Field termination of cardiac arrest

[daedalus]

I got into a huge argument with my partner today (he is a paramedic). We were in the ED dropping someone off and saw another crew bring in a cardiac arrest code 3. I shook my head and said I wish they didnt transport. Sure enough the MD comes in and calls it within 30 seconds! What a waste of resources, time, and danger to the public for transporting code.

My partner flew off the handle and lectured me that of course cardiac arrests were transported to the ER. He acted like I committed a deadly sin by saying otherwise. I told him there is a trend in EMS right now leaning away from transporting cardiac arrests as it brings false hope to the family, endangers the public with a emergent transport, and is a waste of time and resources seeing that the medic has a defib, monitor, and cardiac drugs. The medics have the same ACLS as anyone in the ER. He laughed at me and said no way in hell, all arrests get transported. He gave in that asystole should stay on scene, but I thought that even pulseless V fib was to be worked fully in the field, after all I asked him what more the ER could do for a dead person. He said continue CPR.... well so can we!

Thoughts?

 

[reaper]

Your partner is old or uneducated?

 

[firecoins]

Your right. Most codes are not going to be transported. Pulseless V-Fib does get transported here.

 

[Grady_emt]

We used to be fairly lax about our field terminations, and many arrests were left in the field. This was until a crew called a code and left the body with PD awaiting the M.E. in the middle of a packed resturant on a friday night.

Now our policy is that they must start in asystole, stay in asystole through two rounds of drugs and be intubated. If any of the above are not met, they must be transported.

Obviously, the ones that are obviously dead are not worked.

 

[KEVD18]

this discussion is directly related to the sids thread ffrom a few weeks back:

http://www.emtlife.com/showthread.php?t=9382&highlight=sids

must we relive it again?

 

[reaper]

Gotta have something interesting. It is getting boring around here lately!!!

 

[traumateam1]

Here you don't generally transport cardiac arrest patients. There are a few exceptions, like MD's orders, or the scene is unsafe. Other than those two criteria, all arrest patients are to stay at the scene and be worked until a termination of cardiac arrest protocol is met, or a transportation protocol is met.

Usually it's the termination, rather than transport tho.

 

[Sasha]

We transport all cardiac arrests here unless the reason for cardiac arrest is like a crushed in rib cage (like a truck rolled over their chest where theres just no room for the heart to contract) or missing head or their legs are over THERE and the rest of them is over HERE kind of cardiac arrest, generally things were it is completely hopeless), though there is talk about moving away from transporting or even working traumatic asystole.

 

[daedalus]

this discussion is directly related to the sids thread ffrom a few weeks back:

http://www.emtlife.com/showthread.php?t=9382&highlight=sids

must we relive it again?

Actually, yes we do. I need information pertinent to my situation, and it is really getting boring in here.

We cannot let this search before posting thing get to the point of absurdity

 

[KEVD18]

that thread moved away from just sids to the general topic of field termination and was discussed as such for several days.

its the same topic with no new angle. your partner is an idiot. you were right but until your state puts it on paper and makes all the old school medics tale a class on it, you wont see a change.

 

[MMiz]

Back in 2005 our protocols changed to work a code on scene for 30 minutes with ALS, and then call it or transport.

 

[VentMedic]

This is not about termination exactly but the idea is there. I think we all know that the back of a truck is not ideal for effective CPR.

More CPR on scene boosts cardiac arrest survival

Mon Oct 27, 2008 7:01pm EDT

http://www.reuters.com/article/healthNews/idUSTRE49Q88Y20081027

CHICAGO (Reuters) - Firefighters and paramedics in Los Angeles who spent at least 20 minutes giving advanced life support to people with cardiac arrest before rushing them to the hospital were far more successful at getting hearts started again, U.S. researchers said on Monday.


Cardiac arrest occurs when the heart stops circulating blood. Survival rates for cardiac arrest that occurs outside of a hospital are very poor.


But firefighters and paramedics in Los Angeles who used the new protocol succeeded in restoring heart beats 29 percent of the time, a 70 percent improvement over the 17 percent success rates seen in a prior study in Los Angeles.

 

[Outbac1]

If the pt is not obviously dead and is worked in the field we transport if we get a pulse and/or respirations back. To terminate on scene we need a tube, a line, have given three rounds of epi, atropine or lidocaine as appropriate and asystole or PEA and about 20 min. of working it. We then call our online Dr. tell them what happened, what we did and now have with some pt hx. The Drs almost always say to call it. The body stays put and becomes a police problem.

We usually stay and help the family a little then clear and go back in service. The need for a tube may change in the near future if we have an adequate airway in place with good manual respirations.

BLS arrests are started, if appropriate, CPR, manual airway, shock as required and transport initated. Hopefully ALS will show up before you get going and it can be worked on scene. In 7 1/2 years as a (Canadian) BLS provider I have never done a BLS arrest. I've started a couple but ALS arrived.

Myself I usually ask whoever is there if they know if the pt would want resuscitation. I have no problem confirming VSA and leaving them dead.

