cardiac arrest tips and tricks you have learned along the way...?

[mmorgan184]

Don't be afraid to call for orders to stop CPR if you are getting no response after a reasonable attempt. There is nothing the hospital is going to do in this situation that we cannot do onscene. The cardiac arrest patient isn't going to get any worse, and let's face it, they rarely get better. We need to stop needlessly transporting corpses. Think about it. How many cardiac arrest patients have you taken into the ER that have been worked for more than just a few minutes before the doc calls them? Chances are, very few.

I know it is protocol in my area to contact Med Control after 20 minutes to cease resuscitation efforts.

 

[djmedic913]

Remember Dead is the most stable patient you have. Our job on a code is to try and make them unstable again. Always remember BLS before ALS. Blood goes round and round with CPR and aire goes in and out with a BVM and OPA. ET tubes, IV's, IO's are helpful, but even a Basic can work a code.

1 tip I can add about starting an IV that they did not teach me in class, I learned on my 1st code...Don't be surprised if you don't get a good flash...remember not enuff pressure. Anyway I was an Intermediate running my 1st code alone and my mind was racing...Everything went well except for the IV coz I got a bad flash so I thought it was blown, but after removing the angio and looking for another vein the 1st spot kept bleeding with CPR...doh...anyway, that was my tip I learned...

i thought a contraindiction to nasally intubating was an apenic pt? it was my understanding that they needed spontaneous respirations? or maybe thats just by county/st

Apnea is a contraindication to nasal intubation. You need the patient to take a breath to pass the tube. when the pt inhales you advance the tube. You keep doing this until the tube is in place.

if you cant open the jaw how can you can you get an LMA/Combi in?
maybe i read something wrong from the OP

Good question

I think continuous capnography monitoring should become the gold standard.

It is heading that way..we are gearing up to start using it...

I know it is protocol in my area to contact Med Control after 20 minutes to cease resuscitation efforts.

Our most recent protocol roll out, states we can work the code for 15 mins in the house and call it. No med control required. I don't want to call a code in the house if I started working him..obvious death equals no working, I will call those at the scene. But I don't the responsibility of having to inform a family that there is nothing else we can do. The way I look at it from a families perspective, we did not do all we could because we never transport the pt to a doc. Sometimes the mere perception of doing all we can, is what makes the family feel better.

 

[rmellish]

Our most recent protocol roll out, states we can work the code for 15 mins in the house and call it. No med control required. I don't want to call a code in the house if I started working him..obvious death equals no working, I will call those at the scene. But I don't the responsibility of having to inform a family that there is nothing else we can do. The way I look at it from a families perspective, we did not do all we could because we never transport the pt to a doc. Sometimes the mere perception of doing all we can, is what makes the family feel better.

Life's rough. I'd much rather work for a few rounds in the living room than bouncing down the highway, or some backa** country roads l/s just so the doc in the ER can can call the patient within five minutes of rolling through the door.

No, if I'm on a medic unit, I'd much rather work on scene and call on scene. No sense risking my life for one that's probably over before we even get there.

 

[Epi-do]

But I don't the responsibility of having to inform a family that there is nothing else we can do.

So, what about the little old lady that keeps telling you to help her husband despite the obvious signs of death because she is in denial? Like it or not, telling family that a loved one is deceased is part of our job. In all honesty, most of them do already know when they call us, they just don't know what else to do. Been there, done that - even on patients that we have started to work but did not respond to our efforts and have remained in asystole.

The way I look at it from a families perspective, we did not do all we could because we never transport the pt to a doc. Sometimes the mere perception of doing all we can, is what makes the family feel better.

We are going to have to agree to disagree on this one. Transporting a corpse "to make the family feel better" does more harm than good in my opinion. But I digress to the multiple other times we have discussed this in other threads. No reason to beat a dead horse.

 

[reaper]

Remember Dead is the most stable patient you have. Our job on a code is to try and make them unstable again. Always remember BLS before ALS. Blood goes round and round with CPR and aire goes in and out with a BVM and OPA. ET tubes, IV's, IO's are helpful, but even a Basic can work a code.

Can we stop dumbing down medicine?
Apnea is a contraindication to nasal intubation. You need the patient to take a breath to pass the tube. when the pt inhales you advance the tube. You keep doing this until the tube is in place.

In some protocols it may be, but you can pass a NT in an apenic pt.






Our most recent protocol roll out, states we can work the code for 15 mins in the house and call it. No med control required. I don't want to call a code in the house if I started working him..obvious death equals no working, I will call those at the scene. But I don't the responsibility of having to inform a family that there is nothing else we can do. The way I look at it from a families perspective, we did not do all we could because we never transport the pt to a doc. Sometimes the mere perception of doing all we can, is what makes the family feel better.

So we want to work in the medical field, but not have the responsibility of it?

