# Stopping CPR w/ V-fib?



## VirginiaEMT (Nov 19, 2012)

I was involved in a resuscitation attempt where the upper 70's year old man arrested in front of one of his children. CPR was started with instructions from dispatch. We worked the arrest for 50 minutes or so, the patient remained in fine v-fib the entire time. He was shocked 6 times, given 7 mg of epi. 1/10000, 450 mg amiodarone, 100 meq. if sodium bicarb, and 2 mg of Narcan, At what point would you have stopped effort to resuscitate (contact med control)?


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## DesertMedic66 (Nov 19, 2012)

Any rhythm other then asystole gets transported.


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## NomadicMedic (Nov 19, 2012)

VirginiaEMT said:


> I was involved in a resuscitation attempt where the upper 70's year old man arrested in front of one of his children. CPR was started with instructions from dispatch. We worked the arrest for 50 minutes or so, the patient remained in fine v-fib the entire time. He was shocked 6 times, given 7 mg of epi. 1/10000, 450 mg amiodarone, 100 meq. if sodium bicarb, and 2 mg of Narcan, At what point would you have stopped effort to resuscitate (contact med control)?



Was it fine VF or "slightly squiggle asystole"? Did you transport? Was this a witnessed arrest with good bystander CPR started promptly?
There are some studies that relate survival after 20+ minutes of resuscitation is greatly reduced, even with effective CPR and defibrillation.
If this was a prolonged code with no rhythm changes after 20 minutes of Epi, a series of  shocks and some amiodorone, I would have discussed calling it.  (However, I doubt our med control would let us terminate efforts on a PT still in VF. ) There is no benefit in transporting a "working arrest". The ACLS I do is the same as the ED's ACLS.


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## BigBad (Nov 19, 2012)

Transport after 15 min of persistent vfib or vtach per my protocol


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## TheLocalMedic (Nov 19, 2012)

I really don't like the argument that "any rhythm except asystole gets transported" and I'll tell you why...

Are they going to do anything different in the ER than what we're doing in the field?  As long as you have enough trained hands, what you do on a code is essentially the same as what a physician would order to be done, and, if I may be so bold, I think that us field medics actually do a really really good job on codes as a whole.  I think it's because we're a little faster and more practical?  

I'm a big proponent of working an entire code to the end on scene.  Transporting only degrades your CPR effectiveness.  And to that end, if you do get pulses back, I strongly recommend that you actually hang out on scene for about 10 minutes before hitting the road, as a patient is more likely code in the first few minutes following a successful resuscitation.  

Granted, if you have a refractory v-fib and you're working for a really long time, at some point you may just throw your hands up and make the call to just load and go.  But I still think you're better off working it into the ground where you are.


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## the_negro_puppy (Nov 20, 2012)

If you worked on him for 50 minutes and he was in VF the whole time, how come he was only shocked 6 times. This does not make sense.

We do not transport corpses. We will work any cardiac arrest until if in VF / VT and go through our protocols. Only transport if we are really close to hospital, ROSC achieved or exceptional circumstances.


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## Achilles (Nov 20, 2012)

TheLocalMedic said:


> I really don't like the argument that "any rhythm except asystole gets transported" and I'll tell you why...
> 
> Are they going to do anything different in the ER than what we're doing in the field?  As long as you have enough trained hands, what you do on a code is essentially the same as what a physician would order to be done, and, if I may be so bold, I think that us field medics actually do a really really good job on codes as a whole.  I think it's because we're a little faster and more practical?
> *Medic school: 1 year
> ...


...


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## VFlutter (Nov 20, 2012)

TheLocalMedic said:


> Are they going to do anything different in the ER than what we're doing in the field?  As long as you have enough trained hands, what you do on a code is essentially the same as what a physician would order to be done, and, if I may be so bold, I think that us field medics actually do a really really good job on codes as a whole.  I think it's because we're a little faster and more practical?
> 
> And to that end, if you do get pulses back, I strongly recommend that you actually hang out on scene for about 10 minutes before hitting the road, as a patient is more likely code in the first few minutes following a successful resuscitation.



