Transporting an Arrest, Question on a Call

[ghost02]

Take a look at our Determination of Death protocol:

http://www.co.kern.ca.us/ems/dofdeath.pdf

Page 4 has the termination of resuscitative efforts protocols.

 

[Christopher]

My personal opinion is to work the arrest on scene, and if no ROSC with shocks, drugs, and an airway in place after 20 minutes get with med control and call it. My protocol makes that a little more difficult.

Please make this 40 minutes. Please. If you're not working at least 40 minutes you're leaving behind survivors. Neuro intact ones at that. There should be no "maximums" based on time alone. You need other endpoints...and statistically you need at least 40 minutes to know these things.

(I'm not going to touch on anything else as everybody has pretty much said what I would.)

 

[MonkeyArrow]

With the 40 minute neuro-intact survival time frame, what is happening at the 40th minute that is not (or cannot) happening at the first? Is it just that the heart has had time to rest and recover or... In other words, why do people regain ROSC at minute 40 and not at minute 5 or 10?

 

[Brandon O]

With the 40 minute neuro-intact survival time frame, what is happening at the 40th minute that is not (or cannot) happening at the first? Is it just that the heart has had time to rest and recover or... In other words, why do people regain ROSC at minute 40 and not at minute 5 or 10?

Great question. I don't think anybody has a good answer.

 

[DesertMedic66]

Please make this 40 minutes. Please. If you're not working at least 40 minutes you're leaving behind survivors. Neuro intact ones at that. There should be no "maximums" based on time alone. You need other endpoints...and statistically you need at least 40 minutes to know these things.

(I'm not going to touch on anything else as everybody has pretty much said what I would.)

For us if the patient is Asystole/PEA less than 10, no shocks delivered, medical arrest, no bystander CPR, and unwitnessed we are only required to do 2 rounds of "indicated interventions" and if no ROSC then we call the patient.

 

[epipusher]

If forty is good why not 50?

 

[vcuemt]

I suggest anyone who doesn't quite understand statistics take a look at Nate Silver's excellent book The Signal and the Noise.

The numbers we use are the numbers we use because they apply to most people in most situations, based on the available evidence. That is the answer to "why not 50".

Nothing happens "at the 40th minute" that doesn't necessarily happen at the 1st or 20th or 41st minute. But, presumably, that is when the statistical likelihood of ROSC tips from likely to unlikely enough where the folks who write his protocols don't want him to continue. For what it's worth, my protocols suggest I consider terminating resuscitation efforts after 15 minutes of CPR without ROSP.

However, to the original topic: what is driving down a bumpy road going to do to your AED when it's trying to analyze for a shockable rhythm? Do you stop the truck briefly every time to need to analyze? I was taught you work it on scene until you get ROSC or you call it, and if you lose someone in the back you consider stopping the ambulance and working it right there.

 

[Christopher]

I encourage folks to review the data from Wake County and SAS on this topic (PDF). The survival curves are very interesting (slide 22).

"Conclusions​

• • 90 percent of neurologically intact survivors had ROSC at 40 minutes of resuscitation
  • 29 of 42 survivors with resuscitation beyond 40 minutes had NIS (69%, (CI 54-81%)).
  • ...

What Does This Mean?​

• • If we had followed the 25 minute rule, ~ 100 neurologically-intact survivors would have had their resuscitative efforts abandoned prematurely"

Nothing happens "at the 40th minute" that doesn't necessarily happen at the 1st or 20th or 41st minute. But, presumably, that is when the statistical likelihood of ROSC tips from likely to unlikely enough where the folks who write his protocols don't want him to continue.

Exactly.

With the 40 minute neuro-intact survival time frame, what is happening at the 40th minute that is not (or cannot) happening at the first? Is it just that the heart has had time to rest and recover or... In other words, why do people regain ROSC at minute 40 and not at minute 5 or 10?

I enjoy @vcuemt's "tipping the scales" wording. If we made each cardiac arrest patient weigh as much as their "length of resuscitation", and put survival CPC 1-2 on one side and CPC 3-5 on the other, there is now evidence to show that instead of 20-25 minutes the happy average to avoid missing potential survivors is 40 minutes.