 

[Flight-LP]

Apnea is a contraindication to nasal intubation. You need the patient to take a breath to pass the tube. when the pt inhales you advance the tube. You keep doing this until the tube is in place.

Can someone please provide factual documentation stating this (other than a physicians opinion, i.e. a protocol).

I would really like to know how securing an ETT via direct tracheal intubation can be contraindicated in a pt. who will tolerate better than most without need for paralysis or sedation. You do NOT need the pts. breath to advance the tube. Yes it can be a little more complex, but ETCO2 will confirm proper placement. What options do you have if you can't RSI them and cannot ventilate them via BVM. ANSWER: Only one option and that involves slicing their neck open.

If I was subjected to the inadequent environment of this scenerio, I'll nasal them, thank you...............................

 

[djmedic913]

Life's rough. I'd much rather work for a few rounds in the living room than bouncing down the highway, or some backa** country roads l/s just so the doc in the ER can can call the patient within five minutes of rolling through the door.

No, if I'm on a medic unit, I'd much rather work on scene and call on scene. No sense risking my life for one that's probably over before we even get there.

So, what about the little old lady that keeps telling you to help her husband despite the obvious signs of death because she is in denial?

As I said previosly...

obvious death equals no working, I will call those at the scene.

We are going to have to agree to disagree on this one. Transporting a corpse "to make the family feel better" does more harm than good in my opinion. But I digress to the multiple other times we have discussed this in other threads. No reason to beat a dead horse.

Customer service = perception...end of story...As I said before, you can screw up in front of the family but if you have good customer service they will not lodge a complaint...you can be the best medic in the world, if if you have crappy customer service, complaints WILL be filed.

In a cardiac arrest you have more then 1 pt. there is the obvious dead pt, but you also have the distraught family. I would rather the distraught family be in the hospital waiting room or family when they receive the news where counselors are present.

I have started codes on scene and I never thought anything would come from..dead, still dead, remaining dead. but since I transported so my time with Pt is now 20-30 mins by the time I arrive at the hospital with spontaneous pulses back. Many have died the next day but again the family has bought another 24 hrs to say goodbye...[I know taking up an ICU bed for nothing...wasting money...etc] but last time I checked Emergency Medical SERVICE and customer SERVICE has nothing to do with money...

 

[djmedic913]

Can someone please provide factual documentation stating this (other than a physicians opinion, i.e. a protocol).

I would really like to know how securing an ETT via direct tracheal intubation can be contraindicated in a pt. who will tolerate better than most without need for paralysis or sedation. You do NOT need the pts. breath to advance the tube. Yes it can be a little more complex, but ETCO2 will confirm proper placement. What options do you have if you can't RSI them and cannot ventilate them via BVM. ANSWER: Only one option and that involves slicing their neck open.

If I was subjected to the inadequent environment of this scenerio, I'll nasal them, thank you...............................

I believe you read it wrong...apnea is contraindicated in NASAL intubation...
apnea and Endotracheal intubation go hand in hand...

below is what I originally stated:

Apnea is a contraindication to nasal intubation. You need the patient to take a breath to pass the tube. when the pt inhales you advance the tube. You keep doing this until the tube is in place.

 

[Flight-LP]

I did not read it wrong, nor did you supply any supporting evidence to the contrary.

Your response makes no sense. "Apnea and Endotracheal intubation go hand in hand". O.k. i'll give you the semantics to that one, but how are you going to drop that tube if the pt. is clenched????????

Go back and read it again. While your at it, bring the proof of contraindication............

 

[reaper]

Sure it does. When you transport a show code you are handing a grieving family a huge EMS and ED bill, that they do not need.

Same way as you don't fly someone, unless they need it. I know medics that will fly a pt just so they do not have to transport. They do not care about the 5k flight bill that pt will get stuck with.

So yes, money is a factor in your customer service side.

BTW- I will take doing what is right and getting a complaint filed. Rather then playing hero, so I do not receive one!

 

[Flight-LP]

I believe you read it wrong...apnea is contraindicated in NASAL intubation...
apnea and Endotracheal intubation go hand in hand...

below is what I originally stated:

And yes, BTW I am baiting you as you bring a strong teaching point to this thread........

I'll explain later and this is actually a subject that I will be starting a thread about soon.

 

[djmedic913]

And yes, BTW I am baiting you as you bring a strong teaching point to this thread........

I'll explain later or PM with the explanation and this is actually a subject that I will be starting a thread about soon.

OK, now I am confused. I am bringing a strong teaching point to this thread? I am lost...I must have made a wrong turn at Albuquerque.

The information I have, which was I was taught in medic school and yes my current protocols as well, is that nasal intubation requires the breath to in essence help 'suck' in the NT tube since it is a blind insertion device...

Yes a clenched jaw is a reason to try to nasally intubate but with no breath, it becomes near impossible to get that tube in the trachea

This is what I was taught in medic school...

