# Cardiac Arrest order?



## Stephanicole729 (Aug 4, 2011)

I know a lot of Paramedics have a routine way of approaching cardiac arrests. I  just want to compare the way people do things & see how many people actually do things  b


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## Stephanicole729 (Aug 4, 2011)

Do things alike**


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## socalmedic (Aug 4, 2011)

arrive> ABC> have FF start thumping the chest> other FF BVM> Pads and 4 lead> set up IV supplys> Rhythm/pulse check Q2min> defib af indicated> establish IV> meds Q4min (every other pulse check)> intubate if needed (1/2 don't get tubed). after 20 min pronounce, transport if rosc or sustained VF/VT.


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## ah2388 (Aug 4, 2011)

Arrive-check responsiveness, initiate cpr if indicated, pads/4lead, EZ IO, meds, partner drops a king at some point...hope someone is really lucky....terminate resusc.


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## Shishkabob (Aug 4, 2011)

Once we establish we're working the code:

I have my partner drop a King first thing while I establish an IO.  Gets the airway out of the way quickly without interrupting CPR.  If he can't get the King, I intubate.   If he can get the King, I'm happy going the whole code with just the King unless something changes and necessitates intubation.  Then the rest of the arrest is trying to get a pulse back / finding out the cause.


I don't transport dead bodies.  They die where they lay.   I typically work for about 30ish min, though there are variables to consider before I decide to cease resuscitation.


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## emtpche (Aug 5, 2011)

Linuss said:


> Once we establish we're working the code:
> 
> I have my partner drop a King first thing while I establish an IO.  Gets the airway out of the way quickly without interrupting CPR.  If he can't get the King, I intubate.   If he can get the King, I'm happy going the whole code with just the King unless something changes and necessitates intubation.



Why intubate at all if you can't get the King? Bagging with a OPA works just as well.


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## Shishkabob (Aug 5, 2011)

emtpche said:


> Why intubate at all if you can't get the King? Bagging with a OPA works just as well.



1) Who says an OPA would be working, let alone "just as well"?    Most of the patients I've had where a King didn't work, it necessitated intubation due to a poor airway to begin with.


2) I can't cease resuscitation without either a King or ETT.   Heck, I'd even do an LMA if I could, but it has to be one of those 2.

I don't feel like transporting a dead person just because I want to use the minimum that works in airway control.  Plus, you can't effectively monitor EtCo2 on a cardiac arrest patient without an advanced airway, and EtCO2 is a good indicator of when you should cease resuscitation.


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## mycrofft (Aug 5, 2011)

*OPA does not equal ET.*

OP (and to a lesser degree NPA) are the basic life support poor man's airway, they used to include the old Johnson and Johnson "S" tube variation*  in basic first aid kits. ET and it's neices and nephews *controls* the airway, pharyngeal airways just try to establish one.

OP, read and follow your company protocols. Start with the basics, get someone doing deep rapid CPR going STAT, then ventilation, buying yourself seconds and convincing bystanders you know what you are doing.


*"S" tube airway: imagine two Hudson OP airways, "Large" and "Ginormous", grafted together at the flanged ends to form a big "S" shape, and with a concave shield the size of a shoe's heel cup at the junction which you can slip off and reverse for some reason. Can't even find a google image of it.


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## mycrofft (Aug 5, 2011)

*OP, literal response to your question title:*

I don't honor orders to initiate cardiac arrest:rofl:.


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## jjesusfreak01 (Aug 5, 2011)

mycrofft said:


> I don't honor orders to initiate cardiac arrest:rofl:.



Hey, don't worry, its just a shot of Adenosine...you'll only be dead for a few seconds.


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## medicsb (Aug 5, 2011)

BLS or PD usually would initiate CPR and AED application.  One medic would attach the LP12 (pads + 4 lead) while compressions in progress.  Then that medic would go to an arm for an IV.  Other medic would go to the head.  Usually would intubate during compressions.  Some medics would stop compressions for intubation.  If I had trouble visualizing during compressions, I'd have them stop temporarily in order to pass the tube, then resume compressions while cuff inflated, stylet removed, and ETCO2 attached.  Brief pause to check for equal lung sounds and then secure during compressions.
If the medic on the arm couldn't get an IV, the medic at the head would assess for an EJ.

