Arrest

[WTEngel]

I stand corrected.

 

[Melclin]

Thought there might be a better turn out than ths. Mind you it's not trauma so maybe it's not that exciting.

I'll give the "answer" then (how I worked it anyway)

CPR continued, epi 1mg given with no change. Intubated, size 9 tube, no extensions or so forth to minimize dead space in the circuit. Initial end tidal of 160mmHg, SpO2 of 77%. Ventilated at a rate of about 6/min with a Vt of about 8-10ml/kg. ILS crew continued giving epi and CPR under direction.

Then the kicker: bilateral chest decompression with pneumocaths- immediate release of copious free air from both sides with an almost immediate ROSC, AF rate of 150, BP 170/100. Occassional agonal respiratory effort, increasing with time, and pt starts to not tolerate the tube so well but GCS remains 3.

SpO2 increased to 98% EtCO2 trending down to about 100mmHg on arrival at hospital. Chest is still tight, but now has biphasic wheeze and is significantly more compliant.

So, now we have an output, how would you continue management?

So, now we have got an output

How did you work it like that being an EMT-B, do you mean that you were with a medic who did that, or are you telling little phibs about your level of practice? Student maybe?

Vt seems a little high even for a normal pt. Were you wanting to increase the Vt in an asthmatic arrest? I would have thought you'd back off on the Vt what with dynamic hyperinflation and so on...focussing more on the expiratory phase. With their functional residual capacity through the roof you don't need to be overloading them.

 

[VentMedic]

Vt seems a little high even for a normal pt. Were you wanting to increase the Vt in an asthmatic arrest? I would have thought you'd back off on the Vt what with dynamic hyperinflation and so on...focussing more on the expiratory phase. With their functional residual capacity through the roof you don't need to be overloading them.

If this patient is hyperinflated with a bronchospasm, the chances of bagging with much to any Vt will be slim to nil without excessive pressure which will of course cause the pneumos. If the patient has bilateral tension pneumos, the chances of ventilating with PIPs of less than 60 cmH2O would not be likely. Of course, even with the pneumos decompresssed the inflammation and bronchospasm will persist and if it is servere enough to cause the patient to code one still won't be able to bag unless they happen to be carrying heliox on their truck.

 

[VentMedic]

Intubated, size 9 tube,

Size 9 tube?

CPR continued, epi 1mg given with no change. Intubated, size 9 tube, no extensions or so forth to minimize dead space in the circuit. Initial end tidal of 160mmHg, SpO2 of 77%. Ventilated at a rate of about 6/min with a Vt of about 8-10ml/kg. ILS crew continued giving epi and CPR under direction.

What was the PetCO2 during the cardiac arrest?

Where was the pulse ox placed?

 

[Melclin]

If this patient is hyperinflated with a bronchospasm, the chances of bagging with much to any Vt will be slim to nil without excessive pressure which will of course cause the pneumos.

Gotcha. That makes sense. What role does gastric insufflation play? Surely you'll be inflating the stomach long before an iatrogenic pneumo.

If the patient has bilateral tension pneumos, the chances of ventilating with PIPs of less than 60 cmH2O would not be likely. Of course, even with the pneumos decompresssed the inflammation and bronchospasm will persist and if it is servere enough to cause the patient to code one still won't be able to bag unless they happen to be carrying heliox on their truck.

You mean positive inspiratory pressure (PIP) right? Not P1P (intrapleural pressure). You meant that you will likely need to provide >/= 60cmH2O of pressure to overcome the compression caused by the tension pneumo? Just checking, I'm no RRT.

How useful is heliox in this situation? It makes good sense, being a lower density, and it obviously has some mesurable desirable effects, but everything I've read has said that the evidence just isn't there that it improves outcomes (although there does seem to be a distinct lack of evidence in general regarding heliox's use in ventilated pts). Do you use it to aerosolise medications as well?

EDIT: Our guidelines still say to ventilate everyone with Vt of 10ml/kg although we have all been instructed that 6-7 are better numbers. Why such high numbers if the normal Vt is more like 3-5? Any idea why our service keeps pushing this idea of 10mls/kg despite the fact that it seems to be way too much and impossible for us to measure.

 

[VentMedic]

Gotcha. That makes sense. What role does gastric insufflation play? Surely you'll be inflating the stomach long before an iatrogenic pneumo.

The ETT size 9 was mentioned. But you are correct that the belly would be well ventilated and unless an NG or OG was placed, that also would further impede ventilation.