How far away from a Hospital are you? Level one trauma? 

You can rule out the various causes of cardiac arrest (Hs & Ts) and perform the necessary interventions more effectively than an ER physician? You can relive tamponade in the field? Do you carry blood products? To say that you are faster and more practical than a Level one trauma team is very bold. 

I am not advocating transporting every arrest but to say that an arrest will be handled the same in the field as it is in the ER is a little bit of a stretch. Ill take my chances in the hospital.....

Also, you sit on scene for 10 mins post ROSC just incase they code again? What do you do during that time?


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## TheLocalMedic (Nov 20, 2012)

When was the last time you watched a code happen in the ER?  12 years of medical school is great, but the drugs given and the way it is worked is virtually the same as we play it in the field.  In fact, many docs still put a premium on an ET tube and will interrupt CPR for extended periods in order to place one.  Granted, they can use an ultrasound to check for cardiac activity, but otherwise we're playing the same game with the same tools.


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## TheLocalMedic (Nov 20, 2012)

Okay, trauma is altogether a different deal, and I'll be the first to advocate getting someone to a surgeon in a trauma case.  But as far as non-trauma codes go, I still think it's better to work it in the field.  And why do people still like to work traumatic arrests?  If its trauma and they ain't alive, then you can't really fix that... Even with a surgeon.


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## TheLocalMedic (Nov 20, 2012)

Oh, i forgot to mention... In those post-conversion minutes that's when you reassess, pop in another line, grab their history and home meds and prep for transport.


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## VFlutter (Nov 20, 2012)

TheLocalMedic said:


> When was the last time you watched a code happen in the ER?  12 years of medical school is great, but the drugs given and the way it is worked is virtually the same as we play it in the field.  In fact, many docs still put a premium on an ET tube and will interrupt CPR for extended periods in order to place one.  Granted, they can use an ultrasound to check for cardiac activity, but otherwise we're playing the same game with the same tools.



Its been a month or two. Ya, 12 years of medical is great. Do the Physicians in your area blindly follow the ACLS algorithms? I rarely see ER physicians run a textbook ACLS code like medics would, they frequently deviate based on clinical judgment and patient presentation.


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## Merck (Nov 20, 2012)

Have to agree with the why only 6 shocks if 50 minutes of VF?  Also, I'd sure like to see a strip of parts of that code.

Transporting the arrest is not a great idea - I'd stay myself.  As someone mentioned the effectiveness of CPR during transport sucks.  And the idea of racing off to the emerg so a doctor can see them is a little silly.  Consider the case - 50 minutes down will not be emergently put on ECMO if the hospital is even capable of it.

I would work this and call it when appropriate.  I'm not sure there's stats for it but I'm guessing that 70 year olds who collapse and have >20 minutes of CPR don't often recover.

Also, not sure if he was shooting heroin with his grandkids but the narcan is interesting.


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## Veneficus (Nov 20, 2012)

TheLocalMedic said:


> I really don't like the argument that "any rhythm except asystole gets transported" and I'll tell you why...
> 
> Are they going to do anything different in the ER than what we're doing in the field?  As long as you have enough trained hands, what you do on a code is essentially the same as what a physician would order to be done, and, if I may be so bold, I think that us field medics actually do a really really good job on codes as a whole.  I think it's because we're a little faster and more practical?
> 
> ...



I am of the opinion that codes should be worked in the field. 

Not for the same reasons listed here.

First, let me just presumptiously state I am really good at working codes. 

That is not the same as being really good at following an ACLS algorythm. (which I am also exceptionally skilled at) 

Back to our regularly scheduled program...

the ACLS guidlines are designed based on epidemiology. Since 70% of SCA is because of vfib, and arrhythmia is the most common side effect of MI, The early CPR and shock will work on most codes. (which is why there is such a push for community CPR and AEDs)

In the event of ROSC, you do not simply wish the patient a good day. You transport to the hospital where that patient receives ongoing resuscitation and treatment of the underlying condition that caused the arrest.

