CPR and transport, when to stop it and just drive...

[Hotshot007]

Hi all, I currently work for an ambulance company doing mostly IFTs and hospital discharges to convalescent homes in Los Angeles, CA, but the company has been looking into getting a 911 contract with one of the nearby cities and or fire departments. My question stems from a blind spot I have found in the training manuals that is pretty critical. When responding to a call where CPR is determined to be necessary, how long after initiating CPR are you supposed to transport them if there is no pulse. I mean, say you roll up on scene, you determine CPR is necessary, and you begin, 5 mins go by, you have tried to shock them, it does or doesn;t determine shock advised, and you still do not have a pulse, what is the protocol for determining when to transport? Hope that ALS has arrived by then? Transport while just having the attendant bag them with air and hope the ER can revive them? Or throw a sheet over them after 10 mins of CPR and call it a day?

In my textbook, the scenarios invariably cut off right after it says initiate CPR, and any followup is determined 'by local protocol'. Well in LA it goes by individual company protocol which is merely supposed to follow the guidelines of CA EMSA, but the problem is we have not been doing 911 calls yet so there is no protocol in place to follow! Can anyone tell me what other Los Angeles CA based companies do in this situation?

 

[JPINFV]

In my textbook, the scenarios invariably cut off right after it says initiate CPR, and any followup is determined 'by local protocol'. Well in LA it goes by individual company protocol which is merely supposed to follow the guidelines of CA EMSA, but the problem is we have not been doing 911 calls yet so there is no protocol in place to follow! Can anyone tell me what other Los Angeles CA based companies do in this situation?

No, in LA it goes by LEMSA (Los Angeles County EMS in your case), not your company medical protocol. Besides, if you're responding to 911 calls in Los Angeles county, I will guarantee that you will always have fire medics respond with you for anything that could possible be a cardiac arrest. If you're working IFT without paramedics, your best option is to pick up the nearest phone and dial 911, which will bring paramedics quickly.

 

[Handsome Robb]

How close to an ER are you? Will it take longer to get an ALS intercept than it will for you to transport to the ER? If transport time is less than intercept time haul *** to the ER.

ACLS says no transport until you have ROSC, but thats with ALS medications and providers available.

If you run on a cardiac arrest and there is no medic or firemedic on scene, take a firefighter with you during transport. If you transport the patient with only airway/ventilatory support and no compressions you just signed the patient's death warrant and a big old negligence lawsuit on your part.

If you do get a 911 contract this is a protocol your medical director will have to write. Any call that is dispatched as a priority 1 or 2 call should get an ALS response, in my opinion, unless all ALS units are tied up.

 

[JPINFV]

How close to an ER are you? Will it take longer to get an ALS intercept than it will for you to transport to the ER? If transport time is less than intercept time haul *** to the ER.

This is actually one of the instances where I'd argue that EMTs are essentially as good as paramedics AND both should work it on scene. Cardiac arrests are -the- time sensitive emergency and the only thing decreasing the time until brain death is good quality compressions. There's zero evidence that ACLS medications increase survival to discharge (yes, they increase ROSC and all survival to discharge achieves ROSC). There is evidence that CPR in the back of a moving ambulance is essentially no CPR. By focusing on packaging and transport instead of quality compressions and AED delivered defibrilations, the EMS providers are essentially signing the patient's death certificate unless they are immediately across the street from the hospital.

 

[abckidsmom]

I do not transport dead people anywhere, as a general rule. If you don't have your own pulse, we're staying put until you do, or until we stop CPR.

 

[Anjel]

I do not transport dead people anywhere, as a general rule. If you don't have your own pulse, we're staying put until you do, or until we stop CPR.

But as bls we cant make that call. Unless obvious death.

I know this is something I wouldnt have to worry about since.i would never get dispatched by myself to an arrest.

But Im curious. If no ALS available. Get them on the stretcher asap. Grab a police officer or someone else trained. Throw them on the chest...you bag...and away we go. No time limit. I dont think there is anyways.

Heck...i could probably do cpr by myself if I had to.

 

[Hunter]

As far as I've been taught as BLS, we don't stop CPR unless the Death is obvious, dependent Lividity, Decapitations, ect. in those cases we actually probably wouldn't even start CPR actually but once you've determined the need for it, you don't stop unless a doctor Orders you to.

 

[Anjel]

As far as I've been taught as BLS, we don't stop CPR unless the Death is obvious, dependent Lividity, Decapitations, ect. in those cases we actually probably wouldn't even start CPR actually but once you've determined the need for it, you don't stop unless a doctor Orders you to.

Yes...thats what I was taught as we. So if there is no ALS.coming then PUHA

 

[Tigger]

Transport while just having the attendant bag them with air and hope the ER can revive them?

Whatever you do, don't do this.

Compressions are the most important part of CPR. That's (simplistically) why the lay-person CPR has been changed to "hands-only." If for someone reason there is no one else at all available to ride in with you and the time to hospital is shorter than the time to ALS intercept, just concentrate on good quality compression. That's going to be tough enough as it is since you're in the back of an ambulance that is probably hauling and it's just you.

Sadly my area has not moved passed the idea of not transporting dead people. There are very few scenarios in which CPR should be done in a moving ambulance.

 

[DrParasite]

There are very few scenarios in which CPR should be done in a moving ambulance.

organ harvesting for transplants?

