NO CPR is better than moving CPR...true or false?

[Tigger]

but if you cant revive the pt on scene are you supposed to transport or just pronounce them or transport them while you just stare at there body. decreased effectiveness cpr is better than no cpr and you can stand next to the stretcher while someone holds you and switch when you stop for the aed to analyze

If we treated patients based on the premise that "some treatment is better than no treatment," well then we would be well, something. I don't know what, but it would be bad.

If you are not delivering high-quality CPR, you may as well not be delivering it at all. And if you are doing so in a moving ambulance, you are placing yourself at significant personal risk.

 

[Chris07]

Alright I'm just going to jump right in. As a forewarning...I've only read PART of the thread so if this has been touched on already please forgive me...

I've heard quite a few people state that a cardiac arrest patient will receive the same treatment in the field as they would in the ER, and because of that all cardiac arrests should be worked in the field and not taken to the ER. That raises a question for me. What if the underlying cause of the cardiac arrest cannot be corrected in the field but could be in the ER?

For example, I had a full arrest in a 34 y/o male about 2 months ago. He appeared to be significantly underweight and suffered a sudden cardiac arrest at home. His family states that he had been sick for quite a few days (not much information to work with due to a language barrier). He got 3 shocks from the AED, another 2 with the manual defib, and he got the whole ACLS ordeal. In being only 2-3 minutes from the ER the decision was made to transport and continue CPR on the way. The entire time, the patient showed Torsades-de-Pointes on the monitor. He was revived in the ER about 10 minutes after arrival (total down time: about 30 minutes).

Now forgive any of my EMT ignorance, but my understanding is that Torsades-de-Pointes, although rare, is more likely to be seen in those suffering from hypomagnesemia and/or hypokalemia. Both of these by themselves can cause cardiac arrest if left untreated, and common sense should dictate that you have little chance of bringing about ROSC, not to mention retaining it, with the underlying cause of the arrest still present. If an individual is suffering from an arrest brought about by hypokalemia, wouldn't giving the person K+ (as a simplified example) increase the chance of attaining and maintaining ROSC? If so, how can you say that all cardiac arrests receive the same treatment in the field as in the ER? Unless you can give potassium in the field (Which I doubt), then how are you giving this hypokalemic patient the same level of care as an ER that has the ability to attempt correcting it?

I honestly see no harm in transporting special cases where there ER may have something to offer that the medics in the field can't. Do I condone transporting grandma who had a vagal episode and is now in asystole? No. What about Big Bubba who just collapsed at the gym while on the treadmill? No. Do I think a transport to an ER only 3 minutes away for a patient who is showing signs of hypokalemia/hypomagnesia (like with torsades-de-pointes) for which a corrective treatment cannot be even attempted in the field? Yes.

In a short time frame I feel that some CPR is definitely better than nothing. In a moving ambulance you may only get half or even 1/4 of the circulation you would with good CPR, but considering CPR is mostly a time buyer anyway, I feel that buying some time is better than buying none at all. Sure half-assed CPR in a moving ambulance may not be buying you much time, but at least its buying something.


As a side note: I understand that with a 30 minutes total down time quality of life post-resuscitation may not be optimistic, but for me, that is a different argument altogether.

 

[reaper]

If he was in Torsades and "received full ACLS", then he should have had Mag administered in the field! That is the standard treatment for Torsades.

 

[Tigger]

Alright I'm just going to jump right in. As a forewarning...I've only read PART of the thread so if this has been touched on already please forgive me...

I've heard quite a few people state that a cardiac arrest patient will receive the same treatment in the field as they would in the ER, and because of that all cardiac arrests should be worked in the field and not taken to the ER. That raises a question for me. What if the underlying cause of the cardiac arrest cannot be corrected in the field but could be in the ER?

