Cardiac Arrest: Breaking the mold

[NPO]

My agency is implementing some new protocols for cardiac arrest, and I was curious to see what others have to say about some of the changes and see if anyone is doing something similar.

Current: Initial oxygenation provided by NRB and OPA, with ETI to follow later in the algorithm after other priorities are competed. We utilize "CCR" pit crew style algorithms with 2 ALS ambulances and a supervisor, in a moderately rural area. We currently do DSED for refractory VF after 5 failed defibrilations.

Updates:
- Early termination of unwitnessed asystole arrest.

- NRB replaced with NC to allow for continued oxygenation during ETI. ETI still delayed.

- ITD added to all airway devices.

- ETI moved to high priority for PEA.

- Dopamine 10mcg/kg/min for PEA, no epinephrine.

- Refractory VF threshold reduced from 5 defibrilations to 3.

- Refractory VF transported earlier (result of earlier definition of rVF), preferably to Cath Lab.

- Esmolol 500mcg IVP, followed by 50mcg/kg/min.

 

[VFlutter]

Looks pretty well thought out. I like delaying ETI, and even PPV, during the initial phases of resuscitation. Esmolol is a nice addition. With ELCS and Intra-arrest PCI becoming more common it make sense to get these patients to the cath lab quickly in refractory VF. Do not know the literature on Dopamine vs Epi in PEA, curious about that.

 

[NPO]

Our limiting factory getting rVF patients to PCI is our hospital. They haven't bought in to the idea yet. We have been doing rVF transports for about 2 years and have had 1 instance where cardiology accepted the patient intra arrest, and this was very recent. So we are hoping the door is opening and if we bring them more of these patients they will start doing it.

Do not know the literature on Dopamine vs Epi in PEA, curious about that.

I'll see if we based that off of something specific, or if it was mostly anecdotal.

The idea is that many PEAs are actually pseudo-PEA, and do have cardiac wall movement, just not enough to generate a palpable pulse by adrenaline pumping paramedics and EMTs.

We did a trial for cardiac arrest POCUS about a year ago, so some of the data may have come from that.

The reason for dopamine vs another vasopressor is simply availability. We only carry dopamine and try as I might, I have had no movement in getting other ones adopted.

 

[E tank]

The reason for dopamine vs another vasopressor is simply availability. We only carry dopamine and try as I might, I have had no movement in getting other ones adopted.

Yeah...gotta say the dopamine is a head scratcher. Both the drug itself and the rate. 10/kg/min for most folks is around 30 cc's an hour which is being pushed around by chest compressions. So to actually move it around you need a really good IV running wide open the same rate the whole time. Just a wild guess what kind of consistent blood levels you'd end up with.

There is no substitute for a bolus of anything and we don't bolus dopamine. I wouldn't even know how to begin to figure out how to effectively. That and dopamine is so variable among patients you don't always know what it will to. For example, that dose will drive the HR in some folks along with bumping contractility, sometimes it won't. Very dirty drug.

Lastly, epi has the advantage of treating a direct cause of PEA which is profound anaphylaxis. Sometimes that is a diagnosis you've got to figure out after you've resuscitated the patient. Won't happen with dopamine.

You can get esmolol but not epi? How does that work?...Keep agitating for epi...don't know the rest of your protocol for refractory VF, but I assume that if you're starting esmolol, you aren't giving any epi boluses, correct?

 

[NPO]

Lastly, epi has the advantage of treating a direct cause of PEA which is profound anaphylaxis.

You can get esmolol but not epi? How does that work?...Keep agitating for epi...

The protocol has us giving epi until dopamine is available. So that will probably be 2-3 rounds because no one is going to be hanging dopamine with only one medic on scene. Additionally, we still CAN give epi if we suspect anaphactoid reactions.

As far as why we can't get norepi or even epi, I think it's because they have pushed very hard for simple drips. We have premix dopamine packaged with a chart, a dial-a-flow, and IV tubing with the idea being everything should be easy. With epi we would have to mix it ourselves, or stock a second premix bag, and dopamine is currently our only pressors for post resuscaitative care.

But like I said, I'm pushing for other vasopressors.

 

[VFlutter]

The protocol has us giving epi until dopamine is available. So that will probably be 2-3 rounds because no one is going to be hanging dopamine with only one medic on scene. Additionally, we still CAN give epi if we suspect anaphactoid reactions.

To add onto E Tank, are you stopping Epi boluses a few cycles before giving Esmolol?

As far as why we can't get norepi or even epi, I think it's because they have pushed very hard for simple drips. We have premix dopamine packaged with a chart, a dial-a-flow, and IV tubing with the idea being everything should be easy. With epi we would have to mix it ourselves, or stock a second premix bag, and dopamine is currently our only pressors for post resuscaitative care.

But like I said, I'm pushing for other vasopressors.

1mg Epi prefilled squirted into a 100ml bag of D5/NS is pretty simple. Like E Tank said, keep fighting. Dopamine is a drug that isn't really great at anything. There are better pressors, better inotropes, and better chronotropes.

 

[E tank]

The protocol has us giving epi until dopamine is available. So that will probably be 2-3 rounds because no one is going to be hanging dopamine with only one medic on scene. Additionally, we still CAN give epi if we suspect anaphactoid reactions.

Oh...so you are still giving epi to PEA...didn't get that.