What flight medics can do over and above a regular medic, I do not know...I don't have that extra training....yet...someday perhaps..

 

[Flight-LP]

Man, you almost had it, you were putting up a really good fight until the end.

Google "contraindications to Nasal Intubation" and there it is; in many printed formats that apnea IS considered a contraindication to nasaling a patient. Backing up your statements with evidentiary documentation is part of proficient critical thinking. If you know you are right, then stick to your guns. It will make you a stronger and more respected medic.

Alas, falling back on the "I was taught this way" and "its in my protocols" is the very premise restricting us from being able to advance our career. We must know the why's!

Please do not take this as a personal attack, I just find it very frustrating when medics make a solid statement, but fail to produce the proof of why. Consider this part of a life long advancement of education.......................

I stand behind my opinion, before I tell you why, lets look at what the professionals say. In the United states, there is a professional opinion that is not only accepted by medical professionals, but also those within the legal system. That would be the professional views from Dr. Ron Walls. In his book, "Manual of Emergency Airway Management", he clearly outlines various algorhithms that truly define airway management. It is on the foundation of this accepted manual and beliefs that I base my view.

So lets look at this scenerio..................

Clenched patient, apnic (o.k. I know that this is a highly unusual circumstance having these two together, but I digress as it can potentially happen), no RSI available. So in essence, you have a "can't intubate" situation. Hopefully, you can still oxygenate with patent nasal passages. If so, then simply assist ventilations with a BVM and get them to more definitive care. If not, as in the assumed scenerio, you now have a "can't intubate, can't oxygenate" (CICO) situation. There is generally only one solution; immediate tube cricothyrotomy. There is only one possible exception to the "CICO = immediate cric" rule; the ability to rapidly place an extraglottic airway device simultaneously with the preparation of the cric (Walls - Manual of Emergency Airway Management, Ch.2-19). In other words, if you can pass a device and successfully turn a CICO into a simply "can't intubate, but CAN ventilate" situation, then you may forego the cric.

Now lets take it a step even further and actually truly secure the airway while simultaneously setting up for the cric. How is it possible, dropping an ET tube on an apnic patient will take longer and is significantly more difficult?!?!?!?!? Or is it?????

In today's age of EMS, we have all sorts of new toys that help with intubation. One of those is the GUM elastic bougie................See where I am going with this??????

How do we perform intubation on grade III or IV airways? We use the bougie to blindly guide us. This is the same concept. Insert the ETT into the nasal passage and hold in the posterior nasopharynx. Slide the bougie through and aim anteriorly, wait for the "clicking" feeling when the bougie slides against the tracheal rings and the advance the tube. It really is that simple and can be done in a matter of seconds. Try it sometime...........

Now of course, RSI would be the ideal remedy as also viewed by Dr. Walls. Also, again the likelihood of having an apnic and clenched pt. is unlikely. But, more people are likely to have bougies than RSI it seems as many medical directors are still shying away from it. Thats a separate argument all in itself!

Hope this was somewhat insightful. Maybe I'll start doing some more scenerios like I used to do a while back. Ever since getting back to the US, I have been re-introduced to the failed education shortcomings of many in EMS. Since we are all here as one happy dysfunctional family, why not have an educational experience when we read throught these threads. Unless we want to continue the current trends of bashing and pointless discussions on TV show similarities and differences. Besides, it will help keep me out of trouble (well, maybe not!).

Stay safe everyone!

 

[djmedic913]

Man, you almost had it, you were putting up a really good fight until the end.

Google "contraindications to Nasal Intubation" and there it is; in many printed formats that apnea IS considered a contraindication to nasaling a patient. Backing up your statements with evidentiary documentation is part of proficient critical thinking. If you know you are right, then stick to your guns. It will make you a stronger and more respected medic.

Alas, falling back on the "I was taught this way" and "its in my protocols" is the very premise restricting us from being able to advance our career. We must know the why's!

Please do not take this as a personal attack, I just find it very frustrating when medics make a solid statement, but fail to produce the proof of why. Consider this part of a life long advancement of education.......................

I stand behind my opinion, before I tell you why, lets look at what the professionals say. In the United states, there is a professional opinion that is not only accepted by medical professionals, but also those within the legal system. That would be the professional views from Dr. Ron Walls. In his book, "Manual of Emergency Airway Management", he clearly outlines various algorhithms that truly define airway management. It is on the foundation of this accepted manual and beliefs that I base my view.

So lets look at this scenerio..................

