# The effect of ALS before cardiac arrest



## SeeNoMore (Apr 19, 2010)

I've seen a lot of research and studies done around ALS for cardiac arrest, most of it seeming to speak against any appreciable benefit. 

I was curious though about whether there is conclusive evidence on the effect Paramedics have on patients experiencing chest pain or problematic rythms before they have a heart attack. Or is this too difficult to determine? 

It seems that Paramedics often get judged by the effect treatments have on patients in the most dire situations, which makes some sense. But it seems like ALS might be the most effective as it is used to prevent these situations from occuring.


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## TomB (Apr 19, 2010)

SeeNoMore said:


> I've seen a lot of research and studies done around ALS for cardiac arrest, most of it seeming to speak against any appreciable benefit.
> 
> I was curious though about whether there is conclusive evidence on the effect Paramedics have on patients experiencing chest pain or problematic rythms before they have a heart attack. Or is this too difficult to determine?
> 
> It seems that Paramedics often get judged by the effect treatments have on patients in the most dire situations, which makes some sense. But it seems like ALS might be the most effective as it is used to prevent these situations from occuring.



I don't know what it would take to prove it, but I feel certain that we benefit peri-arrest patients. Personally, I think the ALS/BLS distinction is an antiquated way to look at EMS. We need to move away from that kind of paradigm and look at prehospital care much more broadly as we move kicking and screaming into the evidence-based era.

Anecdotally, I'm certain that failure to identify life-threatening hyperkalemia has caused several patients their life. Requiring all paramedics to be educated to the ACLS-EP level would be a nice start.

Tom


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## mgr22 (Apr 19, 2010)

One approach is to compare prehospital impressions and care to hospital diagnoses and dispositions. It can get pretty complicated, but it does provide useful feedback once you work out the logic and build the necessary relationships.


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## usafmedic45 (Apr 19, 2010)

It's a pain in the *** to do prehospital cardiac arrest research.  The issues of case volume, consent, randomization are the major reasons why there is very little on the subject that interests you.


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## Veneficus (Apr 19, 2010)

TomB said:


> I don't know what it would take to prove it, but I feel certain that we benefit peri-arrest patients. Personally, I think the ALS/BLS distinction is an antiquated way to look at EMS. We need to move away from that kind of paradigm and look at prehospital care much more broadly as we move kicking and screaming into the evidence-based era.
> 
> Anecdotally, I'm certain that failure to identify life-threatening hyperkalemia has caused several patients their life. Requiring all paramedics to be educated to the ACLS-EP level would be a nice start.
> 
> Tom



But the EP course is not an "if: then" algorythm, it would require paramedics to have considerably more knowledge than is currently called for, which puts us in the endless education debate yet again.


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## TomB (Apr 19, 2010)

Seriously! So maybe it's not ALS that doesn't save lives, but rather poorly trained paramedics providing substandard ALS care that doesn't save lives. What a mess!


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## Veneficus (Apr 19, 2010)

TomB said:


> Seriously! So maybe it's not ALS that doesn't save lives, but rather poorly trained paramedics providing substandard ALS care that doesn't save lives. What a mess!



Welcome to my world.


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## reaper (Apr 19, 2010)

Come on, we dont need to be educmacated. We have these fancy machines that tell us what is wrong with the pt!


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## mycrofft (Apr 19, 2010)

*Everything is an "if:then; else:..." deal except for the terminal "yes/no".*

It's just that the more you know the more nuanced it gets. And the more you have to work on cutting to the chase.

There is little which could be designed to give a more negative outcome than tabulating how many cinically dead people can be brought back to life after the delays to get field care. When cardiac measures, starting with CPR, were moved out of the hospital, it was recognized that around 70% of people who presented thier cardiac conditions would do so with "sudden death" asystole and the street/field/swamp whatever measures would never be as good as a hospital, but were the victim's only/best chance. One side ratcheted the level of care and public expectations up, the other wants to measure it without accounting for the fact that the majority of cases seen by street ALCS are amongst the greatest-risk patients, along with premature births and drastic traumas.

