working codes in the field

[skyemt]

hi...

i was wondering if you have protocols as to when to work codes in the field, vs. working them during transport...

pros and cons of working it in the field?

thanks.

 

[Epi-do]

It is somewhat at the medics discression around here. I have noticed that where I work, we are getting more and more away from transporting cardiac arrests, but rather working on scene to see what happens, and then calling for orders to stop CPR if it is appropriate.

Two of the three arrests I have been on in the last week we called onscene. The third one we did transport, but more because of circumstances onscene than because we thought we had a chance to get the patient back. We had pushed four rounds of drugs by the time we got to the ER. They pushed one or two more rounds, and then called her.

 

[Grady_emt]

It is somewhat at the medics discression around here. I have noticed that where I work, we are getting more and more away from transporting cardiac arrests, but rather working on scene to see what happens, and then calling for orders to stop CPR if it is appropriate.

Two of the three arrests I have been on in the last week we called onscene. The third one we did transport, but more because of circumstances onscene than because we thought we had a chance to get the patient back. We had pushed four rounds of drugs by the time we got to the ER. They pushed one or two more rounds, and then called her.

Very much the same here with the following different. If the Pt is not obviously dead upon arrival, pt must be in asystole, tubed, 2x epi and atro, remain in asystole. If you are in anything but asystole you are going to the ER, barring any DNR etc.

 

[Ridryder911]

I feel I have to more "justify" working one than just because there is someone in cardiac arrest. Alike others, if it is asytole then I attempt to work and get a DNR. (we are in the process of change in protoclols for field termination).

R/r 911

 

[KEVD18]

if the crew faces a complicated extrication, i see more codes being worked on scene then trying to get permission to call it.

if its a street call, your probably going to put em in the truck instead of working it on the sidewalk. once they have a line and tube, theres really no point not to be moving.

 

[Ridryder911]

if the crew faces a complicated extrication, i see more codes being worked on scene then trying to get permission to call it.

Do you mean the opposite? Trauma codes are generally called immediately and if there is a delay that is justification enough not to work it. If the patient dies while extricating, we have the permission to call it. Trauma codes do not respond.

R/r 911

 

[skyemt]

I feel I have to more "justify" working one than just because there is someone in cardiac arrest. Alike others, if it is asytole then I attempt to work and get a DNR. (we are in the process of change in protoclols for field termination).

R/r 911

so do i take that to mean that you will like to work the arrest enroute to the ER? unless you feel that it is a lost cause?

 

[Ridryder911]

My point was opposite. Right now it is a case by case situation. Personally, I would not work half of them, if I did not have to. We are attempting to get clarification of working them for 20 minutes and if no ROSC occurs, then we will declare them.

I believe working majority of the codes is futile. I will gather as much information as possible not to work them. Cardiac arrests have a very poor to dismal outcome if no resuscitation measures are being made prior to ALS arrival. At this time I will call and get verbal DNR if there is justification to do so.

Basically, I don't work them if I don't have to.

R/r 911

 

[skyemt]

My point was opposite. Right now it is a case by case situation. Personally, I would not work half of them, if I did not have to. We are attempting to get clarification of working them for 20 minutes and if no ROSC occurs, then we will declare them.

I believe working majority of the codes is futile. I will gather as much information as possible not to work them. Cardiac arrests have a very poor to dismal outcome if no resuscitation measures are being made prior to ALS arrival. At this time I will call and get verbal DNR if there is justification to do so.

Basically, I don't work them if I don't have to.

R/r 911

ok.. i understand...

how about the calls where efforts are started within, say 8 minutes from arrest... perhaps, AED attached, quality CPR, and BVM...

will you still have the same approach?

 

[Ridryder911]

If there is any ROSC or defib from the AED maybe. For right now, our policy until it is changed is to work them. If I know the ER Doc on, I will call and they usually give me a verbal DNR order after my second round of med.'s (statistically very rare for someone to respond after the second round).

Hopefully, we will terminate after the second round or 20 minutes, no matter the situation (again it should be the Paramedic discretion).

R/r 911

 

[bonedog]

With new CPR they should mainly be worked at the scene.

Personally I don't transport unless it is a treatable cause for which I don't have the tx.(transport is rare, call em' save some backs)

 

[ffemt8978]

With new CPR they should mainly be worked at the scene.

