutes until we were able to palpate a definite pulse. The family ended up withdrawing shortly after and the patient passed quickly. I realize you're supposed to treat the patient and not the monitor, but my question is: doesn't a pulsatile waveform indicate there is a pulse? Maybe it was so faint we just had to doppler it? Or was it right to carry on like this for 20 more grueling minutes?

[SionainnRN]

You couldn't feel a pulse so you continued to code the pt until you did. I'm not seeing what you would have done differently. You were treating the pt since you had no pulse and continued the code. Did you think you should have stopped coding them because of the art line reading? I guess I'm confused as to what you think was done wrong.

[RN543]

This sounds like PEA or pulseless electrical activity. Although there is some electrical activity, there is still insufficient cardiac output to produce a pulse and the patient is still in cardiac arrest. CPR would still be administered under this circumstance. Great question. Hope that helps.

[nursejackie821]

I guess some of us just wondered if the patient indeed had a pulse after the third round, maybe just not bounding enough to feel, or the person checking the pulse just was frantic and missed it. How do you get a pulsatile waveform without a pulse? In hindsight, it makes sense that it could have been faint and CO would have been present but insufficient (and probably not sustained) had we stopped. Thanks RN543 :)

[Nalon1 RN/EMT-P, BSN, RN]

Yup, you don't feel a pulse, you do CPR. When you question if you should be doing CPR, you should be doing it.

If you had a pressure in the 200's like the A-line said, you would have easily felt a pulse. It was appropriate to continue until you were able to feel a pulse.

Now as to why the A-line said you had a pressure and waveform, no idea.

[psu_213, BSN, RN]

If you had a pressure in the 200's like the A-line said, you would have easily felt a pulse.

I'm not an expert on A lines, but that was what I was thinking too. Either way, if you cannot definitely palpate a pulse, keep going with the code.

I might suggest having a second person checking for a pulse (but not for too long while CPR is on hold) if you think the one person checking for a pulse is frantic and missed it.

[delphine22]

Once during a code when we weren't sure about a pulse, we got the ultrasound machine and the MD visualized the heart, which wasn't moving.

[akulahawkRN, ADN, RN, EMT-P]

Something I wonder is that the patient could have been extremely peripherally vasoconstricted thus the A-line might actually have been seeing a SBP of 200+ and showing a waveform, but since the pulse wasn't palpable, clearly there wasn't sufficient flow. What was the A-line measured DBP?

In any event, I think it was absolutely appropriate to continue working the code until a pulse was palpable. In any event, the fact that the patient passed very quickly after the family withdrew life support simply tells me that this one was very, very sick.

[kool-aide, RN]

Best indicator for ROSC is etco2 monitoring according to AHA.

[occc2010rn]

If the pulse is not strong enough to palpate then it's not strong enough to oxygenate. Continuing CPR was absolutely the right thing to do.