BLS Epi in cardiac arrest?

[Mariemt]

That last statement is a pit fall of the systems you have seen apparently. The area I work, as well as myself, strive to ensure paramedics continue to provide great bls care while adding als....I know its an issue all across the country (probably world) and sadly its a training/mindset issue

Well it all depends on the situation. I know good basics can handle a variety of issues. Many times a medic isn't necessary, however medics can offer things a basic can not and knowing what I know, I would be perfectly happy with a basic caring for my family for a basic type call... but there are those calls that are not basic calls

 

[STXmedic]

That last statement is a pit fall of the systems you have seen apparently. The area I work, as well as myself, strive to ensure paramedics continue to provide great bls care while adding als....I know its an issue all across the country (probably world) and sadly its a training/mindset issue

I don't think he's referring to poor paramedics as much as the lack of evidence for reduction of morbidity/mortality that many of the paramedic skills are supposed to provide; for example, cardiac meds and RSI/ETI.* Again, not poor execution, but lack of verifiable benefit.

*Sentence structure sucks. Don't want to change it.

 

[WBExpatMedic]

this. exactly why im starting medic school next fall. I hate providing oxygen, comfort and ASA to patients and thinking im helping them.

hogdweeb you've gotten kind of beat up over your views. I felt similar when I was an EMT and there is nothing wrong with wanting to do more for your patients. BLS can and does save lives, but the key to being excellent at any level of EMT is to never stop learning and I applaud you for wanting to continue your education.

Most of the EMT's that want to trash medic's do it for a couple of reasons. 1 They failed out of medic school or 2 They are afraid to tray.

 

[omak42]

Well it all depends on the situation. I know good basics can handle a variety of issues. Many times a medic isn't necessary, however medics can offer things a basic can not and knowing what I know, I would be perfectly happy with a basic caring for my family for a basic type call... but there are those calls that are not basic calls

Sorry, I guess I just misread your statement

 

[Mariemt]

Sorry, I guess I just misread your statement

It wasn't my statement you read. Lol

 

[Mariemt]

hogdweeb you've gotten kind of beat up over your views. I felt similar when I was an EMT and there is nothing wrong with wanting to do more for your patients. BLS can and does save lives, but the key to being excellent at any level of EMT is to never stop learning and I applaud you for wanting to continue your education.

Most of the EMT's that want to trash medic's do it for a couple of reasons. 1 They failed out of medic school or 2 They are afraid to tray.

Unfortunately I see more medics trash EMTs. Just online, here more than anywhere .

I believe there is a place for both in the system. Medics are an absolute necessity, so I can't understand the friction.
EMTs that bash medics? Um why?
Maybe it is because in our system we get along very well. I mean our medic will tell us nice job, couldn't do iT without you etc etc . Because we all know our role, job and do it like a well greased wheel

The ems world needs medics, EMTs have no right to bash medics and really, medics should respect their EMTs

 

[Tigger]

Let's try and keep this thread on topic, which is BLS Epi in Cardiac Arrest if you have forgotten.

 

[Wheel]

I would say that we shouldn't have it. While Epi in cardiac arrest has no evidence that it harms, it really has no evidence it helps either. I think we shouldn't be adding treatments just to add them, without a good clinical reason to do so. Also, epi is not free. It's going to cost someone some money, and for what clinical benefit?

 

[hogdweeb]

hogdweeb you've gotten kind of beat up over your views. I felt similar when I was an EMT and there is nothing wrong with wanting to do more for your patients. BLS can and does save lives, but the key to being excellent at any level of EMT is to never stop learning and I applaud you for wanting to continue your education.

Most of the EMT's that want to trash medic's do it for a couple of reasons. 1 They failed out of medic school or 2 They are afraid to tray.

youre completely right. Medics save lives, Basics save medics. I've never heard a basic trash a medic thoughunless the medic treats his basics like POS'. Work with couple I's that work with medics... and some medics dont wont let them spike their bags cause they dont feel they are "competent" to do it at another service.

Back on topic, as Wheel said. no harm, no good, why do it?

 

[blindsideflank]

^^^^ Thanks tigger
here are my thoughts on the issues that have been discussed so far.

1. EMT's shouldnt have their scope expanded. Just go do your medic.
In BC (canada) where I work, there are very few ALS practitioners, none rurally, and there is no push to change this.

2. Epi doesnt have a proven benefit.
True, but it is a standard of care for emerg/ALS and all other hospital departments. (sometimes not ie: ive seen protocols post heart surgery, stack 3 shocks then crack the chest but this is special situations )
I dont necessarily disagree with this though

3. EMT's dont do IV's.
They do here. And if they fail to get an IV then they run a code like they normally would.

4. cost
no commment. its always a factor

5. ALS vs BLS
i hate this term. ALS should be synonomous with starting from the top (including BLS skills). I hate the turf war involved in this. Also, the comments regarding some ALS interventions not being proven to help annoy me.
As with all of EMS education, this is another saying that gets thrown around by most practitioners (refer back to BLS before ALS). "Referencing the research" is the new way of saying I am too smart to follow protocols. I agree with it but sometimes people dont understand the limitations od said research. There is so much that has not been researched that saying something isnt proven to work is NOT synonomous with proving it doesnt work. It may just mean it has not been researched well (or at all). In this case, sound clinical judgment is the reason these treatments exist.

Has oxygen in a hypoxic patient with partial airway obstruction been proven to work in the PREHOSPITAL setting? Probably not. (who would do that research?). Our profession is also so young that even where we need research, it simply hasnt happened yet.

