# Field termination of cardiac arrest



## daedalus (Nov 6, 2008)

I got into a huge argument with my partner today (he is a paramedic). We were in the ED dropping someone off and saw another crew bring in a cardiac arrest code 3. I shook my head and said I wish they didnt transport. Sure enough the MD comes in and calls it within 30 seconds! What a waste of resources, time, and danger to the public for transporting code.

My partner flew off the handle and lectured me that of course cardiac arrests were transported to the ER. He acted like I committed a deadly sin by saying otherwise. I told him there is a trend in EMS right now leaning away from transporting cardiac arrests as it brings false hope to the family, endangers the public with a emergent transport, and is a waste of time and resources seeing that the medic has a defib, monitor, and cardiac drugs. The medics have the same ACLS as anyone in the ER. He laughed at me and said no way in hell, all arrests get transported. He gave in that asystole should stay on scene, but I thought that even pulseless V fib was to be worked fully in the field, after all I asked him what more the ER could do for a dead person. He said continue CPR.... well so can we! 

Thoughts?


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## reaper (Nov 6, 2008)

Your partner is old or uneducated?


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## firecoins (Nov 6, 2008)

Your right.  Most codes are not going to be transported.   Pulseless V-Fib does get transported here.


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## Grady_emt (Nov 6, 2008)

We used to be fairly lax about our field terminations, and many arrests were left in the field.  This was until a crew called a code and left the body with PD awaiting the M.E. in the middle of a packed resturant on a friday night.

Now our policy is that they must start in asystole, stay in asystole through two rounds of drugs and be intubated.  If any of the above are not met, they must be transported.  

Obviously, the ones that are obviously dead are not worked.


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## KEVD18 (Nov 6, 2008)

this discussion is directly related to the sids thread ffrom a few weeks back:

http://www.emtlife.com/showthread.php?t=9382&highlight=sids

must we relive it again?


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## reaper (Nov 6, 2008)

Gotta have something interesting. It is getting boring around here lately!!!


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## traumateam1 (Nov 6, 2008)

Here you don't generally transport cardiac arrest patients. There are a few exceptions, like MD's orders, or the scene is unsafe. Other than those two criteria, all arrest patients are to stay at the scene and be worked until a termination of cardiac arrest protocol is met, or a transportation protocol is met.

Usually it's the termination, rather than transport tho.


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## Sasha (Nov 6, 2008)

We transport all cardiac arrests here unless the reason for cardiac arrest is like a crushed in rib cage (like a truck rolled over their chest where theres just no room for the heart to contract) or missing head or their legs are over THERE and the rest of them is over HERE kind of cardiac arrest, generally things were it is completely hopeless), though there is talk about moving away from transporting or even working traumatic asystole.


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## daedalus (Nov 6, 2008)

KEVD18 said:


> this discussion is directly related to the sids thread ffrom a few weeks back:
> 
> http://www.emtlife.com/showthread.php?t=9382&highlight=sids
> 
> must we relive it again?



Actually, yes we do. I need information pertinent to my situation, and it is really getting boring in here. 

We cannot let this search before posting thing get to the point of absurdity


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## KEVD18 (Nov 6, 2008)

that thread moved away from just sids to the general topic of field termination and was discussed as such for several days.

its the same topic with no new angle. your partner is an idiot. you were right but until your state puts it on paper and makes all the old school medics tale a class on it, you wont see a change.


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## MMiz (Nov 6, 2008)

Back in 2005 our protocols changed to work a code on scene for 30 minutes with ALS, and then call it or transport.


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## VentMedic (Nov 6, 2008)

This is not about termination exactly but the idea is there.  I think we all know that the back of a truck is not ideal for effective CPR.

*More CPR on scene boosts cardiac arrest survival*

Mon Oct 27, 2008 7:01pm EDT

http://www.reuters.com/article/healthNews/idUSTRE49Q88Y20081027



> CHICAGO (Reuters) - Firefighters and paramedics in Los Angeles who spent at least 20 minutes giving advanced life support to people with cardiac arrest before rushing them to the hospital were far more successful at getting hearts started again, U.S. researchers said on Monday.
> 
> 
> Cardiac arrest occurs when the heart stops circulating blood. Survival rates for cardiac arrest that occurs outside of a hospital are very poor.
> ...


