Question: I was just wondering the reasoning as to why we don't check for a pulse after we deliver a shock, and instead jump right into CPR? I have watched many VSA's ran in the ER and always see the ER physicians check for a pulse after delivering a shock before resuming CPR. I have asked several co-workers and no one seems to have an answer for this.
Great question! Just because you see something being done in ER doesn't necessarily mean it is "by the book" unfortunately€¦
One of the reasons that it is important to jump back onto the chest and re-initiate CPR following a defibrillation is to maximize the "time on chest" CPR fraction. We know that the CPR pauses around a shock being delivered add up to a significant amount of time where no forward flow or circulation is being delivered to the brain. We also know from the work of Dr Cheskes and his team at Sunnybrook that these perishock pauses (although not necessarily the post shock pause) are independently associated with a decrease in survival to hospital discharge (Circulation. 2011;124:58-66).
Further, from our own auditing work, we have found that most of the time in the immediate post shock period, the stunned myocardium shows up on the monitor as asystole at least initially. In the past, this has led some ACP to treat this rhythm with epinephrine and atropine (not that we do that anymore) when really had we waited 20 seconds (again- undesirable time delay to CPR) we would have seen that the actual rhythm is refractory ventricular fibrillation which requires an antiarrhythmic and a further defibrillation at the next cycle.
Now, we jump right back onto the chest and perform CPR for 2min and treat whatever the last rhythm that was interpreted until the next analysis or the patient demonstrates returns of signs of life. Hope this helps!