If ACLS is found lacking, well, ok. Decide what the next step is but refine the mission/expectations and _then_ the measures, don't just condemn the participants (except where they deserve it of course).


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## MrBrown (Apr 19, 2010)

TomB said:


> Seriously! So maybe it's not ALS that doesn't save lives, but rather poorly trained paramedics providing substandard ALS care that doesn't save lives. What a mess!



Agreed!

ALS care is not required here (or in Australia) to consider termination of resuscitation efforts.  Look at the evidence, the evidence is that amiodarone might help a little and so may adrenaline, but all we're doing is trying to make defibrillation more effective.  

When we get our upskilling program finished there will not be a need for an Intensive Care Paramedic (ALS) to attend a cardiac arrest ere because the only additional skill they can bring is intubation (whic isn't really required) and IO.

Dare I say those two minute response times and a Paramedic on every fire truck aren't required? Maybe ALS does not save as many lives as some like to think?


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## DrParasite (Apr 19, 2010)

MrBrown said:


> When we get our upskilling program finished there will not be a need for an Intensive Care Paramedic (ALS) to attend a cardiac arrest ere because the only additional skill they can bring is intubation (whic isn't really required) and IO.


but you got to admit, tubing someone and IV access are pretty important in a cardiac arrest


MrBrown said:


> Dare I say those two minute response times and a Paramedic on every fire truck aren't required? Maybe ALS does not save as many lives as some like to think?


absolutely not!!!! every patient needs a paramedic, only paramedics should be on ambulances, and the more paramedics a system has, the better it is for the patients.


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## MrBrown (Apr 19, 2010)

DrParasite said:


> but you got to admit, tubing someone and IV access are pretty important in a cardiac arrest



No I don't, infact they have little evidence as being effective and neither is required to terminate a resuscitation effort out-of-hospital here in New Zealand.



> The endotracheal tube was once considered the optimal method of managing the airway during cardiac arrest...
> 
> Studies ...failed to show a link between long-term survival rates and paramedic skills such as intubation, intravenous cannulation, and drug administration.
> 
> ...





DrParasite said:


> absolutely not!!!! every patient needs a paramedic, only paramedics should be on ambulances, and the more paramedics a system has, the better it is for the patients.



Again, you couldn't be further from the truth.

Systems like Los Angeles and Miami who want to put a Paramedic on every street corner have worse results when it comes to cardiac arrest survival rates.

Cities like Seattle, Tulsa and Boston who limit the number of Paramedics have better numbers.

A zillion paramedics fighting over each other for limited opportunities to use thier skillset leads to rustout and clinical risk.



> The it in this case is a five-city study showing that fewer paramedics are associated with higher cardiac survival rates in urban areas..
> 
> When procedures are performed routinely, it is reflected in outcomes, said Dr. Slovis, a professor and the chairman of emergency medicine at Vanderbilt Medical Center who serves as Nashville's EMS medical director. The results of the study by Michael Sayre, MD, and colleagues mimic findings across health care, Dr. Slovis said. Conversely, *when procedures such as intubation are done more infrequently, success rates are lower*, he added.
> 
> ...



Look at Australia and New Zealand; our Intensive Care Paramedics are very igly trained and there has been a deliberate upskilling program across almost every State in Australia and here in New Zealand over the past decade to ensure they are using thier specialised skills frequently.

Soon, an Intensive Care Paramedic will not be required at a cardiac arrest here anymore because Paramedics will have amiodarone (some already do), they already have adrenaline, IV access, fluid, manual defibrillation etc.  They aren't running off to jobs to give a bit of morphine or some GTN because other crews have those competencies.