For example, I had a full arrest in a 34 y/o male about 2 months ago. He appeared to be significantly underweight and suffered a sudden cardiac arrest at home. His family states that he had been sick for quite a few days (not much information to work with due to a language barrier). He got 3 shocks from the AED, another 2 with the manual defib, and he got the whole ACLS ordeal. In being only 2-3 minutes from the ER the decision was made to transport and continue CPR on the way. The entire time, the patient showed Torsades-de-Pointes on the monitor. He was revived in the ER about 10 minutes after arrival (total down time: about 30 minutes).

Now forgive any of my EMT ignorance, but my understanding is that Torsades-de-Pointes, although rare, is more likely to be seen in those suffering from hypomagnesemia and/or hypokalemia. Both of these by themselves can cause cardiac arrest if left untreated, and common sense should dictate that you have little chance of bringing about ROSC, not to mention retaining it, with the underlying cause of the arrest still present. If an individual is suffering from an arrest brought about by hypokalemia, wouldn't giving the person K+ (as a simplified example) increase the chance of attaining and maintaining ROSC? If so, how can you say that all cardiac arrests receive the same treatment in the field as in the ER? Unless you can give potassium in the field (Which I doubt), then how are you giving this hypokalemic patient the same level of care as an ER that has the ability to attempt correcting it?

I honestly see no harm in transporting special cases where there ER may have something to offer that the medics in the field can't. Do I condone transporting grandma who had a vagal episode and is now in asystole? No. What about Big Bubba who just collapsed at the gym while on the treadmill? No. Do I think a transport to an ER only 3 minutes away for a patient who is showing signs of hypokalemia/hypomagnesia (like with torsades-de-pointes) for which a corrective treatment cannot be even attempted in the field? Yes.

In a short time frame I feel that some CPR is definitely better than nothing. In a moving ambulance you may only get half or even 1/4 of the circulation you would with good CPR, but considering CPR is mostly a time buyer anyway, I feel that buying some time is better than buying none at all. Sure half-assed CPR in a moving ambulance may not be buying you much time, but at least its buying something.


As a side note: I understand that with a 30 minutes total down time quality of life post-resuscitation may not be optimistic, but for me, that is a different argument altogether.

There is zero evidence showing that poor CPR does any good for outcomes.

There is excellent evidence showing that not wearing your seatbelt in a moving vehicle is a poor practice.

While I agree that a blanket policy of "no arrest is ever transported" is poor policy, such transports should be extraordinarily rare. I am not well enough versed in studies regarding automatic CPR devices to comment on whether or not they should be used or not in this case.

 

[Brandon O]

I agree that refractory arrests due to presumed-correctable underlying causes (and I mean actually correctable where you're transporting to -- not, for instance, due to MI if you're not going to a STEMI center) should probably be transported with CPR ongoing.

I understand Tigger's concerns, but until we all start wearing seatbelts back there anyway it may be somewhat moot (yes, I realize you probably do).

 

[TraprMike]

You would feel comfortable/safe doing this in a moving ambulance?

got to do what ya got to do..

you saying the back of an ambulance is not "scene safe"?

 

[Chris07]

I understand Tigger's concerns, but until we all start wearing seatbelts back there anyway it may be somewhat moot (yes, I realize you probably do).

Agreed. I find it hard to believe that you all wear your seatbelt in the back. It's absolutely stupid that we don't, but since most of us don't do it normally, why is a cardiac arrest any different?

 

[Medic Tim]

got to do what ya got to do..

you saying the back of an ambulance is not "scene safe"?

If you want to straddle the pt go for it . Best of luck to you.

It is not safe more times than we all would care to admit ( the ambulance is not some magical home base where nothing bad happens) Transporting a code in progress just to have it pronounced at the hospital fits into the whole not safe arena.

I also wear my seatbelt in the back whenever I can.

I have been injured in the back while transporting a code more than once.

 

[usalsfyre]

but if you cant revive the pt on scene are you supposed to transport or just pronounce them or transport them while you just stare at there body. decreased effectiveness cpr is better than no cpr and you can stand next to the stretcher while someone holds you and switch when you stop for the aed to analyze

We tended to call it and leave the body for the people who actually dealt with that sort of thing....

 

[Bullets]

Alright I'm just going to jump right in. As a forewarning...I've only read PART of the thread so if this has been touched on already please forgive me...

