NaHCo3 and Atropine in PEA

[ShotMedic]

Hey Guys just reviewing the new San Diego COunty ALS protocol updates. It appears that they took out Atropine and NaHCo3 from our PEA protocol.

Does anyone see why this would be beneficial? I'm a little worried about the Hs and Ts, and could see the use of Bicarb beneficial in many codes i'm faced with out in rural parts of the county. Im sure I could still receive a variation for bicarb but it seems like a hassle.

Any thoughts?

 

[BEorP]

Hey Guys just reviewing the new San Diego COunty ALS protocol updates. It appears that they took out Atropine and NaHCo3 from our PEA protocol.

Does anyone see why this would be beneficial? I'm a little worried about the Hs and Ts, and could see the use of Bicarb beneficial in many codes i'm faced with out in rural parts of the county. Im sure I could still receive a variation for bicarb but it seems like a hassle.

Any thoughts?

These are both no longer recommended for routine use in cardiac arrest care. Good on them for adjusting to keep in line with the best evidence!

http://circ.ahajournals.org/cgi/content/full/122/18_suppl_3/S729

 

[cruiseforever]

Give med. control a call if you want it. You might just get it.

 

[usalsfyre]

The whole thought of the cholinergic stimulation causing asystole is vastly overplayed, hence why atropine has almost no utility in this situation. It MAY be useful in a "pseudo-PEA" where cardiac output is not sufficient to generate a pulse, but generally a vasopressor/inotrope like dopamine or epi is a far better choice.

Unless you suspect primary METABOLIC acidosis as the cause of arrest (like say, an empty bottle of antifreeze laying beside your patient with a trickle of green liquid from his lips), it's far better to ventilate the patient appropriately then to end up causing a left shift with bicarbonate and making it more difficult for oxygen to unload at the cells.

 

[HotelCo]

My question is: Why did you decide to call it NahCo3, instead of bicarb?

Do you call it that in the field?

"Quick! Pass me the NahCo3!"

 

[medicRob]

My question is: Why did you decide to call it NahCo3, instead of bicarb?

Do you call it that in the field?

"Quick! Pass me the NahCo3!"

Probably from years of seeing HCO3 on blood gases. Also, I have been known to ask what the pt last HCO3 was out of habit. I used to take Hollister shirts and write "3" on them with permanent marker.

 

[ShotMedic]

Thanks for the info!

 

[8jimi8]

Bicarb a dependent variable in acid/base. All you are going to do is create more CO2 to be blown off.

 

[mycrofft]

Historically, paramedics gave too much bicarb

or some other way the pt's getting bicarb in the field were getting too alkaline. This was being commented upon by some hospitals as early as the late 1980's, field treated pt's were coming in alkaline.

Doesn't over-alkalinizing haemoglobin makes its oxygen load less bioavailable?

 

[8jimi8]

or some other way the pt's getting bicarb in the field were getting too alkaline. This was being commented upon by some hospitals as early as the late 1980's, field treated pt's were coming in alkaline.

Doesn't over-alkalinizing haemoglobin makes its oxygen load less bioavailable?

Yes, Alkalinity causes a left shift in the oxyhemoglobin curve, which causes O2 to disassociate less easily from the hemoglobin.

On the other hand, acidity causes a right shift, where the O2 to disassociates more freely to the tissues. --- This is why you see COPD'ers living just fine at spo2 of 88. Sure they may look cyanotic, but they are oxygenating their tissues just fine.

 

[usalsfyre]

Yep, all things considered it's a lot better to be critically ill and a little acidotic than alkalotic.

 

[omak42]

Hey Guys just reviewing the new San Diego COunty ALS protocol updates. It appears that they took out Atropine and NaHCo3 from our PEA protocol.

Does anyone see why this would be beneficial? I'm a little worried about the Hs and Ts, and could see the use of Bicarb beneficial in many codes i'm faced with out in rural parts of the county. Im sure I could still receive a variation for bicarb but it seems like a hassle.

Any thoughts?

As stated before they aren't recommended in the routine use anymore, however there was an interesting article on JEMS about the use of Sodium Bicarb and how in some places it is starting to make a comeback......

 

[jwk]

Yep, all things considered it's a lot better to be critically ill and a little acidotic than alkalotic.

One of the first drugs given in late 70's arrests was two amps of bicarb to EVERYONE, and just to make sure, we gave another amp q5-10 minutes. (that and IC epi because it was cool to do it) Evidence based medicine? Not back then - mainly "that's the way we've always done it".