You mean positive inspiratory pressure (PIP) right? Not P1P (intrapleural pressure). You meant that you will likely need to provide >/= 60cmH2O of pressure to overcome the compression caused by the tension pneumo?

Either a pneumo or bronchospasm will cause a dramatic increase in PIP (Peak Inspiratory Pressure).

How useful is heliox in this situation? It makes good sense, being a lower density, and it obviously has some mesurable desirable effects, but everything I've read has said that the evidence just isn't there that it improves outcomes (although there does seem to be a distinct lack of evidence in general regarding heliox's use in ventilated pts). Do you use it to aerosolise medications as well?

There is definitely not a lack of evidence for heliox and ventilated patients. Over the past 25 years, there would have been many more deaths due to asthma if heliox had not been used with the ventilator. As well, it has kept many patients from being intubated.

http://scholar.google.com/scholar?q=heliox+ventilator&hl=en

http://search.aarc.org/search?clien..._occt=any&as_dt=i&as_sitesearch=&sort=&as_lq=

http://ajrccm.atsjournals.org/cgi/s...edef=1+January+1994&tdatedef=15+November+2009

EDIT: Our guidelines still say to ventilate everyone with Vt of 10ml/kg although we have all been instructed that 6-7 are better numbers. Why such high numbers if the normal Vt is more like 3-5? Any idea why our service keeps pushing this idea of 10mls/kg despite the fact that it seems to be way too much and impossible for us to measure.

10 ml/kg is a middle of the road number. 12 ml/kg had been considered the norm and is the number many of the studies use. Anesthesiologists and organ procurement teams still prefer 12 - 15 ml/kg as many CT surgeons had in the past. For an ARDS prtocols we will rarely run less than 6 ml/Kg and that is generally with much higher levels of PEEP. If we do run at 6 ml/kg and the patient is spontaneously breathing, deep sedation and a paralytic may be necessary to prevent the complications of low VT ventilation by over breathing. Of course, atelectasis is also a complication of VT ran too low for extended periods of time like more than 1 hour. Attempting to run a low VT protocol without a very good graphics setup on a very good transport ventilator would be very difficult and probably a little dangerous unless it is the only way you can ventilate the patient due to increased airway resistance. Then, the ventilator should have some monitoring capabilities.

http://www.ardsnet.org/system/files/Ventilator+Protocol+Card.pdf

http://www.ardsnet.org/

 

[Smash]

How did you work it like that being an EMT-B, do you mean that you were with a medic who did that, or are you telling little phibs about your level of practice? Student maybe?

Qualifications changed; it's all about the badge and status

Vt seems a little high even for a normal pt. Were you wanting to increase the Vt in an asthmatic arrest? I would have thought you'd back off on the Vt what with dynamic hyperinflation and so on...focussing more on the expiratory phase. With their functional residual capacity through the roof you don't need to be overloading them.

Vt should probably be a bit lower and probably was. Bearing in mind that this is with hand operated recoil bag it is difficult to judge. Rate was only around 6, so allowing time for expiratory phase of the cycle, and this is actually lower than the recommended by the ERC, however it was judged to be appropriate in this instance.

PIPs is peak inspiratory pressure. An orogastric tube as placed as soon as possible following intubation and the stomach decompressed. The lower oesophageal sphincter tends to have poor tone in these situations, so it is highly likely that it will be over inflated.

Size 9 tube?

Yes.

What was the PetCO2 during the cardiac arrest?

Where was the pulse ox placed?

EtCo2 levels as noted, ILS do not have capnography, so numbers unknown until immediately before and after intubation. Spo2 probe placed on an earlobe.

Anyway, ongoing treatment was: Infusion of IV beta-agonists. Sedation and paralysis with therapeutic hypothermia. There continued to be some free air via the pneumocaths, however ventilation considerably easier. BP and HR trended towards normal, EtCo2 eventually down to 100mmHg on arrival at hospital.

12 days in ICU and the patient was discharged to home, neurologically intact and with no ongoing health issues as a result of this episode.

 

[VentMedic]

EtCo2 levels as noted, ILS do not have capnography, so numbers unknown until immediately before and after intubation. Spo2 probe placed on an earlobe.

Interesting.

Anyway, ongoing treatment was: Infusion of IV beta-agonists.

What country are you working in?

12 days in ICU and the patient was discharged to home, neurologically intact and with no ongoing health issues as a result of this episode.

How was his voice after a size 9 through his cords?

 

[Melclin]

Very illuminating as usual. Thank you. Very interesting about the different Vt's, we are evidently not being told the whole story. Another trip to the med library may be in order.

