ACLS Medications, ROSC, and Theraputic Hypothermia

[Melbourne MICA]

All good stuff

It's all about fantastically complex systems and that's the problem. The ethical, religious, practical, governance, philosophical and economic underpinnings for why we do anything are every bit as complex as any process we apply to meet a need or solve a problem - even a medical resuscitation of cardiac arrest victims.

Why do we still use epi if it doesn't work? The logic is if you remove it from guidelines it won't have any effect on outcomes? But what outcomes? And how do we prove it to ourselves through our systems of analysis and examination? I suspect it is still in use because it may assist but we just don't really know for sure no matter how many studies we do. And that's the dilemma - Its imperfect science dealing with a complex interplay of factors that we not only don't fully understand but can't even recognise.

Consider this. The patients body is imperfect. The approach to the patients collapse and recognition of cardiac arrest is imperfect. The EMS systems applied to the patient are imperfect. The equipment and materials they use are imperfect. The delivery systems for the chosen therapies are imperfect. The manufacture of those therapies is imperfect. The science behind those therapies is imperfect. The operators who apply those therapies are imperfect. The conditions for applying those therapies are imperfect. The retrospective analysis of this whole cycle is imperfect.

And you are dealing with an complex organism made up of trillions of cells and millions of bio-chemical/electrochemical reactions which can happen in time frames of picoseconds.

Its virtually impossible to know which drug or therapy makes a "real" difference (whatever that means), whether its Epi, atropine, bretyllium, oxygen, DCCS, ECC, vasopressors - whatever - because unfortunately what we are dealing with are complex systems of bio-chemical function that cannot be mapped, recorded and analysed in real time.

Even if we could somehow map a resus microsecond by microsecond with some full body scanner straight out of Star Trek we would still never be able to keep up with the fantastically subtle yet complex interplay of chemical reactions and energy transfers going on.

Its bloody chaos theory!!!!

The end point of resuscitation outcomes (rather than the resuscitation itself) is directly related to the start-point but each is totally different for every individual.

So our resus procedures are just a best fit model that will work some of the time for some of the people - the imperative for "leaders" like the AHA is to increase the likelihood that the system will work a little better each time or at least, not get worse. It is a statement - an admission - of imperfection.

And most of the discussion has been about the how and what and a little bit of why.

The biggest questions of why - IE the ethical, cultural, economic etc are worthy of their own thread. And if you are talking about complex systems there are none better than trying to figure out why we do things like resuscitate dead people.

A great read guys.

MM

 

[Neo]

We did a study on 851 patients were 433 did not get IV and meds, and 418 got IV and meds in a cardiac arrest situation. 9.2% survived of the patients ho did not get IV and meds, and 10.5% survived of the patiens ho got IV and meds. The difference in the numbers are so small that we cant say if the meds work or not, its a dead race. And the difference we see in the numbers are likely coincidences.

 

[firetender]

Conflicting ways to Buy Time

Q) It seems that ACLS medications have show know decrease in patient mortality but can perhaps increase ROSC.

However, I know there has been a lot of work done on prehospital hypothermia for pt's who get ROSC.

Does it then follow that ACLS drugs could become more important with the increased use of hypothermia for cardiac arrest, given that the therapy is available for those who get ROSC? Or are the pts who benefit from this tx usually those who have regained a pulse from rapid defib?

Thanks

I stumbled upon a piece of recent literature by Dr. Sanjay Gupta who, you could say, reflects on current themes and trends in modern medicine and reports back to the common folk. His nickname is "America's Doctor" if that helps. BUT, not only does he speak of what is happening today, but by his prominence in the media, actually popularizes and even promotes the adoption of new approaches.

His book, Cheating Death... examines these very issues. In a nutshell, he's saying that aggressive treatment by a barrage of drugs and interventions, once thought to buy time actually produce poor outcomes.

(In my own experience about 90% of the interventions I used in the late 1970's have been debunked as ineffectual if not found dangerous!)

The way the future will go, he says, is we will buy time by slowing down, if not suspending the patient's bodily processes through such things as, today, hypothermia, and tomorrow, suspended animation.

This new info threw me into a tailspin because I really had to re-think everything I had done -- understand my role at the time in completely different terms -- and re-define what all of us, as medics actually DO!

So, I invite you to check out one of my BLOGS, the EMS Outside Agitator. Start HERE, it is a series of blogs called An Ex-hack's Manifesto.

If you scroll down to the bottom, it'll put you into the Introduction. You read up from there. (Haven't figured out how to fix that yet!)

 

[Veneficus]

I stumbled upon a piece of recent literature by Dr. Sanjay Gupta who, you could say, reflects on current themes and trends in modern medicine and reports back to the common folk. His nickname is "America's Doctor" if that helps. BUT, not only does he speak of what is happening today, but by his prominence in the media, actually popularizes and even promotes the adoption of new approaches.

His book, Cheating Death... examines these very issues. In a nutshell, he's saying that aggressive treatment by a barrage of drugs and interventions, once thought to buy time actually produce poor outcomes.

(In my own experience about 90% of the interventions I used in the late 1970's have been debunked as ineffectual if not found dangerous!)

The way the future will go, he says, is we will buy time by slowing down, if not suspending the patient's bodily processes through such things as, today, hypothermia, and tomorrow, suspended animation.

This new info threw me into a tailspin because I really had to re-think everything I had done -- understand my role at the time in completely different terms -- and re-define what all of us, as medics actually DO!

So, I invite you to check out one of my BLOGS, the EMS Outside Agitator. Start HERE, it is a series of blogs called An Ex-hack's Manifesto.

If you scroll down to the bottom, it'll put you into the Introduction. You read up from there. (Haven't figured out how to fix that yet!)

Have you considered at all that overtime pathology evolves, and what is debunked in the pathology of today may have actually been useful in the pathology of yesterday?

 

[firetender]

Have you considered at all that overtime pathology evolves, and what is debunked in the pathology of today may have actually been useful in the pathology of yesterday?

...kind of like we've built up an immunity to Bicarb, Epi and ZAP!, Bicarb, Epi and ZAP! Bicarb, Epi and ZAP! just like infections successfully treated by this antibiotic yesterday won't respond to the same one today?

Once again, that just makes it look like we can beat death a little bit and for a while, but not much and not very long.

That's a reality as well!

You're point, however, is well taken and reinforces my belief that in the business we are in, we are still fetuses.