I've heard quite a few people state that a cardiac arrest patient will receive the same treatment in the field as they would in the ER, and because of that all cardiac arrests should be worked in the field and not taken to the ER. That raises a question for me. What if the underlying cause of the cardiac arrest cannot be corrected in the field but could be in the ER?

For example, I had a full arrest in a 34 y/o male about 2 months ago. He appeared to be significantly underweight and suffered a sudden cardiac arrest at home. His family states that he had been sick for quite a few days (not much information to work with due to a language barrier). He got 3 shocks from the AED, another 2 with the manual defib, and he got the whole ACLS ordeal. In being only 2-3 minutes from the ER the decision was made to transport and continue CPR on the way. The entire time, the patient showed Torsades-de-Pointes on the monitor. He was revived in the ER about 10 minutes after arrival (total down time: about 30 minutes).

Now forgive any of my EMT ignorance, but my understanding is that Torsades-de-Pointes, although rare, is more likely to be seen in those suffering from hypomagnesemia and/or hypokalemia. Both of these by themselves can cause cardiac arrest if left untreated, and common sense should dictate that you have little chance of bringing about ROSC, not to mention retaining it, with the underlying cause of the arrest still present. If an individual is suffering from an arrest brought about by hypokalemia, wouldn't giving the person K+ (as a simplified example) increase the chance of attaining and maintaining ROSC? If so, how can you say that all cardiac arrests receive the same treatment in the field as in the ER? Unless you can give potassium in the field (Which I doubt), then how are you giving this hypokalemic patient the same level of care as an ER that has the ability to attempt correcting it?

I honestly see no harm in transporting special cases where there ER may have something to offer that the medics in the field can't. Do I condone transporting grandma who had a vagal episode and is now in asystole? No. What about Big Bubba who just collapsed at the gym while on the treadmill? No. Do I think a transport to an ER only 3 minutes away for a patient who is showing signs of hypokalemia/hypomagnesia (like with torsades-de-pointes) for which a corrective treatment cannot be even attempted in the field? Yes.

In a short time frame I feel that some CPR is definitely better than nothing. In a moving ambulance you may only get half or even 1/4 of the circulation you would with good CPR, but considering CPR is mostly a time buyer anyway, I feel that buying some time is better than buying none at all. Sure half-assed CPR in a moving ambulance may not be buying you much time, but at least its buying something.


As a side note: I understand that with a 30 minutes total down time quality of life post-resuscitation may not be optimistic, but for me, that is a different argument altogether.

Multiple shocks on scene, actual measurable and observable electrical activity in the heart, correctable rhythm on scene are reasons to considering moving toward the hospital.

Also you are talking about Torsades, which is not a common occurrence. I had a patient in TdP 3 weeks ago. Our medics had a combined 60 years of experience and neither had ever actually seen TdP in a real strip, only in books or practice.

We are talking about the old way of doing things, where BLS runs in does a few rounds throws the patient on the reeves and runs out the door. Thats poor patient care. Cardiac arrest is a 'stay and play' call in most cases. No shocks, extended downtime, tons of co-morbidities. The patient gets better care, better compressions, in their living room then in the ambulance.

We are having to retrain our FFers who respond a BLS engine on codes. They are sitting there "Do you want to go?" "Think we should go?" "Should i get the reeves?" NO, we are staying here until we can get ROSC stable or pronounce. No shocks, 2-3 hours since seen alive

 

[Tigger]

Agreed. I find it hard to believe that you all wear your seatbelt in the back. It's absolutely stupid that we don't, but since most of us don't do it normally, why is a cardiac arrest any different?

Think again.

It is not hard to keep your belt on for the vast majority of transport. I keep frequently used small pieces of equipment on the bench with me. When I switch seating positions I put on that seat's belt. It's not that hard, especially considering that most patients are not going to be receiving much more than monitoring to the hospital during transport, especially at the BLS level. Most times one can be belted in starting an IV, and there's a reason the captain's chair is also called an airway chair. You can be belted in and bagging someone.

