Stopping CPR w/ V-fib?

[VirginiaEMT]

I was involved in a resuscitation attempt where the upper 70's year old man arrested in front of one of his children. CPR was started with instructions from dispatch. We worked the arrest for 50 minutes or so, the patient remained in fine v-fib the entire time. He was shocked 6 times, given 7 mg of epi. 1/10000, 450 mg amiodarone, 100 meq. if sodium bicarb, and 2 mg of Narcan, At what point would you have stopped effort to resuscitate (contact med control)?

 

[DesertMedic66]

Any rhythm other then asystole gets transported.

 

[NomadicMedic]

I was involved in a resuscitation attempt where the upper 70's year old man arrested in front of one of his children. CPR was started with instructions from dispatch. We worked the arrest for 50 minutes or so, the patient remained in fine v-fib the entire time. He was shocked 6 times, given 7 mg of epi. 1/10000, 450 mg amiodarone, 100 meq. if sodium bicarb, and 2 mg of Narcan, At what point would you have stopped effort to resuscitate (contact med control)?

Was it fine VF or "slightly squiggle asystole"? Did you transport? Was this a witnessed arrest with good bystander CPR started promptly?
There are some studies that relate survival after 20+ minutes of resuscitation is greatly reduced, even with effective CPR and defibrillation.
If this was a prolonged code with no rhythm changes after 20 minutes of Epi, a series of shocks and some amiodorone, I would have discussed calling it. (However, I doubt our med control would let us terminate efforts on a PT still in VF. ) There is no benefit in transporting a "working arrest". The ACLS I do is the same as the ED's ACLS.

 

[BigBad]

Transport after 15 min of persistent vfib or vtach per my protocol

 

[TheLocalMedic]

I really don't like the argument that "any rhythm except asystole gets transported" and I'll tell you why...

Are they going to do anything different in the ER than what we're doing in the field? As long as you have enough trained hands, what you do on a code is essentially the same as what a physician would order to be done, and, if I may be so bold, I think that us field medics actually do a really really good job on codes as a whole. I think it's because we're a little faster and more practical?

I'm a big proponent of working an entire code to the end on scene. Transporting only degrades your CPR effectiveness. And to that end, if you do get pulses back, I strongly recommend that you actually hang out on scene for about 10 minutes before hitting the road, as a patient is more likely code in the first few minutes following a successful resuscitation.

Granted, if you have a refractory v-fib and you're working for a really long time, at some point you may just throw your hands up and make the call to just load and go. But I still think you're better off working it into the ground where you are.

 

[the_negro_puppy]

If you worked on him for 50 minutes and he was in VF the whole time, how come he was only shocked 6 times. This does not make sense.

We do not transport corpses. We will work any cardiac arrest until if in VF / VT and go through our protocols. Only transport if we are really close to hospital, ROSC achieved or exceptional circumstances.

 

[Achilles]

I really don't like the argument that "any rhythm except asystole gets transported" and I'll tell you why...

Are they going to do anything different in the ER than what we're doing in the field? As long as you have enough trained hands, what you do on a code is essentially the same as what a physician would order to be done, and, if I may be so bold, I think that us field medics actually do a really really good job on codes as a whole. I think it's because we're a little faster and more practical?
Medic school: 1 year
Medical School 12 years +/-
I'm a big proponent of working an entire code to the end on scene. Transporting only degrades your CPR effectiveness. And to that end, if you do get pulses back, I strongly recommend that you actually hang out on scene for about 10 minutes before hitting the road, as a patient is more likely code in the first few minutes following a successful resuscitation.

Granted, if you have a refractory v-fib and you're working for a really long time, at some point you may just throw your hands up and make the call to just load and go. But I still think you're better off working it into the ground where you are.

...

 

[VFlutter]

Are they going to do anything different in the ER than what we're doing in the field? As long as you have enough trained hands, what you do on a code is essentially the same as what a physician would order to be done, and, if I may be so bold, I think that us field medics actually do a really really good job on codes as a whole. I think it's because we're a little faster and more practical?

And to that end, if you do get pulses back, I strongly recommend that you actually hang out on scene for about 10 minutes before hitting the road, as a patient is more likely code in the first few minutes following a successful resuscitation.

How far away from a Hospital are you? Level one trauma?