 

[NPO]

Oh...so you are still giving epi to PEA...didn't get that.

Yes sorry. We just discontinue epi once dopamine is ready.

 

[Tigger]

https://emsqaqi.com/2018/01/03/human-sacrifice-the-cost-of-being-progressive-in-ems/

Somebody has to start in order for things to change, and getting out of the "we've always done it this way" is to be firstly commended. But, from the above, which is totally worth the read:

I think a drug without any proven benefit and an association with harm should not be given to patients. Unfortunately many people are playing mad scientist and coming up with their own proprietary dosing regimens: adding a milligram to a liter and running it in over 20 minutes, spaced out dosing, giving some random dose of epinephrine, dosing based on etco2, giving only one or two doses, or a number of other alternative dosing regimens. This is not science, it is alternative medicine. It does not clarify anything; it only muddies the waters further.

 

[johnrsemt]

What is your transport distances?

And do you always have 2 medic trucks and a supervisor available?

I work in an area where we have 3 medic crews Monday to Thursday 24 hours a day, 2 crews Friday to Sunday. Today, 1 medic was dedicated to a detail. and 1 crew transporting (3.5 hours round trip) and 1 crew covering about 70 X 50 miles.

PT job is 3-4 crews (Medic or Advanced); 110-125 miles 1 way to a hospital, 35-50 minutes to get a helicopter; (and they won't fly cardiac arrest); nearest backup ground truck is 110 miles away.

 

[NPO]

What is your transport distances?

And do you always have 2 medic trucks and a supervisor available?

Suburban to super rural.
Anything from 5 minutes to 1.5 hours to our critical access hospital. Tack on an extra 40 to a regional specialty (although we would never bypass our local for a post-arrest).

We almost always have the required resources available. I've never seen a cardiac arrest not get the full dispatch. (Plus first responders, if available). The requirement is 3 paramedics, so if they need to page a second supervisor or a chief, they will.

 

[VFlutter]

35-50 minutes to get a helicopter; (and they won't fly cardiac arrest).

May be worth putting a helicopter on Air Stand-by incase you get a pulse back and they need to be taken to a cath lab.

 

[NPO]

May be worth putting a helicopter on Air Stand-by incase you get a pulse back and they need to be taken to a cath lab.

This was the exact use-case my previous company cited for purchase of the Zoll AutoPulse vs the Lucas 2. The Zoll AP fits on a patient in a 407, the Lucas does not. They don't fly intra-arrest patients either, but they were planning ahead.

They ended up purchasing neither, that I'm aware of.

 

[Tigger]

This was the exact use-case my previous company cited for purchase of the Zoll AutoPulse vs the Lucas 2. The Zoll AP fits on a patient in a 407, the Lucas does not. They don't fly intra-arrest patients either, but they were planning ahead.

They ended up purchasing neither, that I'm aware of.

Our local program that was flying out of a 407 did indeed carry a Lucas onboard.

 

[NPO]

Our local program that was flying out of a 407 did indeed carry a Lucas onboard.

Well I'll be darned.

Perhaps it was an excuse to buy yet another Zoll product since everything they own is Zoll.

 

[jwk]

My agency is implementing some new protocols for cardiac arrest, and I was curious to see what others have to say about some of the changes and see if anyone is doing something similar.


- Esmolol 500mcg IVP, followed by 50mcg/kg/min.

I get the esmolol idea, but haven't seen that routinely used in an arrest, even in the ICU.

BUT I think your bolus dose is incorrect. I think it should be 500mcg/kg IVP. Giving just 500mcg is about 1 drop of esmolol.

 

[rescue1]

I know epi is no longer thought to be the lifesaving ACLS drug that it once was, but I can't imagine why a patient in a depressed cardiac output "PEA" arrest wouldn't respond to 3 doses of IV epi, but would then respond to a relatively low dose dopamine drip.

I like the esmolol idea, I've heard a lot of people talking about it but I've never heard of it actually being done.

 

[NPO]

To stir the pot a bit, I'll throw in our traumatic arrest protocol too, which isn't new.

For any traumatic arrest that we deem workable, we don't use any ACLS drugs. We do CPR at 30:2 (compared to our 200:0 prior to advanced airway in medical cardiac arrest), intubate early, bilateral needle decompression for chest trauma, and dopamine for PEA >40bpm.

PEA <40bpm and asystole meet criteria to withhold resuscitation.

We have no trauma centers within an hour, so we either work 'em or leave 'em.

 

[VFlutter]

The Dopamine and no Epi is still percular to me. Epi should be better for almost anything that would be causing a traumatic arrest.

 

[Tigger]

To stir the pot a bit, I'll throw in our traumatic arrest protocol too, which isn't new.

For any traumatic arrest that we deem workable, we don't use any ACLS drugs. We do CPR at 30:2 (compared to our 200:0 prior to advanced airway in medical cardiac arrest), intubate early, bilateral needle decompression for chest trauma, and dopamine for PEA >40bpm.

PEA <40bpm and asystole meet criteria to withhold resuscitation.

We have no trauma centers within an hour, so we either work 'em or leave 'em.

I think withholding ACLS medications is reasonable and backed somewhat by data. But the dopamine thing? Come on. Who came up with that? Might as well just IV push some essential oils, we'll never know which one is more effective.