On the topic of Heliox (I'm cerntainly not questioning your knowledge on the topic, I'm just trying to reconcile it with what I've read), I read many of those articles listed in those searches. I've not studied them carefully, so maybe I've missed the point. I might point out though that many of those articles weren't not specific to asthma.

As I said, and as many of the articles in the searchs you listed note, there are notable changes in desirable physiological effects, but most reviews seem to go on to say that this has not translated to a difference in outcome.

Finally, one may ask whether there is a role for heliox in mechanically ventilated patients. Studies by Menitove and Goldring10 and Darioli and Perret11 have demonstrated that mortality from mechanical ventilation for asthma can be eliminated using techniques to reduce dynamic hyperinflation. No similar data exist for heliox when it is used in such cases.

Manthous CA. Heliox for Status Asthmaticus? Chest. 2003 March 2003;123(3):676-7.

The existing evidence fails to demonstrate a clear benefit from the administration of helium-oxygenmixtures to all ED patients with acute asthma.
Treatment with heliox may improve pulmonary function in the most severe acute asthma patients; however, clinicians must ensure other evidence-based treatments are employed.

Rodrigo Gustavo J, Pollack Charles V, Rodrigo C, Rowe Brian H. Heliox for non-intubated acute asthma patients. Cochrane Database of Systematic Reviews [serial on the Internet]. 2006; (4): Available from: http://www.mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD002884/frame.html.

I know this is for non-intubated pts, but it was one of the articles I read that generally pushed me in the direction of thinking that some of the evidence for heliox improving outcomes might be a bit soft.

Despite the lack of concrete evidence to support its use in asthma, Heliox still forms an integral part of the treatment algorithms for exacerbations of asthma in some centres....There also exists a small population of patients with status asthmaticus who fail to respond to routine therapy but still have respiratory muscle reserve. It is this second group who they may benefit from breathing Heliox until definitive therapies take hold.

Reuben AD, Harris AR. Heliox for asthma in the emergency department: a review of the literature. Emerg Med J. 2004 March 1, 2004;21(2):131-5.

Reuben etal go on to talk about Bridgeport Hospital, Connecticut and their asthma protocols which involve heliox only for serious asthma that does not yet require mechanical ventilation.


I wasn't talking generally about heliox I was talking specifically about this case. Many of those articles were about heliox in general and I do know how to use an internet search function. Given the articles I've just cited, its not so silly on my part to be asking the question. I'm certainly not against the idea of heliox, I think with the right study design it would prove to be quite helpful in this context, I was commenting on the lack of evidence for its use in this case specifically. But again I'm no expert, if there's something out there I'd really like to see it. I was looking into the possibility of writing a brief outline of its possible uses in pre-hospital settings for a local publication but was disappointed to find a lack of strong evidence for its use, so if you know of something do tell.

Do you feel that the evidence that exists is enough to warrant its use in selected situations in a pre-hospital setting?

 

[Smash]

How was his voice after a size 9 through his cords?

As dulcet as always. At 300lb and 6'6" he could have had a garden hose down there and not noticed the difference.

 

[VentMedic]

Do you feel that the evidence that exists is enough to warrant its use in selected situations in a pre-hospital setting?

It would be impractical in pre-hospital due to the flow factor of heliox and the amount of tanks you might have to carry. For 70/30 you multiply the number set on the flowmeter by 1.6 and for 80/20, 1.8. Thus, the flow is almost 2x for your tank calculation purposes. Putting an H tank on your truck might not be practical.

The articles you cited did make an argument for heliox. As one stated, not "all" ED patient will get heliox. It will depend on the Peak pressures, A-a gradient and the technology available. Not all ventilators are compatible with heliox.

I also did not just do a general internet search but gave you links from the Respiratory Care journal for U.S. RTs and the ATS journal for pulmonologist and critical care physicians. Many do not know about these journals if they are from other countries.

 

[VentMedic]

As dulcet as always. At 300lb and 6'6" he could have had a garden hose down there and not noticed the difference.

Fat or muscle does not count for ideal body weight. The length should not be an issue with an 8 unless you nasally intubated which I hope you didn't with a size 9. Granted I would not put a 7 in but an 8 would be adequate especially with today's modern ventilators. My apologies if your hospital are not that advanced to overcome ETT resistance.

I haven't seen a regular size 9 ETT used except for vetinary medicine and for special OR and ICU procedures where the tube is carefully placed with a videoscope under very ideal situations.