You can rule out the various causes of cardiac arrest (Hs & Ts) and perform the necessary interventions more effectively than an ER physician? You can relive tamponade in the field? Do you carry blood products? To say that you are faster and more practical than a Level one trauma team is very bold.

I am not advocating transporting every arrest but to say that an arrest will be handled the same in the field as it is in the ER is a little bit of a stretch. Ill take my chances in the hospital.....

Also, you sit on scene for 10 mins post ROSC just incase they code again? What do you do during that time?

 

[TheLocalMedic]

When was the last time you watched a code happen in the ER? 12 years of medical school is great, but the drugs given and the way it is worked is virtually the same as we play it in the field. In fact, many docs still put a premium on an ET tube and will interrupt CPR for extended periods in order to place one. Granted, they can use an ultrasound to check for cardiac activity, but otherwise we're playing the same game with the same tools.

 

[TheLocalMedic]

Okay, trauma is altogether a different deal, and I'll be the first to advocate getting someone to a surgeon in a trauma case. But as far as non-trauma codes go, I still think it's better to work it in the field. And why do people still like to work traumatic arrests? If its trauma and they ain't alive, then you can't really fix that... Even with a surgeon.

 

[TheLocalMedic]

Oh, i forgot to mention... In those post-conversion minutes that's when you reassess, pop in another line, grab their history and home meds and prep for transport.

 

[VFlutter]

When was the last time you watched a code happen in the ER? 12 years of medical school is great, but the drugs given and the way it is worked is virtually the same as we play it in the field. In fact, many docs still put a premium on an ET tube and will interrupt CPR for extended periods in order to place one. Granted, they can use an ultrasound to check for cardiac activity, but otherwise we're playing the same game with the same tools.

Its been a month or two. Ya, 12 years of medical is great. Do the Physicians in your area blindly follow the ACLS algorithms? I rarely see ER physicians run a textbook ACLS code like medics would, they frequently deviate based on clinical judgment and patient presentation.

 

[Merck]

Have to agree with the why only 6 shocks if 50 minutes of VF? Also, I'd sure like to see a strip of parts of that code.

Transporting the arrest is not a great idea - I'd stay myself. As someone mentioned the effectiveness of CPR during transport sucks. And the idea of racing off to the emerg so a doctor can see them is a little silly. Consider the case - 50 minutes down will not be emergently put on ECMO if the hospital is even capable of it.

I would work this and call it when appropriate. I'm not sure there's stats for it but I'm guessing that 70 year olds who collapse and have >20 minutes of CPR don't often recover.

Also, not sure if he was shooting heroin with his grandkids but the narcan is interesting.

 

[Veneficus]

I really don't like the argument that "any rhythm except asystole gets transported" and I'll tell you why...

Are they going to do anything different in the ER than what we're doing in the field? As long as you have enough trained hands, what you do on a code is essentially the same as what a physician would order to be done, and, if I may be so bold, I think that us field medics actually do a really really good job on codes as a whole. I think it's because we're a little faster and more practical?

I'm a big proponent of working an entire code to the end on scene. Transporting only degrades your CPR effectiveness. And to that end, if you do get pulses back, I strongly recommend that you actually hang out on scene for about 10 minutes before hitting the road, as a patient is more likely code in the first few minutes following a successful resuscitation.

Granted, if you have a refractory v-fib and you're working for a really long time, at some point you may just throw your hands up and make the call to just load and go. But I still think you're better off working it into the ground where you are.

I am of the opinion that codes should be worked in the field.

Not for the same reasons listed here.

First, let me just presumptiously state I am really good at working codes.

That is not the same as being really good at following an ACLS algorythm. (which I am also exceptionally skilled at)

Back to our regularly scheduled program...

the ACLS guidlines are designed based on epidemiology. Since 70% of SCA is because of vfib, and arrhythmia is the most common side effect of MI, The early CPR and shock will work on most codes. (which is why there is such a push for community CPR and AEDs)

In the event of ROSC, you do not simply wish the patient a good day. You transport to the hospital where that patient receives ongoing resuscitation and treatment of the underlying condition that caused the arrest.

Since CPR is found to not be effective in a moving vehicle, transporting a code effectively means no cpr for the course of transport.

Logically, that is not going to impact the outcome in a positive way.