Since CPR is found to not be effective in a moving vehicle, transporting a code effectively means no cpr for the course of transport. 

Logically, that is not going to impact the outcome in a positive way.

However, if your cardiac arrest is caused by something other than v-fib secondary to MI, the only part of your code likely to work is CPR. (otherwise you will likel see refractory v-fib until the code is called)

You must then figure out what exactly is causing this and attempt to correct it. Unfortunately EMS is both undereducated and underequipped to do this. (basically the other 30% of SCA)

Now just because you perform ACLS on a patient who would benefit from ACLS, does not mean a positive outcome.

By now you may have come to the conclusion that somebody, like a paramedic, will be extremely skilled in working a code because it is the focus of their efforts and they will likely do the exact same thing to every code. Which by the odds, should have the most success in achieving ROSC.

However, ROSC is not discharge neurologically intact. For that, you need a doctor. 

Also, acute care physicians with considerably and exponentially more knowledge, training, and toys backing them, also see as many or more codes than paramedics in their element. Doctors who work outside of acute care will also be more familiar with pathology, identifying, treatment, and likelyhood of resuscitating whatever condition caused the arrest. They may also understand the futility of trying to resuscitate.  

Which means they will be more capable than paramedics to help. It also means they will discover futility quicker or administer specific or alternative treatments than listed in the ACLS guidlines. 

This may give the appearance of "not knowing what to do" because it doesn't look like what a paramedic would do.


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## Veneficus (Nov 20, 2012)

Merck said:


> Also, not sure if he was shooting heroin with his grandkids but the narcan is interesting.



Maybe he was taking high dose opioids for his terminal cancer? :lol:

I like your answer better though.


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## lightsandsirens5 (Nov 20, 2012)

TheLocalMedic said:


> And to that end, if you do get pulses back, I strongly recommend that you actually hang out on scene for about 10 minutes before hitting the road, as a patient is more likely code in the first few minutes following a successful resuscitation.



Wait.....whaaaaa...... Come again? 

What the heck do you advocate doing? Sitting there and staring at them? 

Can you cite your "fact" about re-arresting? 

Would you really rather wait 10 minutes on scene with what is, for all intents and purposes, an extremely unstable patient "in case" they arrest again? Wouldn't you want to have them 10 minutes closer to a DOCTOR if they do arrest again? 

Or am I totally missing something here?


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## Aidey (Nov 20, 2012)

It isn't that strange of an idea. I can't cite a study, but I know for a fact it is what Wake County does, and the reason is that their in house research showed the majority of pts that re arrested did it within 10 minutes. 

Wake County uses kings initially. So during the 10 mins they call the hospital, swap the king for a ET tube, start a second line and any infusions that are indicated, get a 12 lead... Etc. Their MD said they are able to get necessary interventions done with a much lower risk of the pt rearresting while they are trying to package them or en route.


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## NomadicMedic (Nov 20, 2012)

Aidey is right on the money. We have a "wait at least 6 minutes before moving" line in our protocols for ROSC. Once we get a pulse back, we usually intubate, hang any pressors, anti arrhythmic and cold fluids, untangle and package ... And then we get underway. 

If the PT rearrests en route, the LUCAS device does the compressions, so we can safely transport with effective CPR. Although we rarely transport active codes unless there are extenuating circumstances.


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## NYMedic828 (Nov 20, 2012)

About 6 months ago I had a 70+ year old woman arrest into vfib on a plane that had just landed.

Shocked 7 times, 5mg epi, vfib was refractory to amiodarone as first 6 shocks.

Patient walked out of the hospital some days later.

Mind you, CPR was begun at the moment of arrest and only stopped to remove the patient from the plane for 30 seconds.  

Was probably in Vfib for 35 minutes but it wasn't a "maybe it's asystole" waveform.