I just don't get how people can sit their and write their PCRs or check a BP with no belt on. That's the only thing you are right about, such behavior is downright stupid.

got to do what ya got to do..

you saying the back of an ambulance is not "scene safe"?

Yes, I am.

Even with a seatbelt on a significant side impact is bad news. But not wearing one is again, downright stupid. Obviously there are times when it is unavoidable, but these are exceptions and not the rule.

The whole "you gotta do what you gotta" argument is beyond asinine. At no point is anyone's saftey above yours.

 

[BeachMedic]

Stay and play with all cardiac arrests. The pt's best chance for survival is on scene while not being moved. All the evidence backs this up.

I can't count the number times I've been on a code where a couple rounds of drugs were pushed and then somebody decides it is time to, "Load and Go". Next thing you know we are stopping compressions to roll someone onto a backboard. We are stopping compressions to carry a dead body through the house. We are stopping compressions to go down three flights of stairs. Then we are doing half assed CPR all the way to the ER Code 3 with no seat belts on and a rookie driver pumped full of catecholemines who thinks he/she is Mario Andretti.

Guess what just happened? You killed any chance that that Pt had at survival. You also loaded extra people into the, "deadliest vehicle on the road" and drove lights and sirens. Ambulances have a much, much, in fact the highest fatality rate of any vehicle on the road when involved in an accident. So yes, the back of the ambulance is unsafe. It also crumples like a tin can when struck.

Work the code on scene for at least 20-25 minutes before you even "consider transporting". Do not stop compressions to get an ET tube. It's better to just bag in supplemental 02 if you can't get an airway without stopping compressions. If the Pt has had absolutely no response to ACLS for 20-25 minutes then it is a good time to either make base contact or just call the Pt on scene.

Fact of the matter is, as many before me have previously stated, effective bystander CPR and BLS are the only treatments proven to increase the survivability of a patient in cardiac arrest. Do it on scene and do it right. Don't half *** it in the name of getting the patient to a hospital because working a code on scene is intimidating.

" they will only do what you should already be doing"

Then you have a piss-poor hospital and they deserve to lose their license.

Again and again and again...show us the facts, the citations. In the majority of cases in adults and increasing with age, dead is dead; however, I'm also waiting to see the ambulance with an OR, ICU, CT or MRI, even a lab beyond basic oxygen monitoring, fingerstick glucometry, and if you're lucky, a urine dipstick.

If the above is true, start writing on run reports those very words.

How many cardiac arrests get taken to an OR, ICU, CT, MRI, or have labs read prior to getting called in an ER/hospital? If they don't respond to high quality CPR/ACLS i'd be willing to bet that none of them do. Why decrease the effectiveness of CPR and bring the hospital a dead body then?

 

[Veneficus]

Stay and play with all cardiac arrests. The pt's best chance for survival is on scene while not being moved. All the evidence backs this up.

Work the code on scene for at least 20-25 minutes before you even "consider transporting". Do not stop compressions to get an ET tube. It's better to just bag in supplemental 02 if you can't get an airway without stopping compressions. If the Pt has had absolutely no response to ACLS for 20-25 minutes then it is a good time to either make base contact or just call the Pt on scene.

Fact of the matter is, as many before me have previously stated, effective bystander CPR and BLS are the only treatments proven to increase the survivability of a patient in cardiac arrest. Do it on scene and do it right. Don't half *** it in the name of getting the patient to a hospital because working a code on scene is intimidating.

Not exactly.

The guidlines and evidence for SCA presume the inciting factor as MI with its most common complication which is vfib.

The studies are based n 2 things:

epidemiology of SCA and effective interventions for the most common etiology.

There are reversible causes that can cause cardiac arrest that are amiable to treatment if applied rapidly and are not possible in the field.

Hypothermia being the most profound. Especially in pediatrics.

According to last year's numbers, 200,000 people died in the US of cardiac arrest. If you are treating by epidemiology, 60,000 didn't fit your treatment.