Personally I don't transport unless it is a treatable cause for which I don't have the tx.(transport is rare, call em' save some backs)

We had a call where the victim was laying on the side of the road way. Initially, he was in vfib with unknown down time. CPRx2 min, shock, and repeat for multiple series of shocks and compressions. There was a discussion/dissent among the responders as to whether or not we should have stayed on scene (nearest ALS was 40 min away at time of dispatch) or scooped and ran to ALS.

My thoughts were this: he was in vfib on scene with ALS in route (although a ways away). We're supposed to stop the rig every time we need to analyze and shock, so you won't get very far stopping every two minutes. The crew decided to stay and work the patient, but at about 25 minutes, some members became insistent that we load and go. As soon as we loaded him, he went into PEA. We met ALS about 7 minutes later, worked him for another 20 and finally called it.

Thoughts, comments, or concerns?

 

[Ridryder911]

We had a call where the victim was laying on the side of the road way. Initially, he was in vfib with unknown down time. CPRx2 min, shock, and repeat for multiple series of shocks and compressions. There was a discussion/dissent among the responders as to whether or not we should have stayed on scene (nearest ALS was 40 min away at time of dispatch) or scooped and ran to ALS.

My thoughts were this: he was in vfib on scene with ALS in route (although a ways away). We're supposed to stop the rig every time we need to analyze and shock, so you won't get very far stopping every two minutes. The crew decided to stay and work the patient, but at about 25 minutes, some members became insistent that we load and go. As soon as we loaded him, he went into PEA. We met ALS about 7 minutes later, worked him for another 20 and finally called it.

Thoughts, comments, or concerns?

Really no right or wrong on this case. I do understand the philosophy on stopping do to artifact (maybe) although this is the first I have heard of it. Personnally I do not stop when I heve the patient on the monitor to verify v-fib, I may stop to get my partner in the back.

Want to know the worst rythm? Many assume aystole, while ominous at least you have something to work with. PEA/EMD are a dead man's rhythm. Albeit you have electrical firing in the normal pathway there is no association and unfortunately you may never know what to treat s the underlying cause of this event.

V-fib at least you can might be able to shock out of.

Staying on the scene for 25 minutes is a long time to stay on the scene to await ALS. I agree rendezvous ASAP, after the patient has been defib it is past Edison medicine and time for some pharmacological med.'s and see what happens. PEA .. well maybe NaHcO3, maybe correcting the ABG/pH factor or maybe electrolyte such as Mg+, etc. Doubtful, but other than tapping for a pericardial tamponade I have ever seen correction other than Dialysis patients.

R/r 911

 

[ffemt8978]

I should probably clarify a couple of things...

We're a BLS agency that had some Intermediates on scene. Rythym interpretation is not something we're allowed to do. I said VFib because we could shock it, and PEA because it was showing activity on the monitor without a pulse. We use an AED with 3 lead monitor capability, so artifact is/has/will be a concern for us.

During the call, most of us had lost track of time (as is easy to do). We kept asking how far out our ALS rig was and was repeatedly told 5-10 minutes.

That being said, we've worked patients that long on scene before and eventually pronounced them with medical control approval. We've also stayed and worked them until we had a ROSC and then loaded.

 

[KEVD18]

the only benefit i can see from your call was i gather from the arguments on scene that there were a number of people from your agency about. at the very least you can swap out the guy doing compressions frequently enough to ensure good cpr.

other than that, wait on scene for als for 25 min? no sir not in my world. thats 25min closer to the er. 25min closer to transfer of care. 25 min closer to marking back in and maybe helping somebody i can actually save.

im sure R/r has the stats on bls codes. if als coded are statistically almost pointless, were do bls codes rate?

 

[JPINFV]

other than that, wait on scene for als for 25 min? no sir not in my world. thats 25min closer to the er. 25min closer to transfer of care. 25 min closer to marking back in and maybe helping somebody i can actually save.

Why? Cardiac arrests don't age well. Also:

Validation of a Rule for Termination of Resuscitation in Out-of-Hospital Cardiac Arrest
Laurie J. Morrison, M.D., Laura M. Visentin, B.Sc., Alex Kiss, Ph.D., Rob Theriault, Don Eby, M.D., Marian Vermeulen, B.Sc.N., M.H.Sc., Jonathan Sherbino, M.D., P. Richard Verbeek, M.D., for the TOR Investigators


ABSTRACT

Background We prospectively evaluated a clinical prediction rule to be used by emergency medical technicians (EMTs) trained in the use of an automated external defibrillator for the termination of basic life support resuscitative efforts during out-of-hospital cardiac arrest. The rule recommends termination when there is no return of spontaneous circulation, no shocks are administered, and the arrest is not witnessed by emergency medical-services personnel. Otherwise, the rule recommends transportation to the hospital, in accordance with routine practice.

