Patients that go unconscious or back into Cardiac Arrest while en route to Hospital..

[Dutchieee]

So i've studied the scenario enough but have never experienced it first hand. So i'd just want to go over the steps in the event that it does happen. Even if your're from another state with different protocols give me a step by step of what is done. (Im from FL so if anybody has that info that'd be great by the way.)

 

[ERDoc]

Unconscious-ABCs, figure out why

Cardiac arrest-CPR/ACLS

 

[NomadicMedic]

For cardiac arrest? Pull over, call for medics, start CPR.

 

[Jim37F]

If they're just unconscious, but still alive, upgrade code and divert to the nearest ED, manage ABC's, if possible get an ALS intercept, though unless you're out in the sticks somewhere and would have to drive by their base to get to the MAR (Most Accessible Receiving facility) it'll be faster just to drive to the hospital.

If they lose their pulse...stop, pull over, call for ALS, apply AED and start CPR and work it up as a normal arrest.

 

[StCEMT]

Call ALS unless I am closer to a hospital which is a very distinct possibility where I work. Either way, run it like you're taught.

 

[SpecialK]

Personally, I'd defibrillate them. Doing CPR in the back of a moving ambulance is largely ineffective and very dangerous. For a cardiac arrest witnessed by ambulance personnel where a defibrillator is immediately available, what is the point in delaying delivering a shock in favour of CPR?

If somebody literally collapses in front of me in VF or VT, provided a defibrillator was immediately available and in manual mode, I'll give up to three sequential shocks before starting CPR. I know the regime of multiple shocks went out earlier in the century to single shocks at maximum joules, but somebody who literally fell over a few seconds ago is somebody you can likely revert with one or two shocks. With a defibrillator in manual mode, this is quick to achieve. I've had two witnessed cardiac arrests where ROSC has been obtained in one or two shocks.

 

[STXmedic]

Hope for a DNR.

 

[EpiEMS]

Witnessed arrest? No question -- work it.

 

[medichopeful]

So i've studied the scenario enough but have never experienced it first hand. So i'd just want to go over the steps in the event that it does happen. Even if your're from another state with different protocols give me a step by step of what is done. (Im from FL so if anybody has that info that'd be great by the way.)

Panic then call an adult!

In all seriousness though, if they don't have a pulse and are a full code, immediately start CPR. If they're just unconscious, evaluate the airway then go from there, getting ALS as necessary or just going to the hospital.

 

[LocNar]

Precordial thump.

 

[Chewy20]

Don't forget to stop by chic-fil-a on the way there.

 

[Fayettecong]

Personally, I'd defibrillate them. Doing CPR in the back of a moving ambulance is largely ineffective and very dangerous. For a cardiac arrest witnessed by ambulance personnel where a defibrillator is immediately available, what is the point in delaying delivering a shock in favour of CPR?

If somebody literally collapses in front of me in VF or VT, provided a defibrillator was immediately available and in manual mode, I'll give up to three sequential shocks before starting CPR. I know the regime of multiple shocks went out earlier in the century to single shocks at maximum joules, but somebody who literally fell over a few seconds ago is somebody you can likely revert with one or two shocks. With a defibrillator in manual mode, this is quick to achieve. I've had two witnessed cardiac arrests where ROSC has been obtained in one or two shocks.

That's great if you have a defibrillator that is immediately available in manual mode, however seeing this is a BLS question I'd assume that they have a run of the mill AED...

You'd refer back to ABC's. Airway, breathing, circulation. There are way to many variables to give you a straightforward answer, however pulling over and requesting an ALS intercept while performing BLS cardiac arrest protocols would be ideal.(unless your within a hop, skip, and a jump away from an ER)

 

[SpecialK]

That's great if you have a defibrillator that is immediately available in manual mode, however seeing this is a BLS question I'd assume that they have a run of the mill AED...

You'd refer back to ABC's. Airway, breathing, circulation. There are way to many variables to give you a straightforward answer, however pulling over and requesting an ALS intercept while performing BLS cardiac arrest protocols would be ideal.(unless your within a hop, skip, and a jump away from an ER)

Even if I was restricted to using automatic mode, if somebody literally collapses in front of me I'd still defibrillate them prior to CPR. Considering we are talking about ambulance personnel and not the lay public, ambulance monitor/defibrillators will defibrillate in automatic mode within a reasonable time frame (under 10 seconds or so). Depending on the particular device you are using, you may not be able to deliver sequential defibrillations without doing CPR in-between. However, regardless, I would, at least, deliver one shock before starting CPR. Automatic mode is for the lay public or GPs who have to have an automatic defibrillator "just because", I don't see the point in ambulance personnel using automatic mode.

