Cardiac Arrest Prehospital vs. Hospital

Aprz

The New Beach Medic
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3. "A hospital can't do any more for a pulseless patient than we can do in our ambulance". (Wonder where I've read that before).
I honestly believed that, but I am questioning it reading this. I was under the impression that at the hospital, usually just chest compressions, ventilation, shocking, rhythm interpretation, and ACLS drugs were push, and that's it; the things we do in an ambulance/on scene.

In my anatomy book, I read that a pericardiocentesis can be done if the patient is experiencing a pericardial temponade, and a tampondate is one of the H's and T's taught in ACLS. What else could be done for a patient in cardiac arrest in a hospital versus prehospitally? What about a thoracotomy? Is there anything else that could be done during an arrest that can be done at a hospital, but not normally prehospitally? Is it reasonable to do (e.g. wouldn't require chest compressions to be stopped longer than 5 minutes)?
 
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re

ECMO in the big ED's if they have it available, Labs for say a critical hyper K, etc etc. Other then that not alot that we don't already have available in the field.
 
What about a thoracotomy?

Slow your roll there Superfudge. You don't realize how infrequent thoracotomies are outside of trauma center EDs and ORs.

Other then that not alot that we don't already have available in the field.

...and by the time we get the patient to the hospital they are already brain dead or damn close to it. Point of care testing for lab values is such that if people would stop looking for the "Oooooh! That sounds like a fun procedure!" fix for problems that are beyond fixing in the vast majority of cases (such as cardiac arrest) and looked at things that would be beneficial to a larger subset of patients we would be able to look at electrolyte values, cardiac enzymes, etc in the field.


ECMO in the big ED's if they have it available
ECMO for cardiac arrest is pretty much pointless as previously discussed in another thread.
 
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In 99.9% of medical cardiac arrest, what you get from a Paramedic is what you'd get from the hospital. The only true difference where the hospital could do substantially 'more' would be in traumatic arrests, and that really only counts for penetrating trauma.



That's why we are able to call someone in the field, with pretty much the utmost certainty that all that could have been done, was done, without transporting for no reason.
 
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that really only counts for penetrating trauma who present with vital signs at some point during their care prior to the thoracotomy.

Fixed that for you.
 
Slow your roll there Superfudge. You don't realize how infrequent thoracotomies are outside of trauma center EDs and ORs.
Lol, yeh, I kind of guessed that. I actually could only think of pericardiocentesis from reading it out of my anatomy book for pericardial tamponade, and then watching on Youtube that HEMS thing someone posted on here once, and then there was a female HEMS doctor saying how she teachers a class on it, and has done it a lot more than other people have, 10 times in her career.
 
Lol, yeh, I kind of guessed that. I actually could only think of pericardiocentesis from reading it out of my anatomy book for pericardial tamponade, and then watching on Youtube that HEMS thing someone posted on here once, and then there was a female HEMS doctor saying how she teachers a class on it, and has done it a lot more than other people have, 10 times in her career.

In 15 years, I've seen it done emergently maybe four or five times. Honestly, in most situations where it's life or death (read as: traumatic pericardial tamponade), a subxiphoid window followed rapidly by a trip to the OR or an ED thoracotomy for control of the hemorrhage is simply a better option due to the associated risk of recurrence and of the pericardiocentesis catheter becoming obstructed. In other settings, such as massive pericardial effusion secondary to renal failure or severe pericarditis, it very seldom is immediately life threatening so it is usually managed with a pericardial tap but not a rushed one.
 
[YOUTUBE]VFl6e6wikYs[/YOUTUBE]
At 5:42. The link doesn't let me use the t=5m42s thing I guess. Oh well.

That's the video I was talking about.
 
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re

No argument there. I would love to have POC Cardiac testing out here in the sticks where I practice. Definately would help my decision making and help get patients to definitive care faster.

And yeah 18 years of field and ED and only seen 1 pericardiocentesis performed
 
[YOUTUBE]VFl6e6wikYs[/YOUTUBE]
At 5:42. The link doesn't let me use the t=5m42s thing I guess. Oh well.

That's the video I was talking about.

Never would have guessed..... :rolleyes:
 
In 99.9% of medical cardiac arrest, what you get from a Paramedic is what you'd get from the hospital. The only true difference where the hospital could do substantially 'more' would be in traumatic arrests, and that really only counts for penetrating trauma.



That's why we are able to call someone in the field, with pretty much the utmost certainty that all that could have been done, was done, without transporting for no reason.

It is almost all more comfortably done in a controlled setting (the hospital), but unless it's caused by traumatic etiology and can be surgically repaired promptly, it can pretty much be done in an ambulance by well trained providers. We have periocardiocentesis, tube thoracostomy, and cricothyrotomy at my service (after alot of extra learning). Luckily, we have alot of great facilities in my area, so odds are very rare that those procedures would ever be needed in the field, but we train to do it anyway.
 
Ok. CAD is most common. However....

BTW thanks.
1. If cardiac standstill was caused by something besides CAD or electrocution, etc., but by an etiology which it takes a hospital to detect and/or clear up, then the hospital trumps the truck. Something like pericardial tamponade, poisoning, sucked valve will create a time-dependent descending "glass ceiling" to field resuscitation measures and there is little which can be done on scene save gather data and try to maintain circulation, and know when to gather petticoats and book outta there.