Capnography is also a valuable tool for determining patient viability. If you have an ETCO2 of 0 and Vfib for 40 minutes id give it a rest...


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## Christopher (Nov 20, 2012)

VirginiaEMT said:


> I was involved in a resuscitation attempt where the upper 70's year old man arrested in front of one of his children. CPR was started with instructions from dispatch. We worked the arrest for 50 minutes or so, the patient remained in fine v-fib the entire time. He was shocked 6 times, given 7 mg of epi. 1/10000, 450 mg amiodarone, 100 meq. if sodium bicarb, and 2 mg of Narcan, At what point would you have stopped effort to resuscitate (contact med control)?



86 minutes for a code on Sunday. ~60 minutes into the code we transported due to a persistent ETCO2 of ~45mmHg w/ CPR even in the face of asystole. 12 epi's, 300mg lidocaine, 1g calcium, 100 mEq bicarb. Initial was a slow PEA (some pacing) that went to asystole then we got VF after the calcium admin. His AICD shocked 6 times, we shocked another 4 times. Never could get palpable pulses.

If the ETCO2 was lower we'd have stopped in the house, given the pacemaker and high ETCO2 we wanted a magnet available so we transported.


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## medicdan (Nov 20, 2012)

I don't think we carry enough epi for 10+ rounds, or a 50 minute code. We would need another als truck or to transport. Do the dynamics change if you have a Lucas or Autopulse?


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## NomadicMedic (Nov 20, 2012)

You don't have a big 30mg vial of Epi 1:1000? There's enough epi there to run 4 or 5 codes.


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## Veneficus (Nov 20, 2012)

emt.dan said:


> I don't think we carry enough epi for 10+ rounds, or a 50 minute code. We would need another als truck or to transport. Do the dynamics change if you have a Lucas or Autopulse?



If you give somebody that much epi, they probably won't have blood flow to the kidneys or brain anyway so it is not like you are missing out.


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## Christopher (Nov 20, 2012)

Veneficus said:


> If you give somebody that much epi, they probably won't have blood flow to the kidneys or brain anyway so it is not like you are missing out.



I wish we had some stopping point for how many saline flushes...I mean epi...we give during a code. Alas, no such luck. Some neighboring services have gone with normal saline drips...I mean epi drips...after 3 mg.


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## NYMedic828 (Nov 20, 2012)

Christopher said:


> I wish we had some stopping point for how many saline flushes...I mean epi...we give during a code. Alas, no such luck. Some neighboring services have gone with normal saline drips...I mean epi drips...after 3 mg.



:rofl::rofl::rofl:

God forbid there was some weight based dose we could use... but thats crazy talk.


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## mycrofft (Nov 20, 2012)

*Not to detract from pride and talent, but...*

I was thinking just the other day, it's been a while since the "I can do what an ED does" theme had been around.

If all goes well, the mobile unit can do the basic initial measures and do them extremely promptly, barring problems with equipment, supplies, heat/cooling, lighting, power, and the decreased mobility of people working around the patient which delays care when the patient is being prepped or intubated (lain supine, stripped of enough clothing, sometimes shaven a bit, ECG leads placed effectively, etc.).

Once measures are started, the crew and pt are tied down on scene for physical and physiological reasons, not to mention protocols above. This is not significant if patients are cured by ambulance care.

In-hospital, you have a lab, radiology, anesthesiology, surgery, and an ICU etc to backstop your play, and when they are needed, they aren't needed after five minutes, twenty minutes, or an hour on the road.

Beyond those, you have people and room to rapidly position, reposition, prep, and otherwise manipulate the patient, versus in a cramped (and moving) ambulance or someone's front room or bathroom.

Yes, on-scene ACLS and effective layperson bystander CPR _ARE essential_ to a successful conclusion, and yes, sometimes you get into the coffin corner of immobility just because that's the way the case went. But to equate a mobile unit to a hospital can lead to hitches in the thought processes which guide care.