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## Outbac1 (Nov 6, 2008)

If the pt is not obviously dead and is worked in the field we transport if we get a pulse and/or respirations back. To terminate on scene we need a tube, a line, have given three rounds of epi, atropine or lidocaine as appropriate and asystole or PEA and about 20 min. of working it. We then call our online Dr. tell them what happened, what we did and now have with some pt hx. The Drs almost always say to call it. The body stays put and becomes a police problem. 

  We usually stay and help the family a little then clear and go back in service. The need for a tube may change in the near future if we have an adequate airway in place with good manual respirations. 

 BLS arrests are started, if appropriate, CPR, manual airway, shock as required and transport initated. Hopefully ALS will show up before you get going and it can be worked on scene. In 7 1/2 years as a (Canadian) BLS provider I have never done a BLS arrest. I've started a couple but ALS arrived.

  Myself I usually ask whoever is there if they know if the pt would want resuscitation. I have no problem confirming VSA and leaving them dead.

 For more info please see our EHS web site 
http://emergency.medicine.dal.ca/ehsprotocols/protocols/toc.cfm

Hope this has been some help to you.


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## karaya (Nov 6, 2008)

Here is a link to a recent article on this very subject. Interesting study conducted that advocates _not _transporting cardiac arrest patients when given certain parameters.

http://www.jems.com/news_and_articles/news/saving_lives_more_efficiently.html


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## marineman (Nov 7, 2008)

I don't know the exact protocols on transporting or not transporting but I know we don't transport all of them. If we are transporting we go non-emergency unless they have a shockable rhythm.


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## Gi.Josiah6201 (Nov 20, 2008)

*I may be dumb but...*

Is there also not a question of they interval of time in between when  an arrest is found - bls / acls begins and before time on table for possible cardiac catheterization or Fibrinolytic therapy can be initiated?


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## WuLabsWuTecH (Nov 20, 2008)

Outbac1 said:


> If the pt is not obviously dead and is worked in the field we transport if we get a pulse and/or respirations back. To terminate on scene we need a tube, a line, have given three rounds of epi, atropine or lidocaine as appropriate and asystole or PEA and about 20 min. of working it. We then call our online Dr. tell them what happened, what we did and now have with some pt hx. The Drs almost always say to call it. The body stays put and becomes a police problem.
> 
> We usually stay and help the family a little then clear and go back in service. The need for a tube may change in the near future if we have an adequate airway in place with good manual respirations.
> 
> ...


Ok, here's an interesting question.  I'm BLS, I go through CPR/AED/Intubation and am getting in the rig ready to load and go.  ALS was called as soon as we got to the scene but they are still X minutes out.  We are Y minutes from the hospital.

What's the differential needed there for the following 3 options:

Waiting for ALS
Intercepting with ALS
Straight Shot to the Hospital

My guess is that we would wait up to 5 more minutes for ALS unless the hospital was less than 10 min away.

Intercept if they are in the right direction (toward the hospital, never go away from it!) but more than 5 min out and the hospital is more than 20 min away?

Around my city though, I would almost always go straight to the ED since i'm usually less than 5 minutes from an ER and if BLS was called to the scene it's ususally due to the fact that the closest ALS is very far out.


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## medicdan (Nov 20, 2008)

Gi.Josiah6201 said:


> Is there also not a question of they interval of time in between when  an arrest is found - bls / acls begins and before time on table for possible cardiac catheterization or Fibrinolytic therapy can be initiated?



This is not so related to the OP-- so it may warrant a separate disucssion...

Below is a quick summary of my notes from two recent lecures. The first was Dr. Peter Moyer. Feel free to correct me.  

Re: angioplasty:
Different facilities have slightly different standards, but in Boston, its generally considered optimal to get a stent into a patient withing 90 min of symptom onset. 

In Boston we have several cath lab-capable facilities, and in order to maintain certification, both the facilities an the staff need to do a certain number of procedures a year. In most cases, BostonEMS calls a STEMI alert as soon as they get a 12-lead, activating the team, who has to live within 30 min of the hospital. The patient goes to the ER until the lab is ready, and most hospitals try to have a door-balloon time of ~20 minutes. In order for this to happen, ALS needs to get to the scene quickly-- to get the 12-lead, and they have a response time of less then 8 min (4/6 for fire/BLS) For the record, hospitals are doing many fewer CABG procedures, electing for the less invasive cardiac cath. 