***note, im not saying epi works. this last rant was general. Im just saying that we need to understand the limitations when we reference studies or the lack of them.



I thought there would be discussion regarding altering the standard of care to fit EMT's. That a code would get the epi part of it but not amio/lido, bicarb etc.

 

[blindsideflank]

I did hear a quote once regarding ACLS drugs. it was to the effect that
"they arent proven to work, but they are proven to get ROSC. and you cant survive if you dont get ROSC"

with the addition of hypothermic therapy, which shows great benefits, maybe ROSC IS the short term goal of EMS and we should leave neurologocal survival to the hospital...

 

[Carlos Danger]

I did hear a quote once regarding ACLS drugs. it was to the effect that
"they arent proven to work, but they are proven to get ROSC. and you cant survive if you dont get ROSC"

with the addition of hypothermic therapy, which shows great benefits, maybe ROSC IS the short term goal of EMS and we should leave neurologocal survival to the hospital...

This is a tempting point of view, but it isn't the right way to look at it.

Getting pulses back with high-dose epi is like starting an old car with a clogged up fuel system by spraying some starter fluid into the intake manifold. You might get it to turn over and catch and run for a few seconds, but you haven't fixed the car at all, or really even done anything to benefit the situation.

When you bring a post-arrest patient to the ED with pulses, all you've done most of the time is spray some starter fluid into the intake. The patient has suffered a a fatal and irreversible injury.

So the question is, why do we bother continuing to spray fuel into the intake and then claim success just because the engine runs for a few minutes?

IMO, it is time for resuscitation science to stop trying to raise everyone from the dead, and start focusing on identifying those few who can benefit from resuscitation.

 

[hogdweeb]

This is a tempting point of view, but it isn't the
IMO, it is time for resuscitation science to stop trying to raise everyone from the dead, and start focusing on identifying those few who can benefit from resuscitation.

The way I am reading this is, pick and choose through a series of questions and expierence to determine who is likely to have the best outcome...but unfortunately you wont know until after the fact.

Unless i am reading it wrong....

 

[Carlos Danger]

That last statement is a pit fall of the systems you have seen apparently. The area I work, as well as myself, strive to ensure paramedics continue to provide great bls care while adding als....I know its an issue all across the country (probably world) and sadly its a training/mindset issue

I don't think he's referring to poor paramedics as much as the lack of evidence for reduction of morbidity/mortality that many of the paramedic skills are supposed to provide; for example, cardiac meds and RSI/ETI.* Again, not poor execution, but lack of verifiable benefit.

*Sentence structure sucks. Don't want to change it.

Exactly, poetic.

Though omak is right that tunnel-vision towards ALS therapies when BLS ones are important is a common and sometimes serious problem among paramedics, I think, and isn't an issue with EMT-B'S.

 

[blindsideflank]

When you bring a post-arrest patient to the ED with pulses, all you've done most of the time is spray some starter fluid into the intake. The patient has suffered a a fatal and irreversible injury.

hard to disagree with your other points but for the above do you think its would be better to have high quality CPR and no pulse upon ED arrival. Ive never seen any study on this but it would be interesting.

 

[Carlos Danger]

hard to disagree with your other points but for the above do you think its would be better to have high quality CPR and no pulse upon ED arrival. Ive never seen any study on this but it would be interesting.

I don't really think it matters. If a person in poor health is down for more than a few minutes without high-quality CPR, they are dead. Period. Nothing that has been tried in decades of research and constantly evolving recommendations has had much impact on that.

Epi sure hasn't helped. In fact some theorize that epi makes resuscitation even less likely.

I'd just like to see the focus shift towards stressing the use of the few things that we know are helpful, applied only to those who have a reasonable chance of surviving.

 

[Medic Tim]

Instead of changing the protocol or process or treatment guidelines to add this medication why not focus on what has been proven to work. good cpr and defib. Hunkering down on scene and working it there instead of in the back of a moving truck. It is not possible to perform good high quality cpr in a moving ambulance. One of the places I used to work, we had to transport just about every code, now we only transport if we have rosc +10 min or if there are "special circumstances"

I am not sure what your criteria is for calling the pt in the field or what your resources are but I certainly hope you are not transporting these pt's...risking the safety of the crew and public, just to have the doc call it the minute you get to the er.

not saying this pertains to the op, just one of my soapboxes.

 

[blindsideflank]

Hey thanks everyone for all the good discussions. Before I let this thread die off I have one more thing to say.
A lot of the discussion regarding survivability of arrests is based off of experience (our patients aren't surviving). This is pretty logical but we are assuming the permanent damage being done is from the initial lack of perfusion (probably true) but we aren't really taking reperfusion injury into consideration. Some of these patients we are writing off (or wishing we could write off) may be salvageable in the future with increased understanding of reperfusion injury.

 

[Christopher]

I would say that we shouldn't have it. While Epi in cardiac arrest has no evidence that it harms, it really has no evidence it helps either. I think we shouldn't be adding treatments just to add them, without a good clinical reason to do so. Also, epi is not free. It's going to cost someone some money, and for what clinical benefit?

Actually, epi has evidence of harm and little if any evidence of benefit.

If 1mg IVP of 1:10,000 or 1:1,000 epinephrine would be unbelievably detrimental to any living person...why would 1mg every 3-5 minutes be helpful?

There is most likely a time and place for epi in cardiac arrest, we just have no idea when and how much we should give. We do know that we are most likely not helping people with our current protocols. Thankfully folks are actually starting to study this stuff now.

 

[blindsideflank]

Actually, epi has evidence of harm and little if any evidence of benefit.

Source?