 

[VentMedic]

Smash,
I ask again, what country are you from so we can get a better idea about your training, available meds and protocols especially since you did mention the IV beta agonists?

 

[Melclin]

Qualifications changed; it's all about the badge and status

Smash,
I ask again, what country are you from so we can get a better idea about your training, available meds and protocols especially since you did mention the IV beta agonists?

Its not about being fickle. I'm not going to have a go at you about which ticket you have. But its a legitimate question. If you're marked a a B and you're practicing as a P it stands to reason that people will be interested in the why.

Also its helpful in this particular case. I'm a little confused about what happened when, so I was just interested to know to add a little clarity and as Vent said, it'd would be interesting to know a little about where u are in terms of protocols and so on.

 

[Smash]

At the moment I'm lying on a beach in Thailand. Really, where I am or what level of training I identify myself as has no bearing. The scenario was as stated and I was curious to know what people would do and why. Fashions may vary from country to country, protocols may differ, training may not be standardized, but none of that interferes with the discussion of the case or the science (or lack of) behind such treatments. For example, intravenous beta agonists do not find favor in many places and for sound reasons, however in others they are recommended for refractory bronchospasm, and there are also reasonable grounds for this.

What was done was done, and in this instance it had a favourable outcome. I'm happy to hear critique of the actions of the crews in this instance, and I would be happier finding out how others would approach such as case. Thus far I've discovered that most people would just call the undertaker! That and perhaps a 9mm ETT is a good size tube for a horse (or maybe a man built like a horse...) I'm fairly sure that the patient and his family are reasonably hOly that the undertaker wasn't the first option here!

 

[VentMedic]

At the moment I'm lying on a beach in Thailand. Really, where I am or what level of training I identify myself as has no bearing. The scenario was as stated and I was curious to know what people would do and why. Fashions may vary from country to country, protocols may differ, training may not be standardized, but none of that interferes with the discussion of the case or the science (or lack of) behind such treatments. For example, intravenous beta agonists do not find favor in many places and for sound reasons, however in others they are recommended for refractory bronchospasm, and there are also reasonable grounds for this.

You obviously don't understand there is more than just "different protocols" just based on level of training concerned here.

Example: Australia has the chest compression or squeeze method while we are still trialing it in the U.S. at select facilities.

IV beta agonists: That would depend on the medication. There has been a lot of literature on this subject. We've also had discussions about using them for asthmatics with H1N1 to reduce the risk of exposure to health care providers. However, the literature isn't favorable and one of the better medications, albuterol, is not approved for IV use except in a few countries and those are the ones who have produced the literature. If you are using something different or have evidence to prove otherwise, I'm sure others would like to hear about it.

There are also varying views by country for just doing bilateral decompression.

Another example: the treatment of asthma differs from the Pulmonology Society in each country with different recommendations from NZ/AU, EPR-3 (U.S.), ERS and Canada. Thus, EMS in the U.S. may adopt recommendations from these authorities for their treatment such as the use of compressions, sterioids, and mag in the field as well as IV albuterol if it is approved in that country.

You initiate a scenario but can not answer simple questions when asked and get defensive or embarrassed when someone asks about your country or level. That sounds like you are not comfortable with your title and you probably should continue your education so you will understand why some of these questions are relevant to patient care. Even as an EMT-B, one can be advanced enough in education regardless of level to at least answer what country they are citing protocols from and explain a few things concerning treatment. That is what this thread is about and not your ego or beach time in Thailand.

One more question: Did you use 300# as the ideal body weight for calculating VT or did you use the height?

 

[Melclin]

Just thought I'd add this in an asthma dicussion

Oh wow, I didn't realise you guys didn't have IV salbutamol.

Certainly 'gentle lateral chest pressure' is a controversial one. It was almost removed from the guidelines a while ago. A doctor, I believe it was Frank Archer, our current professorial head of department at uni, did some sort of study, not particularly well weighted..case control study I think it was, and apparently it showed impressive results, so it was retained.

Considerable ambiguity abounds throughout the state service about what exactly 'gentle lateral chest pressure' involves. I don't know why. It's not a hard idea to communicate. Some people insist on performing it almost like chest compressions which is quite silly and most probably dangerous.

The hands are applied to the chest; bottom of the palms roughly at the level of the floating ribs, thumps pointing to the ziphoid process, along the lines of the false rib's cartilaginous connections; index finders pointing roughly towards the nipples; and apply a gentle 'inwards and upwards' pressure.