 

[firetender]

Science then, science now; a dynamic process

One of the first drugs given in late 70's arrests was two amps of bicarb to EVERYONE, and just to make sure, we gave another amp q5-10 minutes. (that and IC epi because it was cool to do it) Evidence based medicine? Not back then - mainly "that's the way we've always done it".

This is something that I've gone round and round about with Rogue Medic and I see it coming up regularly in EMS forums so it's worth another look..

"Evidence based medicine" is nothing more than using the knowledge you have available at the time. At any one time you have the limitations of not being able to see into the future as to what "new" will be uncovered. Therefore, at any one time your information is incomplete.

My stock-in-trade, the PRIMARY approach to saving lives in the late 1970's, namely 2 amps Bicarb, Epi and Zap! Bicarb, Epi and ZAP!, Bicarb, Epi and Zap! ad nauseum, was based on evidence that the regimen had a favorable effect. That is to say, enough people in the know believed it to work well enough to set standards of care based on their information and experience which included utilizing scientifically-gathered data.

That information was as scientific as it could be -- for the time. Now what happened is, by more evolved processes and understandings, we've come to understand that those regimens produced what are called "poor patient outcomes". Basically, they didn't really enhance lives, they just saved them for the moment.

(One of the things that I've had to face in my life is that it is quite possible I retrieved many dead and assured them that the remainder of their lives would be spent as "Cardiac Cripples" with no real quality of life to speak of! I have had to come to terms with the fact that my role was to use the best knowledge I had at the time. Or was it to, just like you, "Do what you're told!"? Regardless, as cold as this seems, it's something you're going to have to face as well thirty years from now!)

Every process or procedure starts somewhere. JUST ENOUGH evidence is accumulated to say it's worth using on human beings. Then, as time, further trials, and experience go on, more is learned about its efficacy. It is found to be effective, effective under certain circumstances but not others, or effective for this but damaging to that such that its initial application is rendered useless.

What this means to EMS personnel is that you must understand, as I have had to, that the stuff you're using today may be debunked tomorrow. I can say this because I swear, about 95% of what the paramedic program was BASED on has been found to be ineffectual if not further damaging to the human beings it was meant to help!

If you think I'm crazy, consider this perspective from looking at EMS over the last 40 years or so:

What we have been a part of has been an aggressive attack of death; "Buying time" by pumping drugs into patients that will "jump-start" the parts of a crippled machine back into function.

In a nutshell, what evidence based medicine has shown is that all the stuff I used DID work for the moment, but the rebound effect -- how other bodily systems reacted to the forced support of the primarily affected system -- slowed, stopped or killed any chance of recovery.

You are pretty much doing the same thing today; going at individual symptoms aggressively. You're just using different drugs!

So, the science of today and what you are doing is based on the concept that aggressive treatment in the field produces favorable results. Yet, if you look back you'll see that for every drug you use in your drug box, there were a good ten others that were once claimed to be effective for the same conditions and now are "known to be" counter-productive or useless.

You can't neglect the fact that the majority of these drugs and procedures are introduced into a "marketplace" as salable commodities. The degree to which the perception continues that they are efficacious determines their profitability, therefore, continuing use. As soon as up-to-date science kicks in, then what you could call "the truth" becomes known. In our system, this usually occurs AFTER the introduction.

Science, in this case, becomes a system of checks and balances, not the TRUE initiator of the therapies we use. NOTHING that enters the marketplace is "proven". It is just "proven enough" until more of what we call "scientific" evidence comes in.

How can I bring this home to you?

Consider this: The very definition of "Buying time" is changing, and that means the essence of what you do. The base upon which EMS was founded on is making a paradigm shift.

What once was buying time by interposing powerful drugs into the system to shore up damaged organs is likely to evolve into buying time by "slowing down" the bodily functions AT the scene (through such things as hypothermia and drug-induced suspended animation). Once in the hospital, more advanced teams have days rather than hours to repair the damage.

My point is we can count on science to evolve. Little of what we use today will be used tomorrow and every couple generations the whole concept of what we provide and how we provide it will shift.

What's the lesson? Understand you are an agent of an evolving system whose tools are always changing. Your effectiveness boils down to whittling away at death, one miniscule increment at a time.

That also means you must accept yourself as part of an experiment. Your job is to deliver what appears to be the best that science offers today so it can find out if and how it really does work.