We didn't have an approved adult IO device, so the pt. was screwed if we couldn't get a line (I only recall twice not being able to get a line out of 30-40 cardiac arrests, though there were a few where 3 or more attempts had to be made).  

I probably would have preferred to have done things in a different sequence such as supraglotic airway for the 1st 10-15 minutes, automatic attempt at an EJ (followed by IO if EJ not possible, assuming we were to get an IO device) then followed by an attempt at an IV elsewhere.  (Yes, I still prefer IV over IO even if an IO gets established.)  After 10-15 minutes, attempt intubation during compressions.    

We were relatively well experienced with intubation (94-95% overall success rate), so the majority of pts were successfully tubed, but I think we could have been more methodical about it.  I still think intubation is appropriate for CA if the intubator is well experienced (in terms of frequency not years of practice), but as a caveat I think it should be delayed.


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## jjesusfreak01 (Aug 5, 2011)

Why not drop a BIAD and give yourself a quick airway that works very well most of the time that can be done by an EMT, leaving the medics free for electrical and IV therapies?


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## JonTullos (Aug 9, 2011)

I haven't developed a routine (mainly because I'm not a medic yet) but one thing's for sure: Unless they're heartless, brainless, stiff or have some other injury incompatible with life, they get transported no matter what. We don't call a code on the scene.  Note that I said that's the protocol, not my preference. If they're dead, they'll be just as dead on their floor as they will at the ER.


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## 18G (Aug 10, 2011)

emtpche said:


> Why intubate at all if you can't get the King? Bagging with a OPA works just as well.



Airway needs protected. Aspiration kills. 

If you are successful in getting a ROSC the patient has enough stress to deal with without having to fight off a severe pneumonia because nobody attempted to secure the airway. The increase in mortality from aspiration is extremely high. 

Peds airways are a little different for a few reasons and BVM and OPA have been shown to be highly effective (and as effective) as intubation with short transport times.


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## socalmedic (Aug 13, 2011)

in reply to Linuss and 18G, we dont tube until we decide if we are transporting. if we arent transporting an OPA/NPA and BVM is all we need (protocol states "intubate if UNABLE to maintain BLS airway" we use a two person seal on all BVMs, if I am transporting a will intubate. and yes i have worked in areas where the ambulance is all that gets dispatched to medical calls so i know what its like to not have enough people, king off the bat seamed to work best then intubate when you have time.

as for the king, we use them only as a last resort after two failed intubation attempts, they used to be the frontline airway due to ease and EMT could place them however the statistics showed very bad for the patient, 200% increase in ROSC however hospital discharge decreased 50% this was true in one other county that our medical director overseas as well. we may actually go back to the combi-tube as our rescue airway.


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## Sasha (Aug 13, 2011)

18G said:


> Airway needs protected. Aspiration kills.



I thought the arrest kills! 
Sent from LuLu using Tapatalk


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## usalsfyre (Aug 13, 2011)

socalmedic said:


> 200% increase in ROSC however hospital discharge decreased 50% this was true in one other county that our medical director overseas as well.


How well was the drastic increase in ROSC controlled for?

Were you using the LT or LTS-D? I've seen fairly bad passive regurg with the LT, not so with the LTS-D when something was placed to evacuate the stomach.

Combitube sucks. It's the only BIAD I know of that has a reputation for routinely causing esophageal tears. Plus there's the whole latex issue.


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## usalsfyre (Aug 13, 2011)

Pretty much the same order as Linuss, I will often pull the King and intubate at around the 10 minute if the patients a good candidate.

If I get a ROSC, the patient gets tubed, if I don't have a second line one gets placed, syringe of 1:100,000 epi made up to make it to the truck where an epi drip will be mixed (not infused unless needed). C-collar to protect the tube, hands kerlixed in. HOB elevated and fent prepared for post intubation sedation. 12 lead and transport to a STEMI center if appropriate.