 

[awildstein]

This is actually one of the instances where I'd argue that EMTs are essentially as good as paramedics AND both should work it on scene. Cardiac arrests are -the- time sensitive emergency and the only thing decreasing the time until brain death is good quality compressions. There's zero evidence that ACLS medications increase survival to discharge (yes, they increase ROSC and all survival to discharge achieves ROSC). There is evidence that CPR in the back of a moving ambulance is essentially no CPR. By focusing on packaging and transport instead of quality compressions and AED delivered defibrilations, the EMS providers are essentially signing the patient's death certificate unless they are immediately across the street from the hospital.

I agree with the vast majority of this post. BLS is infinitely more important than any ALS intervention in the setting of cardiac arrest. It is a very important point to be made. Where EMS tends to drop the ball on cardiac arrests, I would argue, is 1 interrupting compressions to intubate and such and (an issue for another day) and 2 working the patient on scene for an extended period of time. The latter is incredibly dangerous pitfall for long term outcomes because EMS does not effectively treat and correct the underlying cause of the arrest. Keeping somebody in Vfib on scene trying to get ROSC is no good when what the patient really needs is a trip to the cathlab to restore myocardial perfusion or an embolectomy or pericardiocentesis ect... After a few minutes you really need to consider moving off scene and getting to definitive care. Think of on scene times for cardiac arrest patients like on scene times for trauma patients.

 

[MrBrown]

The latter is incredibly dangerous pitfall for long term outcomes because EMS does not effectively treat and correct the underlying cause of the arrest. Keeping somebody in Vfib on scene trying to get ROSC is no good when what the patient really needs is a trip to the cathlab to restore myocardial perfusion or an embolectomy or pericardiocentesis ect... After a few minutes you really need to consider moving off scene and getting to definitive care. Think of on scene times for cardiac arrest patients like on scene times for trauma patients.

OMG this is almost the strongest example of super hella mega gangsta seriously bad news white bread style immeasurable fail Brown has ever seen! :unsure:

There is no place for transporting a primary cardiac arrest patient who has not achieved ROSC, ever ... and there is little place for transporting a secondary cardiac arrest who has not achieved ROSC. The one or two examples are somebody with penetrating injury to the heart who will benefit from pericardiosentesis or a pregnant arrest >24wks

 

[Leafmealone]

As far as NYS goes, We are to shock no more than 3 times then begin transport. Obviously, though, this is textbook. In the field we tend to do compressions while we package, and give them some LSD. You can always shock en route if need be, but from what I hear there is rarely a 2nd shock at all when it comes to a code. Best thing to do is get them to a hospital, because even with all the compressions and breaths you do, you aren't a cardiologist.

 

[medicdan]

Now, with the presence of the Lucas or AutoPulse in a BLS ambulance, do you see it as more feasible to transport non-ROSC patients? Even if you have 2-3 providers in the back, it's extremely dangerous (and unproductive) to be doing poor compressions when not belted in.

 

[MrBrown]

As far as NYS goes, We are to shock no more than 3 times then begin transport. Obviously, though, this is textbook. In the field we tend to do compressions while we package, and give them some LSD. You can always shock en route if need be, but from what I hear there is rarely a 2nd shock at all when it comes to a code. Best thing to do is get them to a hospital, because even with all the compressions and breaths you do, you aren't a cardiologist.

Remind Brown again what a hospital can do for a cardiac arrest patient that Ambulance Officers cannot besides pronounce them dead?

You know Camp Counsellor Brown was once backed up by a very flustered looking volunteer crew somewhere in New York State, they didn't even have a blood pressure cuff ....

 

[JPINFV]

2 working the patient on scene for an extended period of time. The latter is incredibly dangerous pitfall for long term outcomes because EMS does not effectively treat and correct the underlying cause of the arrest. Keeping somebody in Vfib on scene trying to get ROSC is no good when what the patient really needs is a trip to the cathlab to restore myocardial perfusion or an embolectomy or pericardiocentesis ect... After a few minutes you really need to consider moving off scene and getting to definitive care. Think of on scene times for cardiac arrest patients like on scene times for trauma patients.

If the patient is in refractory v-fib because he needs a cath lab then it doesn't matter because by the time the patient makes it to the cath lab they'll be dead anyways.

 

[JPINFV]

Now, with the presence of the Lucas or AutoPulse in a BLS ambulance, do you see it as more feasible to transport non-ROSC patients? Even if you have 2-3 providers in the back, it's extremely dangerous (and unproductive) to be doing poor compressions when not belted in.

If the mechanical CPR devices have been shown to increase hospital discharge, be it with ROSC at the hospital or prehospital, then sure. Just transporting because it's much safer and more effective CPR, however without improving outcome? NO, because either way the ED is basically stuck with a corpse needlessly.

 

[usalsfyre]

Last time I checked cath labs generally didn't take patients in vfib....

 

[usalsfyre]

...give them some LSD...

Holy halucinogenic Batman! What are your security precautions for lysergic acid diethylamide?!? (Assuming you meant "lights, siren, diesel or some other cute acronym).

because even with all the compressions and breaths you do, you aren't a cardiologist.

Neither is the EM physician that's going to call the code on your arrival. The cardiologist is likely to provide exactly the same treatment, though. Quit shunning responsibility, buck up and start realizing medicine is medicine no matter where it's provided.

 

[usalsfyre]

Now, with the presence of the Lucas or AutoPulse in a BLS ambulance, do you see it as more feasible to transport non-ROSC patients? Even if you have 2-3 providers in the back, it's extremely dangerous (and unproductive) to be doing poor compressions when not belted in.

The big question is why would you want to (besides Zoll and Physio telling you it's a good idea to sell more units). Hasn't been shown to make a difference outcome wise. The real reason this is pushed (in my opinion) is many medics are EXTREMELY uncomfortable with being the final medical provider, taking ultimate responsibility for the care they provide and performing death notifications.