2. Although on scene care is eminently important, it is not definitive. IF you slug it out for forty-five minutes post arrest in the patient's living room and you get a pulse, then you have the ride to the hospital. If you can do more enroute, then forty-five minutes post arrest the patient may be on a pacer, being cardioverted in a controlled setting, getting meds dictated by more sophisticated diagnostic procedures, etc etc. Talking to Billing Department.

3.Given that in the field a "cardiac arrest" can have an etiology not apparent in some cases to field staff; or, it is complicated by other processes like diabetes, trauma, poisoning, pericardial tamponade, congenital heart defect, etc.; or the etiology is not addressable in the field (sucked valve, ETOH heart) ; then the pt will likely be dispatched and classified/diagnosed as having a primary issue of cardiac arrest but the treatment must very promptly go beyond just trying to reestablish circulation; the pulseless state is a symptom, albeit a lethal one. Also, prolonged field treatments do not have the opportunity to address side effects such as emergent polypharmacy (using lots of different chemicals on top of the pt's current meds, causing an unavoidable upset of homeostasis), pH and electrolyte shifts. Not to mention mechanical trauma of CPR, or other iatrogenic trauma.

If such a patient is delivered organically as well as clinically dead, or irretrievably close to it, it can be written off because the cardiac arrest's etiology (which a hospital might have addressed) is considered secondary to asystole as cause of death. THEN yes, the hospital is considered to be inferior to field, but that is because of a conceptual error.

PS: I rewrote this twice to try to make it simpler but not as blunt as "we bury our mistakes and it isn't our fault always").
 
BTW thanks.
1. If cardiac standstill was caused by something besides CAD or electrocution, etc., but by an etiology which it takes a hospital to detect and/or clear up, then the hospital trumps the truck. Something like pericardial tamponade, poisoning, sucked valve will create a time-dependent descending "glass ceiling" to field resuscitation measures and there is little which can be done on scene save gather data and try to maintain circulation, and know when to gather petticoats and book outta there.


While I agree with this part in principal, as a matter of practicality how viable are most patients in cardiac arrest by the time they reach the hospital when the arrest is caused by a reversible cause? There's just not much, if any left, when you consider time before recognition + response time (911 call received to patient contact time) + on scene time + transport time. Sure, the hospital can treat causes of cardiac arrest that EMS can't, but if the patient isn't viable when he reaches the hospital, then the hospital might as well not exist.
2. Although on scene care is eminently important, it is not definitive. IF you slug it out for forty-five minutes post arrest in the patient's living room and you get a pulse, then you have the ride to the hospital. If you can do more enroute, then forty-five minutes post arrest the patient may be on a pacer, being cardioverted in a controlled setting, getting meds dictated by more sophisticated diagnostic procedures, etc etc. Talking to Billing Department.

The only way I could support transporting codes is if CPR is shown to be effective and safe during transport. To that end, I'd like to see studies showing at least equivalence between manual CPR and the CPR machines that was in vogue a few years ago.

3.Given that in the field a "cardiac arrest" can have an etiology not apparent in some cases to field staff; or, it is complicated by other processes like diabetes, trauma, poisoning, pericardial tamponade, congenital heart defect, etc.; or the etiology is not addressable in the field (sucked valve, ETOH heart) ; then the pt will likely be dispatched and classified/diagnosed as having a primary issue of cardiac arrest but the treatment must very promptly go beyond just trying to reestablish circulation; the pulseless state is a symptom, albeit a lethal one. Also, prolonged field treatments do not have the opportunity to address side effects such as emergent polypharmacy (using lots of different chemicals on top of the pt's current meds, causing an unavoidable upset of homeostasis), pH and electrolyte shifts. Not to mention mechanical trauma of CPR, or other iatrogenic trauma.

I simply don't see most hospitals requesting labs and getting them returned in a time frame that would facilitate treatment of a prehospital cardiac arrest.
 
What else could be done for a patient in cardiac arrest in a hospital versus prehospitally? What about a thoracotomy? Is there anything else that could be done during an arrest that can be done at a hospital, but not normally prehospitally? Is it reasonable to do (e.g. wouldn't require chest compressions to be stopped longer than 5 minutes)?

It really depends on the nature of the arrest and how aggresive the doc wants to be at treating the identified cause.

You don't cut somebody's chest open unless you really think it can help that person.

(or you have a resident that needs the practice and the patient loosely fits a criteria)
 
V, remind me to stay away from teaching hospitals.

:ph34r:...........
 
I simply don't see most hospitals requesting labs and getting them returned in a time frame that would facilitate treatment of a prehospital cardiac arrest.

Depends on your gear.

There are now manufacturers making POC lab machines that detect various labs. Our NICU has one that will return an ABG in 2 minutes and self controls and calibrates.
 
And yeah 18 years of field and ED and only seen 1 pericardiocentesis performed

seen it a handful of times, the most outstanding was my second year of med school when the doc in the ED (a surgeon by trade) Dxed one off of an EKG in a 28 y/o female presenting with severe short of breath.

Saw the EKG amplitude decreasing on lead II monitor, called for a needle, and pulled transudate out. (forgot how much) Then she inserted a drain and off to the ICU with them.

It was inspiring.
 
(or you have a resident that needs the practice and the patient loosely fits a criteria)

Which brings the question up, would you advocate a Paramedic doing the same thing (practice a rarely used skill on a patient that loosely fits) when it's going to be an arrest you know you're going to call, such as doing a needle decompression on a blunt traumatic arrest, or a cric on an arrest with facial trauma?
 
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