You need to recognise ALS as being a practitioner of a highly invasive and specalist skillset who needs to frequently use it by giving other crews the tools they need to do what was once considered an "ALS job".  Bit of fentanyl and GTN or some fluid and adrenaline don't require ALS and by sending them off to jobs they really don't need to be at limits opportunity for exposue to use thier high level skills.

So no, an ALS Paramedic on every ambulance is not the best answer.


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## ah2388 (Apr 19, 2010)

MrBrown said:


> No I don't, infact they have little evidence as being effective and neither is required to terminate a resuscitation effort out-of-hospital here in New Zealand.
> 
> 
> 
> ...



i think you missed something in his response

i believe they call it sarcasm.

Interesting point in the 1st statement though


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## MrBrown (Apr 19, 2010)

ah2388 said:


> i think you missed something in his response
> 
> i believe they call it sarcasm.
> 
> Interesting point in the 1st statement though



The interent is a bit of a bugger like that


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## SeeNoMore (Apr 19, 2010)

Thanks for the responses. 

I am trying very hard to become a truly educated paramedic, but need some reassurance that SOMETHING we do is helpful. Just to justify the 8 hour long study sessions before study group meet ups

 As a student I feel like I'm in the twilight zone sometimes learning "skills" in a somewhat haphazard manner. 

Anyway, this seemed like one area where ALS would actually prove beneficial, along with respriratory distress etc. But I see why conclusive evidence would be hard to generate.


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## Shishkabob (Apr 19, 2010)

> No I don't, infact they have little evidence as being effective and neither is required to terminate a resuscitation effort out-of-hospital here in New Zealand.



Little doesn't mean no.  



And even if it raises just 1%, but with no detrimental side-effect, is it not then worth it?


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## MrBrown (Apr 20, 2010)

SeeNoMore said:


> Anyway, this seemed like one area where ALS would actually prove beneficial, along with respriratory distress etc. But I see why conclusive evidence would be hard to generate.



ALS is useful for the next-level up of analgesia (combination midaz/fent or ketamine) and some advanced pharmacology eg thrombolytics, antiarrythmatics/chronotropes (adrenaline, atropine) and steriods for asthma/anaphylaxis.  RSI too if properly done.



Linuss said:


> Little doesn't mean no.
> 
> And even if it raises just 1%, but with no detrimental side-effect, is it not then worth it?



Doesn't mean stop doing it no.


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## mycrofft (Apr 22, 2010)

*Five is four.*

1. Look at the sampling and statistical method. If I were doing it, I would make four categories for initial categorization of calls deemed cardiac:
1. Clinically dead/at least five minutes asystolic before arrival of EMS. (Bystander CPR would count as 0.85 asystole, since it is ineffective). EMD is asystole, we're gauging circulation/pulse, not electrical activity.
2. Clinically dead, less than five minutes asystole pre EMS (EMS called before pt asystolic).
3. Pt with some sort of viable pulse upon EMS arrival even if it is not sustainable for long and response under five min.
4. Pt with some sort of viable pulse etc and EMS arrival over five minutes.

Just the first one would weed out a bunch of cases deemed unsaved by ALS, because what they needed was a sequel since their first episode walking among us is through! (e.g., "dead is dead").

I wonder if time on scene weighed against measured attempted treatments on scene makes a difference. If you get bogged down at the scene you get past the timeframe where transport- while- treating versus on-scene heroics make sense,and those are the very pts who will weigh your stats down with their death.


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## EMTinNEPA (Apr 23, 2010)

DrParasite said:


> but you got to admit, tubing someone and IV access are pretty important in a cardiac arrest



Actually, endotracheal intubation has been deprioritized in the AHA ACLS.  They say if you can manage an airway with a pair of hands, a BVM, and an oropharyngeal airway, then go right ahead.  As for IV access, it can be important, but it isn't always.  Epinephrine is _thought_ to shunt oxygenated blood to the brain and heart through vasoconstriction, but there's no concrete evidence.  The fact of the matter is that early CPR and early defibrillation are what have been proven to make the difference.

