# Pt goes unresponsive en route to hospital



## AlwaysLearning (Jan 10, 2016)

Howdy,

So lets say my patient is on the stretcher and we are on our way to the ER.  Then suddenly our patient goes unresponsive, pulseless, and apneic.

I am an ALS provider, the driver is BLS, and it is just us two.

What do we do?

Considerations I'm thinking about...

Our pt needs to be on a hard surface for good quality compressions.

Time to ER? Are we 2 min away?  If so, is it best to just notify the receiving facility of the upgrade and changes and I just do 1 person CPR til we get there?

Long transport?  Should we call for additional resources whether it be fire or whomever to meet up with us on the side of the road and run the code there? 

Or just one rider to meet up with us so we can stop, get the patient on a backboard and back on the stretcher and resume transport with the additional rider doing compressions while I work on the ALS steps?

Thank you!


----------



## Chimpie (Jan 10, 2016)

In real world scenarios, yes, yes and yes.


----------



## teedubbyaw (Jan 10, 2016)

2 minutes? Throw on pads, shock if needed, do CPR en-route. Any further than that, pull over and work the code or get enough resources to work it en-route. 

We have Lucas machines, so it would still be a juggling act between airway, meds, monitor.


----------



## Underoath87 (Jan 11, 2016)

I'll just add that placing a NRB on them would also help if you get the chance.


----------



## RocketMedic (Jan 24, 2016)

Depends a lot on a lot of variables. Equipment, truck type, time and distance, cause of arrest, etc.


----------



## vf116 (Mar 10, 2016)

teedubbyaw said:


> 2 minutes? Throw on pads, shock if needed, do CPR en-route. Any further than that, pull over and work the code or get enough resources to work it en-route.
> 
> We have Lucas machines, so it would still be a juggling act between airway, meds, monitor.




This...

BLS before ALS!! 

PLUS

-you can get pads on in less than 30secs. 
-Witnessed arrest, hopefully (most-likely) V-fib/tach
-first defib within :30-1:00 boosts chaces!


----------



## SpecialK (Mar 10, 2016)

A cardiac arrest witnessed by ambulance personnel who (should) have a defibrillator immediately available? Doesn't get any better than this really in terms of best possible situation for survival to neurologically favourable discharge!

I'd give up to three shocks at maximum joules without interrupting for CPR provided I had a defibrillator in manual mode.  If I had a defibrillator in automatic mode I would still deliver one shock before CPR if I could not "override" the defibrillator requiring a cycle of CPR in between each analysis.  

The above can be done without stopping, and if we are literally two minutes to hospital I'd just go to hospital.  

I wouldn't bother about doing CPR in the back of a moving ambulance, it's not going to be effective and the risk is too high.


----------



## ERDoc (Mar 10, 2016)

vf116 said:


> BLS before ALS!!









What is up with the pads?  Does no one use paddles anymore?


----------



## vf116 (Mar 10, 2016)

ERDoc said:


> What is up with the pads?  Does no one use paddles anymore?



To specify I was saying for this one particular scenario... 
Witnessed full arrest, 2 minutes from hospital, as an ALS provider, BLS before ALS.
However because he is ALS an early defib can be done.




vf116 said:


> This...
> 
> BLS before ALS!!
> 
> ...


----------



## ERDoc (Mar 10, 2016)

I have to disagree.  This is the exact situation where it should be ALS before anything else.  The first thing you want to know is if you have a shockable rhythm.  Even the 2 minute ride to the ER is too long to wait and you know it is going to be longer than 2 minutes by the time they get shocked.  The sooner you can shock the better the chances for a witnessed arrest.  Stop the ambulance immediately, throw the pads on (or go old school like me and grab the paddles, you will look much more badass) and shock as quick as possible.  I probably have an n=around 50 that I have shocked in less than a minute and have an almost 99% success rate.  These people don't need meds, diesel, CPR or even a doctor.  They need electricity.  As one of my attendings in residency became infamous for says, "Spark 'em up"


----------



## squirrel15 (Mar 13, 2016)

ERDoc said:


> As one of my attendings in residency became infamous for says, "Spark 'em up"


 I really hope they're known as sparky


----------



## ERDoc (Mar 13, 2016)

The rest of the story is a bit off topic but gets even better.  This spark em statement was said to an EMS crew over a radio that the entire county could hear.  This was a volley system with very conservative standing orders and I think they called in for a c/o chest pain originally and while they were on the radio with medical control they say, "Oh, hold on.  He just went into Vfib."
Doc "OK, spark em up."
EMS (distant in the background), defib charge sound, "Hold on sir, this is going to hurt quite a bit."
Sound of defib and a scream.