For us if the patient is Asystole/PEA less than 10, no shocks delivered, medical arrest, no bystander CPR, and unwitnessed we are only required to do 2 rounds of "indicated interventions" and if no ROSC then we call the patient.

That's part of the Universal Termination of Resuscitation guidelines. As far as I'm aware, the above does not contradict U-TOR, merely adds to it. The probability of survival with initial asystole, no transitions to shockable rhythms, no bystander CPR, and unwitnessed is pretty much 0%. Not sure why those would get resuscitated to be honest, but that's another post.

If forty is good why not 50?

TOR rules need some guidance and from the body of available evidence the 90th percentile is likely around 40 minutes.

 

[mycrofft]

The phrase "Nothing to do in the hospital I can't do in my bus" is a sign of pride and hubris and mayube ignorance. The concept of universal "Snatch and run" is a denial of responsibility. Field operators need to know how to balance and choose based on each case; it isn't an either/or, zero-sum situation.

If algorithms showing how to determine irrecoverability in the field have been adopted, then the system has decided how to choose who is not going to need prompt definitive care soon because they are truly irretreivably dead. If an ER decides that field measures (pacing, defib, CPR, drugs ) ARE equivalent to what the have to offer, then their decision not to treat (as the OP seems to be saying) is made and the receiving hospital will have to defend it.

First and foremost, in America most field asystoles are due to infarct, which is (if you think about it) a trauma. Most MI cases presenting with clinical death are not recoverable, and for those cases field treatment without transport IS just as good (or bad). People develop MIs while in hospitals and die there. This is a fact most of us have observed time and again.

CPR and defibrillation do not equal pacing. Field pacing when the pacing mechanism has been insulted (resulting in a potentially mostly-viable myocardium) is a great advancement but not defintive. Those MI cases which are salvageable usually (not always) require prompt pacing and, depending upon the case, cardiovascular surgery either as a vascular bypass, an assistive device, or a transplant. CPR and drugs, without advanced diagnostics and sophisticated interventions, were designed to get the pt in, not to supplant definitive care. Are CPR and field treatment a waste? No, they are absolutely vitally essential, starting with good bystander CPR and hopefully AED. But I resort to the CO2 analogy; you fight your way through the fire, turn around and it's flaming again.

Unconscious and apparently (palpation) pulseless presentation due to extremely weak cardiac activity can respond to defib and drugs but will still need hospitalization. EKG and AED are diagnostic for field treatment and pt may recover consciousness, sometimes spontaneously (Seen it).

Should a traumatic case (gunshot, exsanguination, penetrating injury) present clinically dead and is somehow salvageable, prompt surgery and hospital level treatments to correct mechanical damage and any contributory problems (exsangination requiring blood transfusion, respiratory injury, vascular damage, central nervous system damage, shock, etc) is necessary. Again, field treatment is vital but not definitive because advanced diagnostics and invasive procedurs are probably needed.

As for poisoning leading to clinical death (carbon monoxide, CO2, cardiotoxins like digitalis, drugs of abuse, etc), what are your measures to reverse the toxin in most cases? Not many, and are those carried and trained with? To some degree, the ambulance can equal "wait and see and support vitals" as in the hospital whiel enroute, but as a rule of thumb any case headed for the ICU needs to get there sooner rather than later.

I am not saying "snatch and run" all the time. I am not saying field measures and operators are futile. I am not saying a hospital can do miracles versus a good amblance and crew, or that all crews are target-fixated, "single combat with Death" cowboys. I am saying that the role of field techs, while absolutely essential and important, and in the face of getting more tools and missions, is not general medical practice nor is it defintive for cases of true asystole.

Defintive versus field measure.

 

[Rialaigh]

Christopher, I think I am just too tired but I have having trouble interpreting the Asystole survival by time. I know if that is the initial rhythm the prognosis is poor to start with, but if you could help me out explaining that to me because it will probably directly impact my practice

Where I work currently we can call it at 20 minutes with 3 rounds of cardiac drugs (20 minutes on scene time, not 20 minutes from dispatch). And if I am understanding this data correctly calling at 20 minutes with an initial rhythm of Asystole is probably acceptable still with a worse chance of Neuro intact survival at 20 with Asystole then 40-50 with Vfib.