Clenched patient, apnic (o.k. I know that this is a highly unusual circumstance having these two together, but I digress as it can potentially happen), no RSI available. So in essence, you have a "can't intubate" situation. Hopefully, you can still oxygenate with patent nasal passages. If so, then simply assist ventilations with a BVM and get them to more definitive care. If not, as in the assumed scenerio, you now have a "can't intubate, can't oxygenate" (CICO) situation. There is generally only one solution; immediate tube cricothyrotomy. There is only one possible exception to the "CICO = immediate cric" rule; the ability to rapidly place an extraglottic airway device simultaneously with the preparation of the cric (Walls - Manual of Emergency Airway Management, Ch.2-19). In other words, if you can pass a device and successfully turn a CICO into a simply "can't intubate, but CAN ventilate" situation, then you may forego the cric.

Now lets take it a step even further and actually truly secure the airway while simultaneously setting up for the cric. How is it possible, dropping an ET tube on an apnic patient will take longer and is significantly more difficult?!?!?!?!? Or is it?????

In today's age of EMS, we have all sorts of new toys that help with intubation. One of those is the GUM elastic bougie................See where I am going with this??????

How do we perform intubation on grade III or IV airways? We use the bougie to blindly guide us. This is the same concept. Insert the ETT into the nasal passage and hold in the posterior nasopharynx. Slide the bougie through and aim anteriorly, wait for the "clicking" feeling when the bougie slides against the tracheal rings and the advance the tube. It really is that simple and can be done in a matter of seconds. Try it sometime...........

Now of course, RSI would be the ideal remedy as also viewed by Dr. Walls. Also, again the likelihood of having an apnic and clenched pt. is unlikely. But, more people are likely to have bougies than RSI it seems as many medical directors are still shying away from it. Thats a separate argument all in itself!

Hope this was somewhat insightful. Maybe I'll start doing some more scenerios like I used to do a while back. Ever since getting back to the US, I have been re-introduced to the failed education shortcomings of many in EMS. Since we are all here as one happy dysfunctional family, why not have an educational experience when we read throught these threads. Unless we want to continue the current trends of bashing and pointless discussions on TV show similarities and differences. Besides, it will help keep me out of trouble (well, maybe not!).

Stay safe everyone!

Yeah I wavered at the end...I had figured I missed something...I even double checked my protocols...lol...but at least in the end I actually had a clue...lol

But I like the bougie stick idea...that is a great idea...I actually plan on bringing that idea to my education department... I know 1 of our ed coordinators will love this idea...

And thank you...not for the attack...lol...but for the education about bougie idea with nasal intubation...I hope I will never need it but I can tell ya, I will never forget the idea...

 

[hrmeeks]

Fat bald kid in the back slowy raises his hand and asks

with your difficult intubations why cant you attempt the 1st time and leave it place then reattempt with the same size or ( and in this case with the heavy scar tissue )smaller tube?

serious question

 

[Flight-LP]

Because you can put multiple tubes into the esophagus and look kinda foolish........

 

[terrible one]

so now im curious, as i was also told by protocols and in school you cant nasally intubate an apenic pt. but why?
and also what is a "bougie stick"? maybe its called something different in CA, would you mind describing it?

 

[Ridryder911]

so now im curious, as i was also told by protocols and in school you cant nasally intubate an apenic pt. but why?
and also what is a "bougie stick"? maybe its called something different in CA, would you mind describing it?

I have nasally intubated breathing/non-breathing patients. Yes, more challenging but can be done. As one usally gains clinical experience, you can "feel" the tube go past the epiglottis and pass into and through the cords. Not always sucessful but I attempt before cutting.

Another name for the Bougie for prehospital is the Flex Guide. Their much smaller than the traditional elastic gum bougie or swizzel stick that is used in the hospital setting. Yes excellent tool and nominal costs to use. I have seen services that uses them increase intubations rate to >98% even on difficult airways. Hence reduction of false or failed intubation rates, and the need for less agressive airway procedures.

Another trick I have used is pulling the "bell" off a cheap stethoscope and placing the tube into the ETT itself while performing a breathing patient when attempting to nasally intubate. True, many may whince because of the lack of it not being sterile ... so be it. Especially in conditions where ambient noise such as extrication and sirens makes it difficult to hear.

R/r 911

 

[jedirye]

Fat bald kid in the back slowy raises his hand and asks

with your difficult intubations why cant you attempt the 1st time and leave it place then reattempt with the same size or ( and in this case with the heavy scar tissue )smaller tube?

serious question

Typically when you have a failed intubation and realize this, you need to still oxygenate your pt via BVM. It would be difficult to create a mask seal with a tube sticking out of their nose or mouth still.

 

[djmedic913]

Fat bald kid in the back slowy raises his hand and asks

with your difficult intubations why cant you attempt the 1st time and leave it place then reattempt with the same size or ( and in this case with the heavy scar tissue )smaller tube?

serious question

the text book answer is: in between attempts you are supposed to ventilate your pt. it is impossible to properly vent your pt with an ET tube hanging out. so you are supposed to remove the missed intubation that ended up in the esophagus.