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



## Dutchieee (Jan 21, 2016)

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.)


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## ERDoc (Jan 21, 2016)

Unconscious-ABCs, figure out why

Cardiac arrest-CPR/ACLS


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## NomadicMedic (Jan 21, 2016)

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


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## Jim37F (Jan 21, 2016)

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.


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## StCEMT (Jan 21, 2016)

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.


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## SpecialK (Jan 22, 2016)

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.


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## STXmedic (Jan 22, 2016)

Hope for a DNR.


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## EpiEMS (Jan 22, 2016)

Witnessed arrest? No question -- work it.


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## medichopeful (Jan 23, 2016)

Dutchieee said:


> 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.


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## LocNar (Jan 26, 2016)

Precordial thump.


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## Chewy20 (Jan 26, 2016)

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


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## Fayettecong (Jan 29, 2016)

SpecialK said:


> 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)


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## SpecialK (Jan 29, 2016)

Fayettecong said:


> 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.


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## Jim37F (Jan 29, 2016)

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...


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## chaz90 (Jan 29, 2016)

Jim37F said:


> 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.


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## redundantbassist (Jan 30, 2016)

chaz90 said:


> 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.


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## NomadicMedic (Jan 30, 2016)

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.


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## redundantbassist (Jan 30, 2016)

DEmedic said:


> 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.


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## SpecialK (Jan 30, 2016)

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.


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## NomadicMedic (Jan 30, 2016)

@TomB could weigh in on this.


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## Tigger (Feb 1, 2016)

Jim37F said:


> 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...


Maybe...
http://www.jems.com/articles/print/...ads-nurse-to-shock-concious-boy-with-aed.html


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## luke_31 (Feb 1, 2016)

Tigger said:


> Maybe...
> http://www.jems.com/articles/print/...ads-nurse-to-shock-concious-boy-with-aed.html


Had a PA shock a patient with an AED before. The patient was shivering which must have given enough artifact to be misinterpreted as v-fib


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## Gordon Miller (Feb 1, 2016)

Time and skill level of your unit are a big factor in this question.If you're a BLS unit 5 min or less from an ER  one rescuer CPR/AED and diesel.If you say 10 mins out I would pull over and alternate compressions with your partner till an ALS unit arrived. If you were on an ALS unit 5 min or less I would still go with CPR/difib  and diesel. Being a true 5 min or less. 10 mins out on an ALS unit pull over and and work the code per ACLS guidelines until you had ROSC or 20min with out a pulse. Here is how you justify this,If you're 5 mins or less out BLS or ALS quality CPR is better than delaying transport to the ER to either A.wait for an ALS unit or B. Spend another 15 min on the side of the road initiating full ACLS care. I'm not saying I wouldn't place the fast patches ect but intubation not so much.If they have a line if its handy give them an initial epi. Over 10 mins you're no going to be able to provide quality compressions,this is not an option but fact proven by the AHA.Not only would that be less beneficial to the patient but a lawyer would rip you apart if it went to court. AHA has time after time emphasized high quality compressions and that is the focus of a situation such as this.When it all comes down to it,you can intubate,start IVs and push drugs all you want.But if blood isn't circulating it's all useless.  I'm just glad the ground service I work for has LUCAS's lol.Also just FYI compressions are where it's at,I remember back in the 5:1 days I didn't get ROSC on half the number of patients I do now.


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## wilderness911 (Feb 1, 2016)

LocNar said:


> Precordial thump.



+1 on this! I was going to write the same thing. Witnessed arrest (witnessed by me, that is) and my first move is always going to be a precordial thump. If that doesn't work, on to the algorithm. 

Or in other words, give em the shocker


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## wxemt (Feb 10, 2016)

Witnessed arrest en-route and more than 2-3 minutes out from ER.  Pull over, apply AED\analyze, work them as usual.  Call for a medic and manpower.

Witnessed arrest en-route and less than 2-3 minutes out from ER.  Work them with focus on best CPR possible and AED.  If manpower and time permits, attempt to get a King in them.  By the time we pull over and wait for a medic, we could have already had them to the ER.

Unconscious:  Check my ABCs, call for ALS, get a set of vitals, titrate 02 to SPo2 of 94% - 96% if hypoxic, run a 12-lead and print a strip for incoming ALS if they want it, check sugar, and upgrade to lights and sirens if not already running priority.  May consider calling ER to give initial report, depending on the situation.


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## TomB (Feb 20, 2016)

I agree with those who say relax, pull over, and work the code like a day at the office. In fact we now train for it because our own data showed that 10-15% of our cardiac arrest patient's re-arrested en route to the hospital. For witnessed VF/VT arrests in particular, when you get ROSC, set the VF/VT alarm (we've had 1-2 minutes of unrecognized VF while moving down the sidewalk). Now when we do simulations, we have our crews load the patient for transport and we have the patient re-arrest. They verbalize that they pull over, start compressions, charge the capacitor, shock while minimizing perishock pause, and so on. The worst way you can treat this is "high flow diesel." Those patients die when we lose our cool.


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## Tigger (Feb 20, 2016)

Gordon Miller said:


> Time and skill level of your unit are a big factor in this question.If you're a BLS unit 5 min or less from an ER  one rescuer CPR/AED and diesel.If you say 10 mins out I would pull over and alternate compressions with your partner till an ALS unit arrived. If you were on an ALS unit 5 min or less I would still go with CPR/difib  and diesel. Being a true 5 min or less. 10 mins out on an ALS unit pull over and and work the code per ACLS guidelines until you had ROSC or 20min with out a pulse. Here is how you justify this,If you're 5 mins or less out BLS or ALS quality CPR is better than delaying transport to the ER to either A.wait for an ALS unit or B. Spend another 15 min on the side of the road initiating full ACLS care. I'm not saying I wouldn't place the fast patches ect but intubation not so much.If they have a line if its handy give them an initial epi. Over 10 mins you're no going to be able to provide quality compressions,this is not an option but fact proven by the AHA.Not only would that be less beneficial to the patient but a lawyer would rip you apart if it went to court. AHA has time after time emphasized high quality compressions and that is the focus of a situation such as this.When it all comes down to it,you can intubate,start IVs and push drugs all you want.But if blood isn't circulating it's all useless.  I'm just glad the ground service I work for has LUCAS's lol.Also just FYI compressions are where it's at,I remember back in the 5:1 days I didn't get ROSC on half the number of patients I do now.



Five minutes is a long time to be doing crappy CPR...


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## ParamedicStudent (Apr 9, 2016)

Serious question : do you work them in the back of the ambulance, or do you take the gurney out and put them on the ground?


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## NomadicMedic (Apr 9, 2016)

On the ambulance stretcher.


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## cruiseforever (Apr 9, 2016)

DEmedic said:


> On the ambulance stretcher.



Does anyone still use a CPR board?  I have not seen one used in a long time.


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## NomadicMedic (Apr 9, 2016)

I haven't seen one in ages. Most of my arrests wind up on a board if I'm transporting them. (Usually I work them in the hosue and call it...)

But sure, for the sake of argument, shove something hard underneath.


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## MonkeyArrow (Apr 9, 2016)

cruiseforever said:


> Does anyone still use a CPR board?  I have not seen one used in a long time.


We have these weird looking plastic foldable boards on the bottom of our hopsital strecthers that nobody ever uses. I can't figure out if it is meant to be a CPR board or help/facilitate patient transfer. Nevertheless, no one ever uses them.


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