I stipulate some of them could not be saved no matter what due to comorbid conditions or terminal illness. But some of the 70% also fall into such circumstances.

I concede you will need a relatively short transport time to a facility capable and willing to provide care beyond the epidemiological guidelines, which are almost exclusvely academic centers.

However, logically, these centers are found in population centers, which by the math will see the greatest number of arrests.

These guidlines also do not take into account people already in a healthcare facility with a specific diagnosis and specific treatment for such, which reduces the population it covers even further.

It still represents the numerically best chance, but certainly not the only effective treatment for cardiac arrest.

 

[BeachMedic]

Not exactly.

The guidlines and evidence for SCA presume the inciting factor as MI with its most common complication which is vfib.

The studies are based n 2 things:

epidemiology of SCA and effective interventions for the most common etiology.

There are reversible causes that can cause cardiac arrest that are amiable to treatment if applied rapidly and are not possible in the field.

Hypothermia being the most profound. Especially in pediatrics.

According to last year's numbers, 200,000 people died in the US of cardiac arrest. If you are treating by epidemiology, 60,000 didn't fit your treatment.

I stipulate some of them could not be saved no matter what due to comorbid conditions or terminal illness. But some of the 70% also fall into such circumstances.

I concede you will need a relatively short transport time to a facility capable and willing to provide care beyond the epidemiological guidelines, which are almost exclusvely academic centers.

However, logically, these centers are found in population centers, which by the math will see the greatest number of arrests.

These guidlines also do not take into account people already in a healthcare facility with a specific diagnosis and specific treatment for such, which reduces the population it covers even further.

It still represents the numerically best chance, but certainly not the only effective treatment for cardiac arrest.

At which point would you consider transport or a load and go approach then? On all vfib arrests provided the right facility is within an appropriate distance?

With the facilities of the County I currently work in I am still more inclined to not transport until I get ROSC. At which point I would rip off an EKG and transmit it to the ER so they can notify the cath lab if necessary.

 

[Veneficus]

At which point would you consider transport or a load and go approach then? On all vfib arrests provided the right facility is within an appropriate distance?

With the facilities of the County I currently work in I am still more inclined to not transport until I get ROSC. At which point I would rip off an EKG and transmit it to the ER so they can notify the cath lab if necessary.

I would suggest if you cannot reasonably identify a specific reversible cause you work the code to termination on scene. Like I said, according to the numbers, it is your best chance.

If a specific cause is suspected, with a facility capable of treating it is close enough (pathology specific on the distance) I would support a decision to transport as soon as reasonably possible.

I agree with all of your stated concerns about safety, and suggest a more measured approach than tearing through the streets like a maniac.

I have noticed that most providers who get into a rush are uncomfortable.

Take a breath. Maintain quality CPR. Since CPR is what is keeping the person alive with some possible exceptions like trauma and poisoning, that needs to be the priority no matter what the other suspected etiology.

That may mean that the event escalates from a 2 person medical emergency to a rescue requiring constant effective CPR. This is not the time for haste, it is for calm and calculated action.

Becase of multiple documented cases of survival with neuro intact discharge with prolonged CPR, as long as CPR is maintained, again, with some exceptions like trauma and poison, time is not really the issue. Quality CPR is.

In the name of safety, I advocate against using lights and sirens, even in these cases.

Safety taking priority over a possible save.

Early vfib is pretty much undisputably best treated with dfib, and that also should be done per the conventional wisdom. However, recurrant vfib or resistant vfib may still be salvagable with more advanced treatment than available to EMS.

Try to avoid the pitfall of seeing resuscitation as all or nothing. It is a process.

It sounds like you have mastered the numbers game of cardiac arrest. I encourage you to not settle for that and broaden your expertise to cover a wider range of patient conditions.

