Number of analyses in 'unusual' cardiac arrest circumstances

[Womboz]

For EMS standards in my area, it's typically a max dose of 4 shocks with a manual defibrillator. 3 on the floor, 1 out the door as they say. However, certain circumstances are outlined when that may change.

1) Situations when you initiate rapid transport following 1 analysis:
- Arrest secondary to FBAO that cannot be cleared
- Trauma cardiac arrest

2) Situations when you initiate rapid transport following the first non-shockable rhythm:
- Toxicological overdose
- Pediatric patients
- Anaphylaxis

The document has "etc" under the second category. I'd like to ask the community if you can think of any other situations you would initiate transport for a VSA patient after the first non-shockable rhythm you encounter.

 

[NomadicMedic]

None that I can think of.

Work codes on the scene. Transport if you get ROSC.

 

[Handsome Robb]

Pregnant patient with a viable aged fetus. Witnessed arrest after STEMI recognition but only if you have hospitals willing to do intra-arrest PCI and if you've got a mechanical CPR device.


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[SpecialK]

Wait, you are still transporting primary cardiac arrests? For what purpose?

The only time I can think of is if there is;

a) a clearly identified reversible cause for the cardiac arrest that was,
b) identified early on in the cardiac arrest (say, the first two to ten minutes), and
c) you do not have the ability to treat it, but somewhere reasonably close by can, and
d) you can transport with CPR enroute, OR
e) pregnancy with a viable foetus

 

[Womboz]

Pregnant patient with a viable aged fetus. Witnessed arrest after STEMI recognition but only if you have hospitals willing to do intra-arrest PCI and if you've got a mechanical CPR device.

Thanks, that makes sense.

Wait, you are still transporting primary cardiac arrests? For what purpose?

The only time I can think of is if there is;

a) a clearly identified reversible cause for the cardiac arrest that was,
b) identified early on in the cardiac arrest (say, the first two to ten minutes), and
c) you do not have the ability to treat it, but somewhere reasonably close by can, and
d) you can transport with CPR enroute, OR
e) pregnancy with a viable foetus

I don't really understand your question. We transport every medical arrest that is non-cardiac in origin or do not meet our medical/trauma termination of resuscitation guidelines. As for point c), shouldn't we always be able to transport with CPR enroute if they meet transport parameters? There usually would be Fire tagging along for 2 person CPR while your partner is driving or just do one-person CPR until you meet up with another crew if transport is long enough.

 

[Summit]

Well what is your trauma criteria?

Prehospital traumatic arrest is known to have basically zero survival
http://www.ncbi.nlm.nih.gov/pubmed/8371308

Unless you fly a doc to the scene and bilat Open thoracostomy / clamshell open thoracotomy like this aussie protocol....
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3672499/


Teams

 

[Womboz]

Well what is your trauma criteria?

Yes I understand the situation is rather grim for TCAs but I wasn't even concerned about it in the first place. We haven't covered it yet but will soon as the semester just started. If you're curious, see attached pic for a brief overview of the conditions for a trauma TOR.

I was asking about situations when you want to initiate transport after your encounter your first non-shockable rhythm (while they're still VSA ) and still within your 4 analyses. Robb had interesting contributions which answer this so far.

 

[Handsome Robb]

Yes I understand the situation is rather grim for TCAs but I wasn't even concerned about it in the first place. We haven't covered it yet but will soon as the semester just started. If you're curious, see attached pic for a brief overview of the conditions for a trauma TOR.

I was asking about situations when you want to initiate transport after your encounter your first non-shockable rhythm (while they're still VSA ) and still within your 4 analyses. Robb had interesting contributions which answer this so far.

I should clarify, those are the only patients we transport during cardiac arrest. Every other arrest is terminated in the field if there's no sustained ROSC. Routinely transporting cardiac arrest patients is dangerous for the crew and ultimately detrimental to the patient due to poor-quality CPR during moving the patient to/from the truck and during transport.

The pregnancy example is a snatch and grab job, no working on scene at all. STEMI gets worked on scene then transported once the LUCAS device arrives with a Commander and is placed which takes 2 pulse checks for us just to place it in order to not interrupt compressions.


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[dutemplar]

Typing... too... many... words... need coffee. COFFEE.

Thanks, that makes sense.
I don't really understand your question. We transport every medical arrest that is non-cardiac in origin or do not meet our medical/trauma termination of resuscitation guidelines. As for point c), shouldn't we always be able to transport with CPR enroute if they meet transport parameters? There usually would be Fire tagging along for 2 person CPR while your partner is driving or just do one-person CPR until you meet up with another crew if transport is long enough.

We'll work it and call it with no response. Aside from a set of "they can fix it, we can't" discussed above, there isn't any need for transporting, especially without a transport CPR device (Lucas, etc...). If it's just two of you, seriously, two man CPR until you get help. One provider CPR in the back of a moving, bouncing truck is hideously bad, highly ineffective and is way more likely to get the one in the back hurt. Your scope of practice, protocols and "Mother, may I?" can differ than ours.

Toxicological, unlikely. Not unless you have a clear agent and a clear antidote which is not available prehospitally AND transporting would not place the crew at risk of a secondary exposure, AND if the hospital actually has it readily available. If they die from ingesting cyanide crystals, they're dead unless you get an antidote in them _now_ and not at the hospital in 10-45 minutes. Black mamba bites, yeah.. if they already died, they're dead. Methylethylyukkyshit, if they're dead before they're deconned... see where this is going?

Anaphylaxis? Unless something went very wrong, we best be having epi on board (first line), although given the arrest methodology I might be adding a few more meds into the cardiac arrest matrix. Past the IO/IV adrenaline, for the airway edema we have nebulized epinephrine and salbutamol. For anaphylaxis we have a liter of fluid, more epi, yet more epi, diphenhydramine, hydrocortisone, and phenylephrine.