I've had two or three witnessed collapses of VF or VT revert with one or two shocks delivered immediately; including one with an automatic defibrillator.

The discussion of cardiac arrest en-route is a good reminder to put defibrillation pads on patients at high risk of cardiac arrest, minimises delays to defibrillation and means if you are en-route and have a defibrillator in manual mode you can shock them without having to stop the ambulance, at least for the initial shock, if you cannot immediately pull over. It is also a place where mechanical CPR potentially has a role, i.e. taking patients in VF with good prognostic factors for PCI using mechanical CPR during transport.

 

[Jim37F]

In theory, a pt who's bad enough off to where you honestly believe they have such a high risk of coding during transport that you want to place defibrillator pads preemptively should never be going via BLS anyway. Yes I do have an AED relatively handy (it sits in the bulkhead compartment next to the side door) (We carry the Zoll AED Plus, a commercial model not significantly different than what the general public has access to, just put it on, press a button and let it do its thing, if it does not detect V-Fib/V-Tach it will not deliver a shock no matter how much I want it to)

Since not every patient that goes into SCA is a candidate for defib, I'd argue immediate chest compressions are more vital. Have your partner immediately pull over, radio for ALS, then head to the back to apply the AED. Hopefully their in a shockable rhythm, but if not then they needed those compressions more than the AED...

 

[chaz90]

Since not every patient that goes into SCA is a candidate for defib, I'd argue immediate chest compressions are more vital. Have your partner immediately pull over, radio for ALS, then head to the back to apply the AED. Hopefully their in a shockable rhythm, but if not then they needed those compressions more than the AED...

Actually, the majority of patients that suffer from true sudden cardiac arrest do enter a shockable rhythm for a period of time. Unfortunately, we miss that window a lot (most) of the time in our unwitnessed cardiac arrests with unknown down time and find asystolic corpses by the time we arrive.

Patients that suffer a gradual degradation in cardiac output or HR to some kind of PEA often still have some kind of cardiac contractility and are just not producing a strong enough pulse for us to feel it. Those patients are typically circling the drain for a while before they get to that point. If a patient is talking to you and complaining of severe chest pain before abruptly losing consciousness and a pulse, the smart money is on a shockable rhythm being present.

 

[redundantbassist]

Actually, the majority of patients that suffer from true sudden cardiac arrest do enter a shockable rhythm for a period of time. Unfortunately, we miss that window a lot (most) of the time in our unwitnessed cardiac arrests with unknown down time and find asystolic corpses by the time we arrive.

Patients that suffer a gradual degradation in cardiac output or HR to some kind of PEA often still have some kind of cardiac contractility and are just not producing a strong enough pulse for us to feel it. Those patients are typically circling the drain for a while before they get to that point. If a patient is talking to you and complaining of severe chest pain before abruptly losing consciousness and a pulse, the smart money is on a shockable rhythm being present.

+1 on this. It would also be interesting to see the results of using up to 3 sets of stacked shocks for a patient with a witnessed arrest already attached to a manual defibrillator, with compressions being performed while charging.

 

[NomadicMedic]

I was under the impression that stacked shocks with a monophonic defibrillator were used to reduce the thoracic impedance threshold. Biphasic defibrillators eliminated the need to stack shocks.

 

[redundantbassist]

I was under the impression that stacked shocks with a monophonic defibrillator were used to reduce the thoracic impedance threshold. Biphasic defibrillators eliminated the need to stack shocks.

I believe that stacked shocks were removed due to the increased "hands off" time, which was especially long when using an AED. However, in a situation where a patient had a witnessed cardiac arrest, and pads were already in place prior to the arrest, I believe up to 3 stacked shocks would be feasible. As the human eye can detect v-fib much quicker than a AED, and with compressions being performed while the monitor is charging, it would be probable to have a peri-shock pause of less than 5 seconds. Furthermore, conversion of course refractory ventricular fibrillation before it degenerates to fine v-fib would most likely result in an increase in both ROSC and survival to discharge.

 

[SpecialK]

I am no AED salesman, but I believe most manufacturers have reduced the amount of time it takes for their software to recognise VF or VT and shock it. Automatic mode on the ambulance monitor/defibrillators I have used (MRx, Lifepak 12 and Lifepak 15) takes about ten seconds to recognise, charge and shock which is obviously longer than it takes a manual mode but an improvement over where the technology was in years past. The original AEDs were very slow.

Not sure if by "stacked" shocks you mean one-on-top-of-the-other, or escalating energy (the old 200, 300, 360J) but I'd give up to three shocks at maximum joules.

 

[NomadicMedic]

@TomB could weigh in on this.