I believe ALS prevents more cardiac arrests than it solves.  Just look at the infamous "Hs and Ts" and see how many can be managed by BLS and how many can be solved, or at least slowed down, by ALS before cardiac arrest occurs.


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## Shishkabob (Apr 23, 2010)

It depends on your protocols, but most I've seen won't let you terminate a working code without fluid access established, be it an IV or IO... some even allow an ETT if all else fails.


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## mycrofft (Apr 24, 2010)

*Invasive airway (tube) is only way to effectively vent without belly bloat.*

I think tubes may be downgraded because some folks place them on the wrong pts, and you can get behind the time curve trying to place a tube (e.g., five mnutes trying to place a stubborn tube, or past trismus, when time back to hospital is seven minutes).

IS there somewhere we can read critically the rationales for the inevitable and usually useless changes to life support protocols for field EMS? Or do they get together at Denny's one morning and sketch out stuff on napkins with the waitress's ballpoint?  I am _*convinced*_ that many changes are done outside a scientific, evidenced-supported manner.


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## Melclin (Apr 24, 2010)

Another important consideration is that an advanced airway means you don't have to pause for vents. I might add though that all providers here have LMAs so that covers that base.


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## MrBrown (Apr 25, 2010)

Melclin said:


> Another important consideration is that an advanced airway means you don't have to pause for vents. I might add though that all providers here have LMAs so that covers that base.



Hmm even the basic Johnno vollies here who cannot place an LMA are taught not to pause compressions to bag somebody.  That is, provided a bag mask is in thier scope


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## Needles17 (Apr 25, 2010)

TomB said:


> Seriously! So maybe it's not ALS that doesn't save lives, but rather poorly trained paramedics providing substandard ALS care that doesn't save lives. What a mess!



Simple answer, but the truth.  The only other thing that would help a paramedic determine if a patient is truly having an MI would be blood testing for enzymes.  Other than that, we have everything we need.


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## VentMedic (Apr 25, 2010)

SeeNoMore said:


> I've seen a lot of research and studies done around ALS for cardiac arrest, most of it seeming to speak against any appreciable benefit.
> 
> I was curious though about whether there is conclusive evidence on the effect Paramedics have on patients experiencing chest pain or problematic rythms before they have a heart attack. Or is this too difficult to determine?
> 
> It seems that Paramedics often get judged by the effect treatments have on patients in the most dire situations, which makes some sense. But it seems like ALS might be the most effective as it is used to prevent these situations from occuring.


 
Are you talking ALS or just ACLS? If you are saying ALS has no effect on patients' lives, why bother bringng the patient to the hospital? The ED practices ALS. And, much of what can be done initially in the ED can be done by well educated and trained Paramedic. It is the pre-arrest that the Paramedic should be most effective with. 

How many things precipitate the cardiac arrest? Many, many things do. If it is rhythm disturbances, the Paramedic can do something to slow a rapid heart rate to regain cardiac filling. The Paramedic can treat PVCs if they are interfering with the patient's status to avoid a cardiac arrest. A Paramedic should be able to recognize the signs of sepsis to initiate fluids and pressors. However, too often the signs are overlooked because the medical part of the Paramedic's education/training is the weakest and the "its only a fever" call mentality takes over. They are also in a hurry to unload their patient to get back to wait for a "real emergency" they miss their patient going into cardiac arrest or being intubated just as they are pulling out the driveway. A Paramedic should also be able to stabilize a patient that has ROSC. Then we can go into the hypothermia and its effectiveness which is still being studied. However, if you can not go the distance with the hypothermia protocol to include all variables and meds, the outcome may not be as expected. How about the tension pneumothorax? Obstructed airway? Are you also going to say all the things mentioned in PALS are also useless? What about NRP? Isn't ETI of great importance for the preemie? What about maternal emergencies? How about prolonged seizures? 