Foreign body you can't clear? Can your ER do an emergency tracheostomy on arrival within 2 minutes? Most can't...

Not to mention the newer studies showing you should wait a few minutes after ROSC rather than immediately running to the hospital while the Pt hopefully stabilizes and could re-arrest during extrication and not be noticed.

Clinical hypothermia (which isn't terribly common here, even in winter), select trauma, STEACS/ MI codes that can go straight to the cath lab, pregnant, or working organ donors that police aren't going to hold the body on. Pediatrics is a common "transport no matter what" cardiac arrest. It is, however, worthless clinically while helping to hurt the family emotionally (false hope), getting more family and EMS hurt (MVA, ongoing compressions enroute) while also functioning as an in-writing policy for age discrimination against older patients.

 

[TomB]

"For EMS standards in my area, it's typically a max dose of 4 shocks with a manual defibrillator. 3 on the floor, 1 out the door as they say."

In my system that would be a 7 minute scene time. It's a bad idea, IMHO. The patient's best odds of survival are to achieve ROSC prior to being moved.

 

[usalsfyre]

Hyperkalemia if you can't deliver calcium chloride. I'm unsure of your level and location.

 

[Womboz]

Haha I've been found out! The reason I was confusing/infuriating was because I assumed my level of care would have some inkling of similarities and I could fly under the radar. But obviously, my ignorance was the reason behind the peculiarity of my request. After some Googling, what I'm studying translates to the level of care somewhere between your ALS providers/Paramedics and EMT-A/AEMT/EMT-I (Wow talk about consistency!) which includes IV, cardiac monitoring and ECG interpretation, naloxone, epi, dextrose, ketorolac, etc etc. I've previously browsed through the BLS and ALS topics and I thought this would be the place to ask. However odd this discussion was, it has been very fruitful to my learning.

One major piece of understanding I lacked was how EMTs integrated their scene with paramedics. Now that I've skimmed through some of our Paramedic protocols, they don't have a set number of analyses, would 'run the code', and include epi 1:10000/amiodarone/lidocaine/intubation into the mix as needed. I can see how that could extend scene time by 15/20 minutes compared to the 4 analyses I mentioned. I don't know what fraction of the time it'll be load and go, rendezvous with ALS on the way to the hospital, or transferring care to the ALS unit while we're on scene for 10-15 minutes. I think the principle at work here is not to delay transport for ALS support (and this extends past arrests).

This discussion brings up valid points and raises questions which I'll aim at my professors such as:
- Is transporting arrests/rendezvousing with ALS negatively impacting patient outcomes with statistical significance and worth the risks described above?
- Is there evidence suggesting a dire need to adopt mechanical CPR devices? (cost-benefit)
And more after I've wrapped my head around this.

Thanks for all the responses! I'll probably refrain from protocol-like questions in the future.

Toxicological, unlikely.

I guess that's why it's included as an unusual circumstance I'm pulling this out of thin air but maybe it's more based on recreational drug overdoses that lead to arrhythmias like cocaine.

From what I understand, we'd be vigilant of re-arrests after a ROSC, constantly reassess, and implement other treatments like fluids. At a certain point, they need a resus team's resources either way. I'm talking 10-15 min transport times.

 

[Handsome Robb]

Even as an EMT-B you shouldn't be transporting patients in cardiac arrest except in odd circumstances like have been outlined above.

Truly the only things that are proven to save lives are early, high quality CPR and defibrillation.


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[Bullets]

Is anyone else super confused? Do i just need more coffee?

We transport living patients. Dead people get worked on scene until they are declared dead or are alive. As a BLS provider, i will do great CPR and provide electricity as needed until ALS arrived to initiate treatment that has little support of efficacy.

 

[dutemplar]

Yeah, seems rather outdated protocols and guidance based on 1980s paramedicine.

 

[Womboz]

Do your services not implement some guideline on terminating resuscitative efforts in adult out-of-hospital cardiac arrests based on the American Heart Association recommendations? I don't know how long our ALS will continue efforts so I can't comment on that, but everyone else will patch to TOR a VSA patient that's thought to be of cardiac origin if 1) arrest was witnessed by EMS/Fire and 2) no ROSC and 3) no shocks delivered after 3 analyses. If else, transport. I also don't know what happens if we rendezvous with ALS on the way so I can't comment on that.

I get that the median survival rate is a single digit percentage, and most of those hospital discharges are accompanied with the patient having a ROSC on scene. Bystander CPR prior to EMS arrival is also indicative of highly improved survival rates.

As you can see, it's not no ROSC/shocks?, continue resus UNTIL ROSC, THEN transport. There doesn't seem to be an expectation of a ROSC prior to initiating transport while continuing care. Transporting has always been a consideration. We have been talking about outlier situations the entire time. As experienced medics, I'm curious to know if the majority of your arrest calls were nonviable right off the bat or achieved a ROSC within 10 minutes.

 

[Womboz]

1) arrest was witnessed by EMS/Fire and 2) no ROSC and 3) no shocks

Sorry, typo that I can't fix anymore. unwitnessed*

 

[dutemplar]

If we witness or not, 20 minutes of asystole, injuries incompatible with life, obvious death,...

Called. Can be called on scene, or transporting if it's a distance for the 20 minutes of asystole. Doesn't matter how much we dump into them, defib, or play "Megacode."

If ROSC, guideline is to try and remain on scene 10 minutes while we start the post-resus and monitor prior to immediately loading and running while working to further stabilize and consider things such as ET over LT, sedation for signs of consciousness, etc.

On a side note, this is outside of the US and we use a blend of US and European guidelines.