Sidebar: another reason protocols state you transport patients with any activity because they are a hot potato. If they die in the ER, your stats look better than in your ambulance, and if there is any chance at all, it's there; but, if they are declared in your ambulance, the hit is on you and you have to talk to the coroner etc. 

5=4. I never heard of a patient being referred from a hospital to an ambulance except for transport.


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## NomadicMedic (Nov 20, 2012)

While your points are well taken, let's not forget the point of THIS conversation, which is resuscitating a cardiac arrest. 

As you well know, in the case of the usual "medical arrest", the first 20 minutes will set the tone for the outcome. Good, early CPR and electricity, followed by antiarrythmics and hypothermia when it's going well... A call to pronounce and consolation for the family when it's not. 

I don't ever equate what I do in the field to the capabilities of a hospital, unless its the precision of a well orchestrated "pit crew" style resuscitation of SCA. Then, in most cases, we do it as well, if not better, then it's done in the ED.


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## Veneficus (Nov 20, 2012)

NYMedic828 said:


> :rofl::rofl::rofl:
> 
> God forbid there was some weight based dose we could use... but thats crazy talk.



Epi in cardiac arrest is like oxygen in other patients.

There are some times that it helps, most often it hurts, and it helps much less often than people think.


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## NYMedic828 (Nov 20, 2012)

Veneficus said:


> Epi in cardiac arrest is like oxygen in other patients.
> 
> There are some times that it helps, most often it hurts, and it helps much less often than people think.



I imagine the goal, and the problem, is finding a happy medium behind the theory of increasing blood flow to vital organs while at the same time not restricting blood flow to vital organs.

Seems like a bit of a conundrum to me... We don't exactly have a way of determining if it is or isn't indicated without knowing the cause of arrest. We may as well give 1 of every drug in the toolbox (which is almost what we do anyway)




n7lxi said:


> While your points are well taken, let's not forget the point of THIS conversation, which is resuscitating a cardiac arrest.
> 
> As you well know, in the case of the usual "medical arrest", the first 20 minutes will set the tone for the outcome. Good, early CPR and electricity, followed by antiarrythmics and hypothermia when it's going well... A call to pronounce and consolation for the family when it's not.
> 
> I don't ever equate what I do in the field to the capabilities of a hospital, unless its the precision of a well orchestrated "pit crew" style resuscitation of SCA. Then, in most cases, we do it as well, if not better, then it's done in the ED.



In my experience, the first 2-5 minutes is what sets the outcome. The only patients I have had survive a cardiac arrest and walk out of the hospital back to their lives had CPR initiated by a bystander almost immediately upon arrest. 

I think the best thing we can do as a society is continue to educate EVERYONE on CPR. That high school kid who starts CPR on the old lady at the football game as soon as she collapses is the real hero if she survives. By the time EMS arrives it is usually atleast 5 minutes into arrest usually more. I believe the marker for neurological death is roughly 6 minutes? I would be willing to be the survival rate of out of hospital, witnessed arrests with no bystander CPR is exceptionally low.

My volunteer department offers free CPR training to the community. They currently train national safety council which is garbage. Last year I went and got certified as an AHA BLS instructor but apparently expecting people to show up to a 2-4 hour CPR class instead of a 30 minute one was just too much to ask...

I have taught one class... I don't even remember my login for AHA.


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## Veneficus (Nov 20, 2012)

NYMedic828 said:


> I imagine the goal, and the problem, is finding a happy medium behind the theory of increasing blood flow to vital organs while at the same time not restricting blood flow to vital organs.
> 
> Seems like a bit of a conundrum to me... We don't exactly have a way of determining if it is or isn't indicated without knowing the cause of arrest. We may as well give 1 of every drug in the toolbox (which is almost what we do anyway)



Mycrofft said it best.

EMTechnician vs. clinician. 

There are ways to tell. It just requires education and thinking.