Re: tPA
Some statistics from a different recent lecture. 

~6500 ischemic strokes/year in MA
~20% patients arrive in the ER/ED within 2 hours of symptom onset. 
~5% patients eligible for tPA
Average time delays:
Symptom onset to EMS activation: 66 min
Dispatch to pt contact: 6 min
Pt contact to hosp notification: 17min
pt contact to hosp arrival: 24min
Total: 96min

IV tPA- 3 hours from symptom onset
Intra-aterial thrombotic-- 3-6 hours from symptom onset
mechanical retrieval (coil)--3-6 hours 

Hope this answered your questions (in a long-winded way!)


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## bonedog (Nov 20, 2008)

Unless there is a treatable cause for which I don't have the cure,(not much in reality) work the patient at the scene until ROSC or medic determined celestial D/C. 

Good CPR is paramount, with little or no interuption, in order to keep up the coronary perfusion, otherwise it is all for naught.


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## crayzeeemt (Nov 27, 2008)

*answer*

Many different places have easy to follow guidelines for full arrest.  We have it so the scratch your head guesswork is taken out of it all.  In OKC, if a person is in their home of a nusing home is the ONLY time where you can work them for 30 and if the pt does not come out of asystole or PEA.  If they come out into another rythmn.  BOOM, transport.  If they are ANYWHERE ELSE, we transport.  We do not leave people in the mall, dead, from a heart attack.  The only time we leave poeple where they are is if they are obviously dead.  Rigor, pooling, etc.


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## Melbourne MICA (Nov 27, 2008)

*Arrested Pts*

With the current level of training, education and equipment provided to ambos and the effectiveness of the new ILCOR CPR guidelines, the time is now long passed where resus measures in hospital are considered the definitive care in the arrested pt.

Surely the only reason to transport to hospital is for post arrest management.
This is particularly true given we have now been given much clearer guidelines as to our role, responsibilities, where our authority to make decisions begins and ends and what is reasonable to expect given the various arrest situations that can arise.

As far as I can see, there are only three things we need to do in an arrest (not including drug choices etc).

1. Make a clinical determination as to the pts viability for a resus attempt.
2. Achieve the goal you set yourself by making that determination - achieve   output state.
3. Having done this, move the pt on to the hospital for post resus management using tools, equipment, expertise and drugs that we cannot provide nor utilise.

I posted some stuff along these lines in the RSI thread from a while back. All things being equal there are very few occasions where you do active resus in the truck. If you have to do CPR in the truck, either the pt has rearrested, has just arrested or is a paediatric arrest all of whom are transported except the obviously deceased.

A stable platform to work on, space to work in and enough hands so the arrest protocol can be worked through.

Its not the battlefield so we don't have to race away from the incoming mortar rounds with our arrested pt in tow all the while giving substandard care.

Do it at the scene, get it right, get them going and get them there.

MM


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## bonedog (Nov 29, 2008)

With new CPR and the stats showing good uninterupted CPR having better outcomes, here in BC even the BLS with out ALS will work them to D/C in some circumstances.

The loss of coronary perfusion with transport pretty much outweights the reason's for transport with the >15 sec interuption of compressions.

This also is safer for the crews, no more crumby extrications with dead people on clamshells.....


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## Melbourne MICA (Nov 29, 2008)

bonedog said:


> With new CPR and the stats showing good uninterupted CPR having better outcomes, here in BC even the BLS with out ALS will work them to D/C in some circumstances.
> 
> The loss of coronary perfusion with transport pretty much outweights the reason's for transport with the >15 sec interuption of compressions.
> 
> This also is safer for the crews, no more crumby extrications with dead people on clamshells.....




I think it is becoming clear that with a better understanding of the nuances of CPR ie how the ILCOR guidelines have shifted the emphasis to continuous uninterrupted and effective compressions we are looking at improved viability of those who are viable to begin with of reaching the next stage of successful resuscitation - maintaining perfusion and neurological state to an outcome of survival with minimal deficits and reduced long term complications.

Ambos are in the best position to know who is going to fit into this category of patients. We also know that a certain percentage of our arrested patients are the "end of life" category.

It is a very exciting time as the role of early intervention to reach stage one of resus is an achievable goal. 