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## RocketMedic (Aug 14, 2011)

I personally like to do all of the above, but I also look for the safest, best way out. I really don't like not having a quick way out.

Totally unrelated question- do y'all think that epi might be bad in a cardiac arrest? We do want the pressor effect, but wouldn't that also decrease cerebral perfusion?


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## Shishkabob (Aug 14, 2011)

Rocketmedic40 said:


> I
> Totally unrelated question- do y'all think that epi might be bad in a cardiac arrest? We do want the pressor effect, but wouldn't that also decrease cerebral perfusion?



I've never been a fan of Epi as if you think about it, the moment ROSC is gained, you're then getting the Beta effects of Epi in to effect, causing so much more strain on the heart, increasing it's inotropic and chronotropic effects.  The heart is already probably damaged, and increasing its workload just doesn't make sense.


I much prefer Vasopressin for it's vasoconstrictive effects as that's really all we want in such a drug.


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## 18G (Aug 14, 2011)

Epi is metabolized pretty rapidly so the effect should be very short lived.

And some ROSC patients require pressor support due to hypotension. In these patients prevention and treatment of hypotension is paramount and are gonna require fluids and pressor support.


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## usalsfyre (Aug 14, 2011)

18G said:


> Epi is metabolized pretty rapidly so the effect should be very short lived.


The problem is we give massive overdoses of it and have no clue how much of it hangs out in the peripheral vasculature prior to ROSC and causes cardio or neurotoxic effects after circulation is restored. I wonder if our results wouldn't be better giving it 100mcgs at a time...   



18G said:


> And some ROSC patients require pressor support due to hypotension. In these patients prevention and treatment of hypotension is paramount and are gonna require fluids and pressor support.


Diagnosis is important here in appropriate pressor selection. Epi is a great shotgun choice, unfortunately the default EMS choice seems to be "all dopa all the time".


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## Shishkabob (Aug 14, 2011)

I'm just a bigger fan of Vasopressin due to it's longer duration, and better hemodynamic profile in relation to the organs (IE it shunts pretty much everything but the brain), plus has showed a bigger increase in ROSC when compared to Epi.

If we carried more than just 40u on our trucks, and I actually GOT a EOSC, I'd be calling in pushing for a Vaso drip.


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## aclsjax (Aug 16, 2011)

arrive. CAB. good cpr npa with bvm + defib if needed iv or io. 1st round drugs ( this should take no more than 2 min. then) then think et tube. 2nd round drugs. (et tube is not a must)


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## MrBrown (Aug 16, 2011)

If it is decided an attempt at resuscitation is in the best interest of the patient and clinically appropriate one Ambulance Officer will place an LMA and begin ventilation while the other begins CPR

Cardiac arrest is really quite easy - thump, shock, adrenaline and repeat

We try to get at least three people (four is preferable) to a cardiac arrest.


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## hyperlyeman1 (Aug 18, 2011)

JonTullos said:


> I haven't developed a routine (mainly because I'm not a medic yet) but one thing's for sure: Unless they're heartless, brainless, stiff or have some other injury incompatible with life, they get transported no matter what. We don't call a code on the scene.  Note that I said that's the protocol, not my preference. If they're dead, they'll be just as dead on their floor as they will at the ER.




But dead bodies at home don't waste space in an ER for a saveable child... IMHO. Work the arrest... my opinion, LOC/ABC's, BLS CPR with BLS airway, Monitor/pads, defib if needed, IV/IO and1st round meds, KING/ETT, if PEA<60 or asystole, call base and cover em.

Again this is in my opinion, if i can't get a viable/shockable rhythm after the first round of drugs and a good ALS airway, they are not going to get transported unless I can find a reversible cause. No reason at all to waste resources on dead people. 

I have a close friend who is an ER doctor, if one of the medics I work with brings him a dead patient that should have been called on scene per our protocol, he has been known to go to our QI and have paramedics speak with the QI department. He sits on our protocol board and on the QI board. Thank god for friends in high places ^_^


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