For more info please see our EHS web site
http://emergency.medicine.dal.ca/ehsprotocols/protocols/toc.cfm

Hope this has been some help to you.

 

[karaya]

Here is a link to a recent article on this very subject. Interesting study conducted that advocates not transporting cardiac arrest patients when given certain parameters.

http://www.jems.com/news_and_articles/news/saving_lives_more_efficiently.html

 

[marineman]

I don't know the exact protocols on transporting or not transporting but I know we don't transport all of them. If we are transporting we go non-emergency unless they have a shockable rhythm.

 

[Gi.Josiah6201]

I may be dumb but...

Is there also not a question of they interval of time in between when an arrest is found - bls / acls begins and before time on table for possible cardiac catheterization or Fibrinolytic therapy can be initiated?

 

[WuLabsWuTecH]

If the pt is not obviously dead and is worked in the field we transport if we get a pulse and/or respirations back. To terminate on scene we need a tube, a line, have given three rounds of epi, atropine or lidocaine as appropriate and asystole or PEA and about 20 min. of working it. We then call our online Dr. tell them what happened, what we did and now have with some pt hx. The Drs almost always say to call it. The body stays put and becomes a police problem.

We usually stay and help the family a little then clear and go back in service. The need for a tube may change in the near future if we have an adequate airway in place with good manual respirations.

BLS arrests are started, if appropriate, CPR, manual airway, shock as required and transport initated. Hopefully ALS will show up before you get going and it can be worked on scene. In 7 1/2 years as a (Canadian) BLS provider I have never done a BLS arrest. I've started a couple but ALS arrived.

Myself I usually ask whoever is there if they know if the pt would want resuscitation. I have no problem confirming VSA and leaving them dead.

For more info please see our EHS web site
http://emergency.medicine.dal.ca/ehsprotocols/protocols/toc.cfm

Hope this has been some help to you.

Ok, here's an interesting question. I'm BLS, I go through CPR/AED/Intubation and am getting in the rig ready to load and go. ALS was called as soon as we got to the scene but they are still X minutes out. We are Y minutes from the hospital.

What's the differential needed there for the following 3 options:

Waiting for ALS
Intercepting with ALS
Straight Shot to the Hospital

My guess is that we would wait up to 5 more minutes for ALS unless the hospital was less than 10 min away.

Intercept if they are in the right direction (toward the hospital, never go away from it!) but more than 5 min out and the hospital is more than 20 min away?

Around my city though, I would almost always go straight to the ED since i'm usually less than 5 minutes from an ER and if BLS was called to the scene it's ususally due to the fact that the closest ALS is very far out.

 

[medicdan]

Is there also not a question of they interval of time in between when an arrest is found - bls / acls begins and before time on table for possible cardiac catheterization or Fibrinolytic therapy can be initiated?

This is not so related to the OP-- so it may warrant a separate disucssion...

Below is a quick summary of my notes from two recent lecures. The first was Dr. Peter Moyer. Feel free to correct me.

Re: angioplasty:
Different facilities have slightly different standards, but in Boston, its generally considered optimal to get a stent into a patient withing 90 min of symptom onset.

In Boston we have several cath lab-capable facilities, and in order to maintain certification, both the facilities an the staff need to do a certain number of procedures a year. In most cases, BostonEMS calls a STEMI alert as soon as they get a 12-lead, activating the team, who has to live within 30 min of the hospital. The patient goes to the ER until the lab is ready, and most hospitals try to have a door-balloon time of ~20 minutes. In order for this to happen, ALS needs to get to the scene quickly-- to get the 12-lead, and they have a response time of less then 8 min (4/6 for fire/BLS) For the record, hospitals are doing many fewer CABG procedures, electing for the less invasive cardiac cath.

Re: tPA
Some statistics from a different recent lecture.

~6500 ischemic strokes/year in MA
~20% patients arrive in the ER/ED within 2 hours of symptom onset.
~5% patients eligible for tPA
Average time delays:
Symptom onset to EMS activation: 66 min
Dispatch to pt contact: 6 min
Pt contact to hosp notification: 17min
pt contact to hosp arrival: 24min
Total: 96min

IV tPA- 3 hours from symptom onset
Intra-aterial thrombotic-- 3-6 hours from symptom onset
mechanical retrieval (coil)--3-6 hours

Hope this answered your questions (in a long-winded way!)

 

[bonedog]

Unless there is a treatable cause for which I don't have the cure,(not much in reality) work the patient at the scene until ROSC or medic determined celestial D/C.

Good CPR is paramount, with little or no interuption, in order to keep up the coronary perfusion, otherwise it is all for naught.

 

[crayzeeemt]

answer

Many different places have easy to follow guidelines for full arrest. We have it so the scratch your head guesswork is taken out of it all. In OKC, if a person is in their home of a nusing home is the ONLY time where you can work them for 30 and if the pt does not come out of asystole or PEA. If they come out into another rythmn. BOOM, transport. If they are ANYWHERE ELSE, we transport. We do not leave people in the mall, dead, from a heart attack. The only time we leave poeple where they are is if they are obviously dead. Rigor, pooling, etc.