More importantly this provides a valuable opportunity for the ALS component of the resus patient care to come into play. With years of criticisms of ALS care - you know the stuff, no supporting studies or evidence to justify our role in various clinical circumstances, it is fantastic that we can add  "post resus" perfusion support to our list of interventions where we were can and do make a difference.

It's also a "barrow" we ALS type must push. This might mean we start pressing for some alternative therapies and drugs - vasopressors, dopamine, proper IMED type pumps, proper ventilators etc.

Who knows, one of these days we may actually bring "intensive" care to the streets. Great stuff.

MM


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## crayzeeemt (Nov 30, 2008)

*soooo*



bonedog said:


> With new CPR and the stats showing good uninterupted CPR having better outcomes, here in BC even the BLS with out ALS will work them to D/C in some circumstances.
> 
> The loss of coronary perfusion with transport pretty much outweights the reason's for transport with the >15 sec interuption of compressions.
> 
> This also is safer for the crews, no more crumby extrications with dead people on clamshells.....



Does your state allow you to work them for however long and then leave them no matter where they are?  ]
You are right, technology and training will help a person in cardiac arrest as long as it is not interrupted.  Sometimes, you have to haul no matter what. Our numbers are working out for the better.  Right now, we are #1 in the nation for ROSC.


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## Ridryder911 (Nov 30, 2008)

crayzeeemt said:


> Does your state allow you to work them for however long and then leave them no matter where they are?  ]
> You are right, technology and training will help a person in cardiac arrest as long as it is not interrupted.  Sometimes, you have to haul no matter what. Our numbers are working out for the better.  Right now, we are #1 in the nation for ROSC.



Are you sure about the numbers? I hope you are not basing those numbers from Sacra's little study that is flawed as in proportion and values. Look at the scientific studies not propaganda. 

R/r 911


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## crayzeeemt (Nov 30, 2008)

Ridryder911 said:


> Are you sure about the numbers? I hope you are not basing those numbers from Sacra's little study that is flawed as in proportion and values. Look at the scientific studies not propaganda.
> 
> R/r 911



Wow, someone's been around emsa and doesn't like Sacra.


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## bonedog (Nov 30, 2008)

Here paramedics are considered to valuable and in short supply to be tied up doing body service/coroner work.
Clear for the next live one....


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## bonedog (Nov 30, 2008)

"Does your state allow you to work them for however long and then leave them no matter where they are? "

BC is a province of Canada.

In most cases we don't transport bodies, of course there are exceptions.

Most ALS work a patient until they feel they have run out of options, no specific time guidelines, we have protocols based on ACLS algorythms however are encouraged to think outside of the box and provide treatment for differentials... Transport in CA is only for treatable causes.


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## Ridryder911 (Nov 30, 2008)

crayzeeemt said:


> Wow, someone's been around emsa and doesn't like Sacra.



Actually no. I have never worked at EMSA (proud to say) and John & I are good friends. I have known and worked with John in developing Trauma Centers and State EMS agencies for several decades but I also know the propaganda that was misreported too. Read into the studies and true statistics they are not what they were announced. 

R/r 911


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## tydek07 (Dec 1, 2008)

We transport most of our arrests. The times we would not transport is 1) Of course there is an obvious death  2) The pt has been in asystole the entire time of working them

Those are 2 times we would not, of course every code is different and decisions have to be made accordingly.

But, yes... we end up transport most of our codes to the ER.

Take Care,


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## PapaBear434 (Dec 4, 2008)

For us, it's any "obvious signs of death."  Rigor, lividity, extremely cool to the touch, missing head...  Outside of that, we work the code and transport.

It may cause false hopes in some families when we transport a person who has been pulseless for at least half an hour before we even get there, but I think my agency balances it out with the liability issues of said family thinking we didn't do everything possible to help their loved one.  Let the MD put it on their shoulders and malpractice insurance instead of us, I guess.


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## TomB (Dec 4, 2008)

The recent series in JAMA based on CARES data (Cardiac Arrest Registry to Enhance Survival) should put everyone's mind at ease about terminating resuscitative efforts in the field. AHA has been encouraging this for years.


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## bonedog (Dec 4, 2008)

Excellent point TomB. Much safer to call it than attempt a futile transport. 

I wonder if the transport orders have anything to do with billing?


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