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## Bullets (Nov 20, 2012)

VirginiaEMT said:


> I was involved in a resuscitation attempt where the upper 70's year old man arrested in front of one of his children. CPR was started with instructions from dispatch. We worked the arrest for 50 minutes or so, the patient remained in fine v-fib the entire time. He was shocked 6 times, given 7 mg of epi. 1/10000, 450 mg amiodarone, 100 meq. if sodium bicarb, and 2 mg of Narcan, At what point would you have stopped effort to resuscitate (contact med control)?



After 20 minutes if it was actually FVF and not artifact in asystole

I am surprised by how many here still have Bicarb in their arrest protocols.

 Not that it matters, once patients get the ACLS prescribed dose of Epi you nuked their brain anyway. I transported a patient the other day, no L&S. Blew everyone's mind but i think we got better compression. Shockingly pronounced at the door of the ER (Sarcasm)


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## mycrofft (Nov 20, 2012)

I wonder if enough epi will cause enough of SOME sort of myofascial activity to generate an ECG somewhat like "fine v-fib". 

Yeah, correct and instantaneous CPR in a place luck enough to be accessible and relatively flat makes the first part of the chain of survival. S'truth.


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## Veneficus (Nov 20, 2012)

mycrofft said:


> I wonder if enough epi will cause enough of SOME sort of myofascial activity to generate an ECG somewhat like "fine v-fib"..



Can't say for sure, but from what I do know, I would very seriously doubt it. In fact it would take an almost bullet proof large scale study to convince me otherwise.


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## mycrofft (Nov 20, 2012)

Fishing for a grant?


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## Veneficus (Nov 20, 2012)

mycrofft said:


> Fishing for a grant?



Not for that. I will just stick with guessing "no."


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## Fish (Nov 25, 2012)

ChaseZ33 said:


> How far away from a Hospital are you? Level one trauma?
> 
> You can rule out the various causes of cardiac arrest (Hs & Ts) and perform the necessary interventions more effectively than an ER physician? You can relive tamponade in the field? Do you carry blood products? To say that you are faster and more practical than a Level one trauma team is very bold.
> 
> ...



This sounded like Medical Cardiac arrest, not a traumatic one, not in need of blood or level one trauma


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## Fish (Nov 25, 2012)

lightsandsirens5 said:


> Wait.....whaaaaa...... Come again?
> 
> What the heck do you advocate doing? Sitting there and staring at them?
> 
> ...



I will agree with what he said, Patient's are extremely likely to re-arrest in the minutes directly following ROSC. We are required to Monitor our patient's for 5 minutes following ROSC to watch for recrurrent Cardiac arrest. Now with that being said, we do not just sit there for 5 minutes and stare at the patient, we get a 12Lead(If STEMI, call Code STEMI to receiving hosp), get a set of vitals, Obtain two IVs(if we have time and assuming all we had was an IO) and prepare a bag of Dopeamine(incase) since ROSC patients frequently need vasopressors and when they do need them, they need them quickly.

Why wait on scene for 5 minutes instead of load and go as soon as we detect a pulse? Because like stated before, patient's are extremely likely to re-arrest within the first 5 minutes and the best place to work a patient who has arrest is on the ground, not on a stretcher on its way out to the ambulance, and not in the back of a moving ambulance(which studies have shown is ineffective)


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## ah2388 (Nov 26, 2012)

ChaseZ33 said:


> Its been a month or two. Ya, 12 years of medical is great. Do the Physicians in your area blindly follow the ACLS algorithms? I rarely see ER physicians run a textbook ACLS code like medics would, they frequently deviate based on clinical judgment and patient presentation.



To say that the physicians in the ED you are referring to blindly follow ACLS algorithms would quite obviously be an insult to their incredible ability as clinicians.  With that being said, there are many similarities in the way cardiac arrest is managed in the ED as compared to the field.

With that being said, I pray that if/when I arrest it is in hospital, that is of course should I choose to be resusc.


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## VFlutter (Nov 26, 2012)

ah2388 said:


> To say that the physicians in the ED you are referring to blindly follow ACLS algorithms would quite obviously be an insult to their incredible ability as clinicians.  With that being said, there are many similarities in the way cardiac arrest is managed in the ED as compared to the field.
> 
> With that being said, I pray that if/when I arrest it is in hospital, that is of course should I choose to be resusc.