My other questions is going to revolve around Neuro intact survival. The bottom of your study says of eligible patients 82% of survivors were neuro intact...I am sure that is much higher then other systems but honestly I can say our system is probably well less then 10% on neuro intact survival of those we get a pulse back on. I am not sure if this has to do with our demographics, the way we work codes, our length of downtime with cpr, not running hypothermia, lack of supportive care after rosc...or what, but it is certainly an area I feel my service has leaps and bounds to improve on and I would love to see some data and have some explained to me better that I can take to our medical director for a change in protocol

 

[Chewy20]

Christopher, I think I am just too tired but I have having trouble interpreting the Asystole survival by time. I know if that is the initial rhythm the prognosis is poor to start with, but if you could help me out explaining that to me because it will probably directly impact my practice

Where I work currently we can call it at 20 minutes with 3 rounds of cardiac drugs (20 minutes on scene time, not 20 minutes from dispatch). And if I am understanding this data correctly calling at 20 minutes with an initial rhythm of Asystole is probably acceptable still with a worse chance of Neuro intact survival at 20 with Asystole then 40-50 with Vfib.

My other questions is going to revolve around Neuro intact survival. The bottom of your study says of eligible patients 82% of survivors were neuro intact...I am sure that is much higher then other systems but honestly I can say our system is probably well less then 10% on neuro intact survival of those we get a pulse back on. I am not sure if this has to do with our demographics, the way we work codes, our length of downtime with cpr, not running hypothermia, lack of supportive care after rosc...or what, but it is certainly an area I feel my service has leaps and bounds to improve on and I would love to see some data and have some explained to me better that I can take to our medical director for a change in protocol

I have found that good CPR is a systematic art form. Are you running pit-crew? What drugs are yall pushing? Why no induced hypothermia? What are you doing after ROSC?

After those are answered some people on here may be able to provide some feedback!

 

[Tigger]

I have found that good CPR is a systematic art form. Are you running pit-crew? What drugs are yall pushing? Why no induced hypothermia? What are you doing after ROSC?

After those are answered some people on here may be able to provide some feedback!

Not much great research for induced hypothermia post-ROSC. Our medical direction team recently pulled it as a result in two counties.

 

[Brandon O]

@mycrofft : I think we'd all mostly agree that penetrating trauma and toxic exposures (when salvageable) are good potential exceptions to the rule. As for MI, I wholeheartedly agree when it comes to post-ROSC care, but transporting BEFORE you get a pulse back is far more harm than benefit except in the rare cases and places where the patient may actually be cathed that way. Hospitals have lots of good stuff to support the post-arrest patient with a pulse, but for the pulseless patient they're playing from a similar playbook.

Pacing has little role in the pulseless patient.

 

[Christopher]

Christopher, I think I am just too tired but I have having trouble interpreting the Asystole survival by time. I know if that is the initial rhythm the prognosis is poor to start with, but if you could help me out explaining that to me because it will probably directly impact my practice.

Where I work currently we can call it at 20 minutes with 3 rounds of cardiac drugs (20 minutes on scene time, not 20 minutes from dispatch). And if I am understanding this data correctly calling at 20 minutes with an initial rhythm of Asystole is probably acceptable still with a worse chance of Neuro intact survival at 20 with Asystole then 40-50 with Vfib.

20 minutes with a presenting rhythm of asystole is predicted to be roughly 2% survival to discharge neuro intact. 30 mins is 1%, and 40 mins is 0.5%. Futility is often defined as <1.0% survival. This assumes a full system of care (HQ-CPR, TH, etc) is in place.

There is some interesting research into rhythm-transition and its influence on survival, which may help inform us as to who makes up that 1.0% of survivors at 40+ minutes.

My other questions is going to revolve around Neuro intact survival. The bottom of your study says of eligible patients 82% of survivors were neuro intact...I am sure that is much higher then other systems but honestly I can say our system is probably well less then 10% on neuro intact survival of those we get a pulse back on. I am not sure if this has to do with our demographics, the way we work codes, our length of downtime with cpr, not running hypothermia, lack of supportive care after rosc...or what, but it is certainly an area I feel my service has leaps and bounds to improve on and I would love to see some data and have some explained to me better that I can take to our medical director for a change in protocol.