Methods The study included 24 emergency medical systems in Ontario, Canada. All patients 18 years of age or older who had an arrest of presumed cardiac cause and who were treated by EMTs trained in the use of an automated external defibrillator were included. The patients were treated according to standard guidelines. Characteristics of diagnostic tests for the prediction rule were calculated. These characteristics include sensitivity, specificity, and positive and negative predictive values.

Results Follow-up data were obtained for all 1240 patients. Of 776 patients with cardiac arrest for whom the rule recommended termination, 4 survived (0.5 percent). The rule had a specificity of 90.2 percent for recommending transport of survivors to the emergency department and had a positive predictive value for death of 99.5 percent when termination was recommended. Implementation of this rule would result in a decrease in the rate of transportation from 100 percent of patients to 37.4 percent. The addition of other criteria (a response interval greater than eight minutes or a cardiac arrest not witnessed by a bystander) would further improve both the specificity and positive predictive value of the rule but would result in the transportation of a larger proportion of patients.

Conclusions The use of a clinical prediction rule for the termination of resuscitation may help clinicians decide whether to terminate basic life support resuscitative efforts in patients having an out-of-hospital cardiac arrest.

Of the 4 that did have ROSC despite being recommended for termination under the guideline, 3 were discharged neurologically intact.

Link goes to full study

 

[Outbac1]

Normally here an unwitnessed arrest with 20 minutes or more of no cpr gets a field pronouncement. Otherwise it gets ACLS work up. With no ROSC in 20 min. and three epi/atro it gets called with online medical control. If a ROSC they get transported. Although most lose ROSC enroute or in hosp and get called by the ER Dr.

If a PCP crew arrives and its workable its cpr with a manuel airway shock if req'd and transport. Waiting for als depends on the eta of als but transport should not be delayed.

I would not wait 25 mins or more. Vehicle motion and potholes can affect a monitor but I probably wouldn't stop unless I absolutly had to. A smooth steady ride is what you want to be able to work in the back. Flat out speed does NOT help the pt as the crew can't do anything but hang on.

 

[Ops Paramedic]

Our decleration (of deathOD) protocols can be practiced by intermediates and avdanced levels. We do not have to contact "medical control", as we don't have such a structure, hence, it is up to the practitioner to make the decision to start, stop or continue. You can make the choice by applying the DOD protocols to the patients presentation, irrespective of it being on scene or in the back of the bus.

There are however special circumstances that you can not just call it, for eg. Hypothermia, drownings and drug ODs. There are aslo circumstances regarding the start of resuscitations (Which are not published in our protocols) such as for academical purposes or for the sake of the family.

I can't post our DOD protocols directly from the text, as i do not have expilicate permision, but i will see if can find out where you can view them...

 

[MedicPrincess]

Our MD is fairly liberal on calling them. As I have had quite the run of cardiac arrest lately, 15 in the last 5 weeks, I have had ample time to talk to our MD.

His "personal opinion" is a pt found to be in cardiac arrest upon our arrival, does not need to be transported unless ROSC is found. From our protocols, along with the "obvious signs of death" our protocols state no resusitative measures are to be taken in the event of:

1. If asystole on the cardiac monitor and any four (4) of the following are present:
2. Vital signs absent
3. Pupils fixed and dilated
4. Advanced age and/or general physical condition of the patient would indicate no resuscitative measures should be taken.
5. The length of time in arrest with no resuscitative measures is longer than compatible with life
6. No independent influences are evident such as drugs or cold
7. Terminal illness that indicates no resuscitative measures should be taken

We are not required to call medical control. We can just call them.

Once resusitation is started, we can terminate after proper intubation and ventilation, and "several" rounds of ACLS. Med control must be contacted in that case.

Of my 15 codes, I called 9 of them based on the above protocols; worked 2 and called on scene, and for various other reasons ended up transporting the others.

We did however have a ROSC on one of them. Chances are she won't be walking out of the hospital though....intresting note, on the one with ROSC, the FD that responded with me arrived first and she was hooked up with an AutoPulse...

 

[paramedix]

You can view our Health Professions Council website on http://www.hpcsa.co.za

You can either view the protocols/download them or request them at info.

The HPCSA is our regulatory board and they decide what protocols stay and which fly...