Exactly, The comment was made that a code is worked exactly the same, if not better, in the field as it was in the ED and that the physicians would not do anything different. I was trying to argue that ER physicians do much more than blindly follow ACLS algorithms like I have seen many medics do. 

Maybe my post came off the opposite way I wanted it to.


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## ah2388 (Nov 27, 2012)

ChaseZ33 said:


> Exactly, The comment was made that a code is worked exactly the same, if not better, in the field as it was in the ED and that the physicians would not do anything different. I was trying to argue that ER physicians do much more than blindly follow ACLS algorithms like I have seen many medics do.
> 
> Maybe my post came off the opposite way I wanted it to.



I dont think it came out the opposite of the way you intended, I read it as youve explained.  With that being said, let us not forget that most often cardiac arrest in the prehospital environment has many similarities to the way the episode is managed in hospital..I suppose that is sort of obvious.  It is not as if being a physician causes you ignore the "standard of care....."  It is more the reason behind the rhyme that many of us prehospital folks fail to gather


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## Clare (Nov 28, 2012)

Regardless of the rhythm I don't believe in transporting cardiac arrests unless there is an exceptional circumstance where the hospital can potentially reverse the cause such as cardiac tamponade, electrolyte imbalance, advanced pregnancy or hypothermia.  If the patient does not get a pulse back then the resuscitation is terminated and they are declared life extinct on the scene.

I also do not believe in commencing resuscitation unless it is in the best interest of the patient; for example traumatic cardiac arrest, patients who have a very poor health related quality of life (e.g end stage cancer or kidney failure) or  asystole as presenting rhythm where the arrest was not witnessed and there is significant discretion available in this area.


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## NomadicMedic (Nov 28, 2012)

Clare said:


> I also do not believe in commencing resuscitation unless it is in the best interest of the patient; for example traumatic cardiac arrest, patients who have a very poor health related quality of life (e.g end stage cancer or kidney failure) or  asystole as presenting rhythm where the arrest was not witnessed and there is significant discretion available in this area.



Do you not feel the resuscitation should occur, but you do it anyway... or are you given the leeway to not resuscitate those patients that you feel may have a "very poor health related quality of life"?


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## Clare (Nov 28, 2012)

n7lxi said:


> Do you not feel the resuscitation should occur, but you do it anyway... or are you given the leeway to not resuscitate those patients that you feel may have a "very poor health related quality of life"?



The idea goes something like Joe Blow rings up and says I have found so and so not conscious and not breathing which is now (as far as ProQA figures) a cardiac arrest until proven otherwise and will be resuscitated unless there is a very good reason not to; for example (as I said above) unwitnessed arrest with asystole, obviously dead or unworkable, traumatic cardiac arrest that doesn't get a very quick return of ROSC (5 minutes or so), patients who are dying from end-stage chronic diseases or have some other cause for a very poor HRQOL such as being in a vegetable state, needs somebody to walk/talk/shower/pee/poo/eat for them etc and also includes patients who have an advanced directive/allow natural death wishes including clearly described verbal wishes.  

All decisions rest solely with the ambulance crew; while the wishes of the family must be considered they do not have the authority to demand resuscitation or infact any treatment or transport that is not (to the crew) clinically indicated.

The only time I would work a cardiac arrest that would not otherwise be worked is if it is in a very public place and even then it would have to be a non-traumatic arrest and would only probably be two rounds of CPR and defibrillation before pronouncing life extinct.


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## NomadicMedic (Nov 28, 2012)

I want to work there!


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## Clare (Nov 29, 2012)

n7lxi said:


> I want to work there!



Working a cardiac arrest with the name Clare brings a whole new dimension to "everybody clear, shocking now!" 

I guess you sort of turn round and go "what?" the first couple of times somebody says "clear!"


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