This is the guideline (a bit old now, but still essentially the same, except that hydrocortisone has been replaced by dexamethasone, and that the COPD guidelines have been separated from the asthma guidelines) if anyone is interested in our approach, or the use of IV beta agonists:
http://www.rav.vic.gov.au/Media/doc...0906-3c3be645-b626-4222-bed6-47076bae9ca1.pdf

 

[Melclin]

A little something from the Aussie perspective

http://www.anzca.edu.au/jficm/resources/ccr/2005/june/Salbutamol.pdf --Australian paper arguing against the use of IV salbutamol.

http://www.nationalasthma.org.au/cms/index.php
--Current recommendations of the the (Australian) National Asthma Council

http://www.anzca.edu.au/jficm/resources/ccr/1999/december/Asthma.pdf
--The typical Australian clinical approach.


A couple of radomised control trials comparing IV and nebulised salbutamol, which seem to be referenced here as the big two:

Swedish Society of Chest Medicine. High dose inhaled versus intravenous salbutamol combined with theophylline in severe acute asthma. Eur Respir J 1990;3:163-170.

Salmeron S, Brochard L, Mal H, Tenaillon A, Henry-Amar M, Renon D, Duroux P, Simonneau G. Nebulized versus intravenous albuterol in hypercapnic acute asthma. Am J Respir Crit Care Med 1994;149:1466-1470.

Our guidelines state that IV salbutamol has no advantage over nebulised salbutamol and that it can in large doses cause intracellular acidosis. This seems to be supported by this literature.

 

[Smash]

You initiate a scenario but can not answer simple questions when asked and get defensive or embarrassed when someone asks about your country or level. That sounds like you are not comfortable with your title and you probably should continue your education so you will understand why some of these questions are relevant to patient care. Even as an EMT-B, one can be advanced enough in education regardless of level to at least answer what country they are citing protocols from and explain a few things concerning treatment. That is what this thread is about and not your ego or beach time in Thailand.

One more question: Did you use 300# as the ideal body weight for calculating VT or did you use the height?

I love it! Not a single thread can go by without snide comments, insinuation and snarky little asides can it?

In terms of this scenario, it is reasonable to assume that the treatment that was carried out was in accordance with local protocol. Knowing for example that I work for the Olomouc Ambulance Service in the Czech republic makes absolutely no difference, unless you happen to have an in-depth knowledge of such protocols to be able to critique what was done in accordance with them. However, it is still possible and indeed desireable (as I was attempting) to find out what others would do in such situations, and to critique the treatment in terms of what is generally accepted in whatever region you come from. I would not have thought that would be too difficult.

If you want to know what beta-agonist was used, you need merely to ask. If you want to know what instruments were used, you need merely to ask. If you want to know on what evidence our protocols are written you need merely to ask.
What geographical, political, religious or other milieu this takes place in is utterly irrelevant in terms of a clinical discussion.

What qualification level or word salad I post after my name also has no bearing. We have in this forum people who identify themselves as having a high level of training/education/experience coming out with such gems as (and I paraphrase here) "Versed doesn't stop seizures it just relaxes the muscles" and "hyperventilating patients have too much oxygen in their systems which makes them posture"
Quite frankly, I'm happier not being identified with such levels of training and prefer to have clinical discussions that can be judged on their merits, not on who types things. Listing qualifications is irrelevant for a number of reasons: 1: it does not actually mean the person has any idea what they are talking about (see above) so are irrelevant) 2: There is no way of knowing whether these are real qualifications, gained at real universities. I could be the head of Trauma Surgery at a major trauma center, or I could be the cleaner. It makes no difference to the discussion.

It would seem to me that someone who is happy with their level of training/education/experience and so forth would not feel the need to be abusive and make personal attacks and could hold a rationale, polite conversation without the need to resort to such obfuscation and intellectually devoid tactics. I realise that fragile egos require frequent stroking, however mine doesn't.

Seeing as there was a straightforward question asked: I use patient's height in centimetres, minus 100 as the ideal bodyweight in kilograms.

MelClin, we too do not use IV beta-agonists if there is adequate air-movement to have an effect with inhaled agonists. However we do not currently have the option of including nebulized medications through a ventilation circuit. We are also very, very wary of using IV beta-agonists in the chronic obstructive patient.

And now, as I am no longer on the beach in Thailand, but rather in the hill country in the north, I am going to lie beside the pool for the rest of the day.

 

[BLSBoy]

Smash, if you would quit dodging, and just ANSWER the questions, then there wouldnt really be much of a problem.