EMCrit 257 was an episode on how the term PEA was stupid and misleading. In that episode, I attempted to disambiguate PEA and how to diagnose and treat it. In this third episode of Ghali Grills, Sam Ghali and I dive even deeper and discuss:
- Avoiding finger based pulse checks
- Sonographic “pulse”
- Sonographic assessment of blood pressure correlates
- When to restart CPR despite a pulse
- PEA epi use
and so much more!!!
Papers
- Cohen Original Paper
- Secondary Analysis of the Cohen Paper dealing with ETCO2
- Teran on CPR with low BP
- Synchronization of Mechanical CPR
From Original Cohen Study
From Cohen Follow up study: 2ndary Analysis
MUCH better accuracy than ETCO2
Systolic > 60 mm Hg: 89% vs ETCO2>20: 59%, ETCO2>25: 58%
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Editor-in-Chief, at EMCrit.org
An ED Intensivist from NY.
Professor
Nassau University Medical Center
No conflicts of interest (coi).
Professor
Nassau University Medical Center
No conflicts of interest (coi).
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RLA graduate.
Great discussion.
Love to hear from the experts.
Why all the profanity?
Not necessary and distracting.
Kinda makes me cringe.
Hi Scott & Sam,
I’m seeking a clarification – you both mention running norepinephrine at “50” during the cardiac arrest.
Can I clarify if you’re referring to 50mcg/min?
Much obliged
Dean
Hi Dean,
Yes you got it, exactly — 50 mcg/min. You could have Epi or Norepi running at that rate in the background and I think either one would be a great way to go.
Sam
Great episode guys, thanks. I was super interested to hear about the PSV and read the Cohen paper but having had a little play around I’ve got to say I’m super dubious about the reliability of the measurement. The angle of insonation makes SO much difference. Tried today on patients with totally normal systolics and had PSVs that essentially didn’t record at 90 degrees and only got over 20 at almost 30. Perhaps it’s a technical issue my end, but have to say super skeptical this can be a reliable tool
Hi Timothy, You’re so welcome my friend, thanks for your kind words! I appreciate your skepticism—this was the exact question I posed to the authors. They said they tilted the probe “slightly cephalad” and when further pressed not more than “30 degrees” (this gives an angle of insonation ~ 60°). There is definitely room for inconsistency here but they seemed to indicate they felt this was fairly consistent. The one thing I would say is make sure the gate is in the very center of the artery (the more peripheral in the vessel the slower the flow). Just to be… Read more »
Sam: “You ask the Paramedic,’Hey what was the rhythm?’ ‘PEA.’ ‘What kind of PEA?’ What do you mean, what kind of PEA?’ Man, paramedics are stupid. Thanks, Sam.
David Leonard, Paramedic
Hi David,
That wasn’t even remotely meant as a slight on paramedics. It was just an example to highlight that what IS stupid is the standard terminology that has been deeply entrenched into our system.
Sam
Scott and Sam, Incredible episode with so many pearls of wisdom. A couple of questions I had: Given that you would suggest starting CPR if the arterial BP is reading very low (I.e. 40 systolic ), when would you feel comfortable terminating resuscitation (in the absence of family asking you to stop)? I can imagine other team members being uncomfortable stopping CPR when objectively there is an arterial waveform and arterial BP on the tele monitor. If the BP is 0 and there is no waveform, I don’t think there would be any question. You may have addressed this during… Read more »