However, if your cardiac arrest is caused by something other than v-fib secondary to MI, the only part of your code likely to work is CPR. (otherwise you will likel see refractory v-fib until the code is called)

You must then figure out what exactly is causing this and attempt to correct it. Unfortunately EMS is both undereducated and underequipped to do this. (basically the other 30% of SCA)

Now just because you perform ACLS on a patient who would benefit from ACLS, does not mean a positive outcome.

By now you may have come to the conclusion that somebody, like a paramedic, will be extremely skilled in working a code because it is the focus of their efforts and they will likely do the exact same thing to every code. Which by the odds, should have the most success in achieving ROSC.

However, ROSC is not discharge neurologically intact. For that, you need a doctor.

Also, acute care physicians with considerably and exponentially more knowledge, training, and toys backing them, also see as many or more codes than paramedics in their element. Doctors who work outside of acute care will also be more familiar with pathology, identifying, treatment, and likelyhood of resuscitating whatever condition caused the arrest. They may also understand the futility of trying to resuscitate.

Which means they will be more capable than paramedics to help. It also means they will discover futility quicker or administer specific or alternative treatments than listed in the ACLS guidlines.

This may give the appearance of "not knowing what to do" because it doesn't look like what a paramedic would do.

 

[Veneficus]

Also, not sure if he was shooting heroin with his grandkids but the narcan is interesting.

Maybe he was taking high dose opioids for his terminal cancer? :lol:

I like your answer better though.

 

[lightsandsirens5]

And to that end, if you do get pulses back, I strongly recommend that you actually hang out on scene for about 10 minutes before hitting the road, as a patient is more likely code in the first few minutes following a successful resuscitation.

Wait.....whaaaaa...... Come again?

What the heck do you advocate doing? Sitting there and staring at them?

Can you cite your "fact" about re-arresting?

Would you really rather wait 10 minutes on scene with what is, for all intents and purposes, an extremely unstable patient "in case" they arrest again? Wouldn't you want to have them 10 minutes closer to a DOCTOR if they do arrest again?

Or am I totally missing something here?

 

[Aidey]

It isn't that strange of an idea. I can't cite a study, but I know for a fact it is what Wake County does, and the reason is that their in house research showed the majority of pts that re arrested did it within 10 minutes.

Wake County uses kings initially. So during the 10 mins they call the hospital, swap the king for a ET tube, start a second line and any infusions that are indicated, get a 12 lead... Etc. Their MD said they are able to get necessary interventions done with a much lower risk of the pt rearresting while they are trying to package them or en route.

 

[NomadicMedic]

Aidey is right on the money. We have a "wait at least 6 minutes before moving" line in our protocols for ROSC. Once we get a pulse back, we usually intubate, hang any pressors, anti arrhythmic and cold fluids, untangle and package ... And then we get underway.

If the PT rearrests en route, the LUCAS device does the compressions, so we can safely transport with effective CPR. Although we rarely transport active codes unless there are extenuating circumstances.

 

[NYMedic828]

About 6 months ago I had a 70+ year old woman arrest into vfib on a plane that had just landed.

Shocked 7 times, 5mg epi, vfib was refractory to amiodarone as first 6 shocks.

Patient walked out of the hospital some days later.

Mind you, CPR was begun at the moment of arrest and only stopped to remove the patient from the plane for 30 seconds.

Was probably in Vfib for 35 minutes but it wasn't a "maybe it's asystole" waveform.

Capnography is also a valuable tool for determining patient viability. If you have an ETCO2 of 0 and Vfib for 40 minutes id give it a rest...

 

[Christopher]

I was involved in a resuscitation attempt where the upper 70's year old man arrested in front of one of his children. CPR was started with instructions from dispatch. We worked the arrest for 50 minutes or so, the patient remained in fine v-fib the entire time. He was shocked 6 times, given 7 mg of epi. 1/10000, 450 mg amiodarone, 100 meq. if sodium bicarb, and 2 mg of Narcan, At what point would you have stopped effort to resuscitate (contact med control)?

86 minutes for a code on Sunday. ~60 minutes into the code we transported due to a persistent ETCO2 of ~45mmHg w/ CPR even in the face of asystole. 12 epi's, 300mg lidocaine, 1g calcium, 100 mEq bicarb. Initial was a slow PEA (some pacing) that went to asystole then we got VF after the calcium admin. His AICD shocked 6 times, we shocked another 4 times. Never could get palpable pulses.

If the ETCO2 was lower we'd have stopped in the house, given the pacemaker and high ETCO2 we wanted a magnet available so we transported.