My advice? Start with a protocol that emphasizes high quality, continuous CPR. Focus should be placed on minimal interruptions (<5 seconds every 2 minutes), precharging for defibrillation. No airway attempts should stop CPR, except for the rare surgical airway. My county's experience has taught us that simply focusing on the basics gets you the largest increase in neuro intact survival. We're suburban/rural, with 9-12 minutes to first hands on chest and survival tripled after going with that basic strategy (PH-TTM was added as well, but the system of care at the hospital was already in place).

Implementing the full system of care with the hospitals and rehab facilities takes quite a bit more work, and ultimately will result in smaller gains. Not that these are not worth it, but they are likely outside of your realm of influence.

 

[Chewy20]

Not much great research for induced hypothermia post-ROSC. Our medical direction team recently pulled it as a result in two counties.

Agreed, but if a temp is sky rocketed after ROSC its at least brings that core temperature back down to a normal range. No idea if it ACTUALLY keeps you from being a vegetable, but that isn't up to me haha.

 

[Tigger]

Agreed, but if a temp is sky rocketed after ROSC its at least brings that core temperature back down to a normal range. No idea if it ACTUALLY keeps you from being a vegetable, but that isn't up to me haha.

Sure. Unfortunately many places don't bother with temperature monitoring anyway.

 

[Chewy20]

Sure. Unfortunately many places don't bother with temperature monitoring anyway.

True luckily the tool is right on the Zoll so its used on every arrest. >37kg, non-traumatic cause, no suspected hemorrhagic cause, temp more than 93.2F, and doesn't follow commands is getting induced.

 

[Chewy20]

20 minutes with a presenting rhythm of asystole is predicted to be roughly 2% survival to discharge neuro intact. 30 mins is 1%, and 40 mins is 0.5%. Futility is often defined as <1.0% survival. This assumes a full system of care (HQ-CPR, TH, etc) is in place.

There is some interesting research into rhythm-transition and its influence on survival, which may help inform us as to who makes up that 1.0% of survivors at 40+ minutes.



My advice? Start with a protocol that emphasizes high quality, continuous CPR. Focus should be placed on minimal interruptions (<5 seconds every 2 minutes), precharging for defibrillation. No airway attempts should stop CPR, except for the rare surgical airway. My county's experience has taught us that simply focusing on the basics gets you the largest increase in neuro intact survival. We're suburban/rural, with 9-12 minutes to first hands on chest and survival tripled after going with that basic strategy (PH-TTM was added as well, but the system of care at the hospital was already in place).

Implementing the full system of care with the hospitals and rehab facilities takes quite a bit more work, and ultimately will result in smaller gains. Not that these are not worth it, but they are likely outside of your realm of influence.

Going off of what you said about the basics. I just looked at a study with 1294 cardiac arrests 79% of PTs were intubated, 10% BVM, 4% Combitube/EOA. After adjusting for age, bystander CPR, witnessed arrest and initial rhythm, OR for BVM vs. advanced airway was 4.5 times greater.

This is why departments are going away with just tubing everything. Just because you can get a tube down someones throat doesn't mean its the right option!

 

[Tigger]

Going off of what you said about the basics. I just looked at a study with 1294 cardiac arrests 79% of PTs were intubated, 10% BVM, 4% Combitube/EOA. After adjusting for age, bystander CPR, witnessed arrest and initial rhythm, OR for BVM vs. advanced airway was 4.5 times greater.

This is why departments are going away with just tubing everything. Just because you can get a tube down someones throat doesn't mean its the right option!

The real issue is not with intubating, it's with poor practices while intubating that result in unacceptable pauses in compressions. And SGAs are not necessarily the answer either as their significant cuff pressures can have a significantly negative effect on cerebral perfusion.

 

[Carlos Danger]

And SGAs are not necessarily the answer either as their significant cuff pressures can have a significantly negative effect on cerebral perfusion.

Do you have a source for that?