 

[Brandon O]

I would say that if you have real reason to suspect a reversible cause of arrest, that can be addressed at the ED but not in the field, and you have worked the code long enough to believe it will prove refractory without reversing the underlying cause, you should consider transport. But that should be with real, intelligent, serious thought given to: what you think the problem is, and how certain you are of that; how readily it can be addressed here versus at the hospital; your chances of getting ROSC and then transporting (always a better choice); extrication and transport time; your ability to maintain CPR during transport (presence of an automated device, for instance); and probably more. You have to know what you're doing, and be very familiar with therapies for various pathological processes as well as your local hospital capabilities (both theoretical, and in reality when you roll in there at 3:00 am on Saturday with Dr. Donovan attending).

Just to snowball some random examples, you can imagine the late-term pregnant mother in arrest, the LVAD patient, the poisoning, the STEMI, the tamponade. Heck, if ECMO gets more widely and aggressively employed, the list might grow.

 

[mycrofft]

Lightning.

 

[CPRinProgress]

I don't want to turn this into a transporting forum but I don't understand when people can say they would have no problem not responding and transporting code 3. If you have a CVA who need to get to the ED for thrombolytics within the allotted time to give the meds. There could be a hour window of when it started and people want us to most on down to the ED stopping at lights and sitting in traffic. I understand that many accidents happen while going lights and sirens but that is the nature of the business. Firemen go into burning buildings cops catch bad guys and ems performs CPR in the back of a moving ambulance while breaking normal traffic laws.

 

[Rialaigh]

I don't want to turn this into a transporting forum but I don't understand when people can say they would have no problem not responding and transporting code 3. If you have a CVA who need to get to the ED for thrombolytics within the allotted time to give the meds. There could be a hour window of when it started and people want us to most on down to the ED stopping at lights and sitting in traffic. I understand that many accidents happen while going lights and sirens but that is the nature of the business. Firemen go into burning buildings cops catch bad guys and ems performs CPR in the back of a moving ambulance while breaking normal traffic laws.

Firemen go into many burning buildings they should not
Cops chase many people that they should not
We do CPR many times when we should not

It is this mindset that is so ingrained in the public service community that leads us to make many many irrational choices.


In many urban areas the difference between code 1 and code 3 in time saved is so negligable that it really does not matter. I know many medics who will transport a code in if they think it is savable but they will transport non emergent at a safe, steady, and sometimes slow pace to ensure quality CPR and interventions are able to be done. I could think of very few situations in which a CVA should be run Code 1 in a setting where the hospital is within a 30 minute drive. I can think of very few situations period in which the benefit outweighs the risk for running code 3.


Now take it out the rural environment where running code 3 might save you a half an hour or an hour. Or take it intercity during rush hour where code 3 is required just to navigate the streets (even within the speed limit). I can justify much more there.

 

[Veneficus]

I don't want to turn this into a transporting forum but I don't understand when people can say they would have no problem not responding and transporting code 3.

Because we are old people who know it doesn't save much time, make a difference in outcome, and have either personally been hurt or know people who have been hurt or killed from driving code 3, despite it not making a difference.

If you have a CVA who need to get to the ED for thrombolytics within the allotted time to give the meds. There could be a hour window of when it started and people want us to most on down to the ED stopping at lights and sitting in traffic..

There are only a handful of illnesses where minutes matter, and it is more often a question of distance than speed. Stroke is not one of them. While there is a guidline for using thrombolytics, the effectiveness is in question and at 3 hours (or 4 depending on the guidline you are using) 6 if you are using direct arterial application, at 3 hours and 1 minute nobody is going to withhold the medication. Nor at 3 hours and 15 minutes, nor at 3:30. Probably not even 3:45. Despite what you are told as a student, medicine is not black and white.

I understand that many accidents happen while going lights and sirens but that is the nature of the business.

No it is not. It is an outdated ignorant and reckless attitude.

Firemen go into burning buildings cops catch bad guys and ems performs CPR in the back of a moving ambulance while breaking normal traffic laws.

Firemen do not go into all burning buildings. There is a risk assessment on whether or not the risk is worth the reward.

Police has a number of escalating options and safety measures to minimize their risks as well.

We have studies showing that CPR while moving without an assist device does not work well. Which means you are doing nothing for the patient while risking yours and others lives for that same nothing.

That type of attitude makes you a danger to everyone around you.