Also, the "ALS" practiced by Flight, some CCTs and Specialty teams has been known to save lives. Yes, Paramedics have the opportunity to increase their education and training to become part of other teams if their ground EMS is stagnant or just suffices for the area they are in. One could also work toward becoming a member of some EMS organization that is progressive and a leader in research such as in Seattle.

As for as research, here's an interesting article from OHSU in Oregon. 

*Emergency Medical Service Providers' Attitudes and Experiences Regarding Enrolling Patients in Clinical Research Trials*

http://www.informaworld.com/smpp/content~db=all~content=a909569374

Here's another article about Paramedics, the 12-lead and door to balloon times.
http://www.informaworld.com/smpp/content~db=all~content=a909570596

There is prehospital research happening but you have to read something besides JEMS to find it. Or, at least pull up the articles in the reference section of the watered down article or personal interpretation done by the JEMS author to see if you get the same information.

Here are some journals which you may be able to read at least the abstracts or if you are in a Paramedic program at a college, they should have access to the full article. 

*Prehospital Emergency Care*
http://www.informaworld.com/smpp/title~content=t713698281

*Resuscitation* - European Journal - see what other countries are doing. RESUSCITATION is the official Journal of the European Resuscitation Council. It is also interesting to look up what and who makes up EMS in another country when you do find an interesting article.

Signup and you will at least be able to see the abstracts.

http://www.resuscitationjournal.com/


*Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine *
http://www.sjtrem.com/

*Emergency Medicine Journal (EMJ)-* an international peer review journal covering pre-hospital and hospital emergency medicine, and critical care. 
http://emj.bmj.com/

Here's an interesting article about studying oxygen and AMIs.
http://emj.bmj.com/content/27/4/283.abstract



> Objective To explore the feasibility of conducting an RCT of oxygen versus air in AMI, by exploring the beliefs of UK professionals who treat patients with AMI about oxygen's benefits, and to establish a baseline of reported practice by asking about their use of oxygen.
> 
> Conclusion Widespread belief in the benefit of oxygen in AMI may make it difficult to persuade funders of the importance of this issue and health professionals to participate in enrolling patients into a trial in which oxygen would be withheld from half their patients.


 
We had the same situation in the U.S. when studying how much oxygen to use for neonatal resuscitation. Telling parents their baby won't or didn't get oxygen if resuscitation is or was required can be a little unnerving.

*Journal of Emergencies, Trauma, and Shock -* another international journal. Some of the articles are available in full as well as abstract.

http://www.onlinejets.org/


*The Journal of Emergency Medicine* 
The official journal of the American Academy of Emergency Medicine
- abstracts can be read

http://www.jem-journal.com/

*One of my favorites:*

*Respiratory and Critical Medicine*
http://ajrccm.atsjournals.org/

Abstracts are available for all and full articles are available for older issues.

This will give some an idea about how indepth critical care medicine is.

Another favorite of mine:
*Journal of Respiratory Diseases* - just when you thought your EMT textbook taught you everything about COPD.

http://jrd.consultantlive.com/home

One more good journal:
*Respiratory Care Journal*
http://www.rcjournal.com/

One might ask why I included journals from Europe and critical care. The answer is very simple. Advancements in other countries and professions eventually trickle into the U.S. or onto the ambulances. Hypothermia and CPAP as well as all the medications used in prehospital have already be trialed and researched in the hospitals long before they made it to the ambulance. CPAP had been around for over 60 years before Paramedics started using it.

One also has to remember certain authors, like those in JEMS, pick out articles for a dramatic flare or to suit their own personal agenda.  An EMT might choose to review all the articles that show "BLS" is the greatest.  A Paramedic might choose articles favoring "ALS".  It is important to read many different articles from many different authors to get a broader perspective.  Some in EMS only like to read one author in JEMS "because he/she thinks just like them".  That is not actually reading for the science of medicine but more for entertainment value.


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