The call review showed that the ambulance never pulled over and the pt was never in Vfib.  It was road artifact.


----------



## johnrsemt (Mar 14, 2016)

Patients can be awake and talk for the first few seconds of V-Fib,  but I would make sure it is V-fib before I shocked them, if they were talking
Monitors do NOT like road noise, and they tend to over react to bumps (try it on a dirt/gravel road if you want to really drive yourself nuts with monitor alarms)


----------



## jaeems (Apr 7, 2017)

ERDoc said:


> I have to disagree.  This is the exact situation where it should be ALS before anything else.  The first thing you want to know is if you have a shockable rhythm.  Even the 2 minute ride to the ER is too long to wait and you know it is going to be longer than 2 minutes by the time they get shocked.  The sooner you can shock the better the chances for a witnessed arrest.  Stop the ambulance immediately, throw the pads on (or go old school like me and grab the paddles, you will look much more badass) and shock as quick as possible.  I probably have an n=around 50 that I have shocked in less than a minute and have an almost 99% success rate.  These people don't need meds, diesel, CPR or even a doctor.  They need electricity.  As one of my attendings in residency became infamous for says, "Spark 'em up"



Very true. 
"The chain of survival."


----------



## hometownmedic5 (Apr 7, 2017)

I'm going to answer this question generically in regards to ALS/BLS because the answer is the same and the patient doesn't care if you're a medic or a basic when they code, so it can happen to anybody. 

If the capacity for defibrillation exists(I'm told there are "ambulances" in some places in the country that don't have aeds), then the immediate priority is for defibrillation. Get out the device(whichever you have), apply the pads, stop the truck, shock if advised/appropriate, and then point the truck at that ER two minutes away and go. 

I personally wouldn't spend any time ALSing this patient(beyond ekg interp and manual defib). The priority here is defibrillation and compressions. Yes, we're going to do a crappy job at it in a moving truck on a patient without a board under them. I get it. If your protocols/companies allow you to play candy crush instead of doing cpr because you can't do cpr wearing a seatbelt, great. Mine don't, my state and company couldn't care less about my safety. My protocols state I must wear my seatbelt unless pt care needs dictate I take it off and if I have to, then I guess I hope I don't die. 

I can deliver you a patient that has been intubated, accessed intravenously, medicated with an arbitrary number of epis and is fully prepared for you to pronounce them 15 or 20 minutes from now; or I can bring you a patient who might actually make it out alive without having done a damn thing in about 2 minutes. Pick one.


----------



## StCEMT (Apr 7, 2017)

Stop-->pulse check-->pads-->shock if shockable, maybe/probably more than once-->Compressions if no success. From there, either I or my partner will insert an igel and hook the vent up. Maybe an IO, but I wont push meds with the 2 minute scenario. Let the vent do the breathing, I will do compressions, drive, shock. 

If I am any significant distance away then pull over and work it like a normal code.


----------



## EMS HOT BOX (Apr 29, 2017)

I guess some people left all they learned at the academy door. If you're ALS qualified you best get them paddles on the patient to see if you've even got a viable rhythm to shock then focus on breath & blood flow. Since it's just you in the back you need to have your partner pull over anyway to help get you through your now emergent patient issue then get to the hospital because no matter what you do and/or how long you're going to delay the trip to the ER you have to show up for continuing care eventually.


----------



## E tank (Apr 29, 2017)

EMS HOT BOX said:


> I guess some people left all they learned at the academy door. If you're ALS qualified you best get them paddles on the patient to see if you've even got a viable rhythm to shock then focus on breath & blood flow. Since it's just you in the back you need to have your partner pull over anyway to help get you through your now emergent patient issue then get to the hospital because no matter what you do and/or how long you're going to delay the trip to the ER you have to show up for continuing care eventually.



Good synopsis of StCEMT's comment.


----------

