High Performance CPR

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Nurses Edition Commentary

Kathy Garvin, RN and Lisa Chavez, RN

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Steve D. -

How does ultrasound fit into this algorithm? Usually I try to get a quick parasternal or subxiphoid cardiac view during the pulse check. I'm not sure how feasible it would be to get that done in the 3-4 seconds you are suggesting to minimize the pulse check to.

Joshua B. -


Thanks for commenting! Great question. I limit ultrasound to a couple of scenarios

1. The patient is in PEA/asystole - Not useful for VF/VT
2. I often go for the parasternal since most of the time, anecdotally, it is quicker. I will go for the subxiphoid if I think that will be easier.
3. I do NOT do this every pulse check - I may do it every 5 minutes or so, or depending on what happened with the rhythm. I limit it to times when it may change management. I know they were in PEA in the last pulse check and did an ultrasound then with cardiac activity, I don't repeat the ultrasound each pulse check.
4. As soon as you get the image and see what's going on - have the compressor get right back on the chest.
5. Perform a TEE intra-arrest - in the future????

Abraham K. -

I tried looking for some papers on HPCPR but I couldn't find any. Do you have recommendations on good articles for journal club so we can start the conversation to change?

Rob O -

Hey Abraham, You might want to check out Resuscitationacademy.org (no affiliation with EM:RAP). The proponents of HPCPR in my area use that as their reference cite as well as training portal.

Joshua B. -

Abraham - If you goto the "resources" page on the website, there are tons of links to videos, talks about the science, an e-book explaining the entire process and basis for high performance CPR and other helpful links. Let me know if you have other questions!

Josh P. -

I wonder if anyone would be willing to comment on the scenario I had the other day and provide feedback. During one of my flight physician shifts, we went to a scene call for a witnessed in-home cardiac arrest with immediate CPR and local EMS response within 6 minutes. LUCAS device and AED were placed, and patient had received 4 shocks from the AED prior to our arrival. Our monitor showed V-tach/torsades on multiple occasions, in fact showing a shockable rhythm for over an hour. We precharged the defibrillator prior to each pulse check, but were never able to achieve ROSC, which was quite frustrating to me. Being on scene, we exhausted our supply of epinephrine and started an epi drip. The patient also received Magnesium 2 grams as well as Amiodarone bolus and infusion. We also gave at least 2 amps of lidocaine. This whole case frustrates me because I hate calling a code when we have a shockable rhythm, but transporting a CPR in progress the 40 minutes by air was just impractical. Does anyone have any thoughts?

Joshua B. -

Yes! And there might be a talk covering refractory ventricular fibrillation/tachycardia in the future ☺️

For refractory VF there are a couple of options.
1. Double sequential external defibrillation - shocking the patient with two at the same time

2. Beta blockers - esmolol bolus and infusion


Limited evidence for the first two, more so for the third.

Josh P. -

That would be awesome! Thanks!

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