Reality of Codes vs. AHA Standards

[LevarBurton]

I've worked as Firefighter/EMT-B for going on 3 years now, and just recently had this question brought forward. In the time I've work I've had approximately a dozen or more viable codes and a few more that were not viable but involved possible donors. The county which I work in has a system of response so that on any ALS level run you will receive a response of a BLS Fire Squad, an ALS Transport, and an ALS Field Supervisor. The ALS service in this county is generally considered a very progressive service as it is a division of very large university's research hospital network and in addition to paying extremely well compared to other services, is also largely involved in using only research backed prehospital care and being involved in pilot programs which largely in the past been focused on ACLS.

In every code which I've worked, I have never observed anyone involved or have myself worked a code to AHA Guidelines. Every code has involved continuous compression with no or minimal stopping only when needed by medic. Respirations are always give at 12 per minute to adults whether they are bagged, combitubed, or intubated. And no cessation of compressions every occur to provide ventiliations while patient is bagged. All codes are pitcrewed by the ALS Supervisor and normally have plenty of personnel on scene to provide care.

I've only ever worked in EMS in this County and had very little interaction with EMS providers from other areas. I've always wondered if other services are much more strict (or looser) about working codes, or if this is the universal standard in EMS.

 

[Akulahawk]

I quite suspect that your experience is not the norm right now.

 

[WolfmanHarris]

If my region cardiac arrest gets two units (1 transport and 1 RRU or 2 transport) for a minimum of 3 medics on scene with at least one ACP as well as FD.

There has been a big push from medical direction and the service for out crew approach emphasizing minimal interruptions and delayed advanced airway placement. We've spent training a on human factor identification and the use of crew resource management techniques in running critical calls. Having more medics on scene has required some adaptation as were used to having fire to direct and not really working as a team and sometimes people have trouble moving into a supporting role.

We transport few cardiac arrests but more and more of our trucks are carrying Lucas 2 or Autopulse for on scene use and in the event of transport.

Research wise we're currently doing a post arrest cooling trial and an Amio vs Lido vs placebo trial.

 

[TransportJockey]

We don't follow acls completely. We give aminophylline for bradysystolic arrests. Thats the biggest difference. Other than that we try to dispatch both in town trucks for codes to have some extra hands on scene.

 

[Carlos Danger]

In every code which I've worked, I have never observed anyone involved or have myself worked a code to AHA Guidelines. Every code has involved continuous compression with no or minimal stopping only when needed by medic. Respirations are always give at 12 per minute to adults whether they are bagged, combitubed, or intubated. And no cessation of compressions every occur to provide ventiliations while patient is bagged. All codes are pitcrewed by the ALS Supervisor and normally have plenty of personnel on scene to provide care.

I've only ever worked in EMS in this County and had very little interaction with EMS providers from other areas. I've always wondered if other services are much more strict (or looser) about working codes, or if this is the universal standard in EMS.

I'm not totally clear on your question. It sounds to me like you guys are giving solid care using the most current best practices.

If you are just asking whether other places do a better job of adhering to the EXACT WORDING of the ACLS protocols......the answer in my experience would be a definite "no".

ACLS guidelines are just that.....guidelines. It can be really hard to implement them perfectly in every situation - especially in the field - and we know most of ACLS has little impact on outcomes anyway.

The important thing is to be really consistent at doing the things that know are important, and it sounds like you guys are doing that as well as any other place.

 

[Household6]

You mean they don't do 30:2.. They give ventilations continuously while doing compressions.

That's how we do it. The only pausing in compressions is during tubing (if necessary) analyze, or applying Lucas.

 

[OnceAnEMT]

The ED I am at is the same when it comes to continous compressions, but still strictly follows ACLS guidelines for meds. I know with the not so new now MD at ATCEMS introducing pit crew there was also a push for continous compressions, so I can only assume that it is the way they role now. In fact, I am certain they do, because they also started using rescue pods.

I am an AT student, and some of the ATs where I am at are old school to the bone. When cardiac arrest is discussed, it is AHA or die. Knock on wood, I hope its my scene if there is a cardiac arrest.

 

[Underoath87]

It sounds like you guys are just ahead of the curve and using upstroke ventilation.

http://www.jems.com/article/patient-care/using-upstroke-ventilation-optimize-coro-0

 

[Christopher]

In every code which I've worked, I have never observed anyone involved or have myself worked a code to AHA Guidelines. Every code has involved continuous compression with no or minimal stopping only when needed by medic. Respirations are always give at 12 per minute to adults whether they are bagged, combitubed, or intubated. And no cessation of compressions every occur to provide ventiliations while patient is bagged. All codes are pitcrewed by the ALS Supervisor and normally have plenty of personnel on scene to provide care.

There are no Class I, LOE A recommendations for airway management besides the use of continuous waveform capnography. If you're doing that, then you're following AHA guidelines for airway management. Maintaining an open airway is Class I but only LOE C. The rest has no good evidence to support any rate/timing, however, their opinion is you utilize positive pressure ventilation of some kind (with no evidence, just that passive ventilation has no evidence either...very frustrating). SGA's vs ETI are Class IIa LOE B. The compression to ventilation ratio has no evidence (Class IIb LOE B), however, tidal volume and breath duration both are Class IIa LOE C recommendations. Asynchronous ventilations are Class IIa, LOE B without any evidence for the rate of ventilations.

Minimization of interruptions in chest compressions was Class IIa LOE B, however, this will likely become Class I, LOE A or B following the compression fraction research presented since the 2010 guidelines. Rate of 100-120 is Class IIa, LOE B; but this also will likely become Class I.

Defibrillation is Class I (LOE B funny enough).

Medications are all Class IIb LOE A at best (most Class IIb, LOE B).

So, in order to following the AHA guidelines you must:
1. Use continuous waveform capnography with all airways (the ONLY Class I, LOE A intervention)
2. Perform chest compressions at a rate of at least 100 cpm (Class IIa, LOE B; likely Class I next guidelines)
3. Minimize interruptions (Class IIa, LOE B, likely Class I next guidelines)
4. Defibrillate VF/VT (Class I, LOE B)

If you're doing those 4...you're following the guidelines.

Part 5: Adult Basic Life Support.
Part 8: Adult Advanced Cardiac Life Support

 

[Handsome Robb]

Did anyone mention upstroke ventilation?

 

[Underoath87]

Did anyone mention upstroke ventilation?

Me

 

[Tunamate]

@ Christopher - nailed the AHA guidelines.
That's how we are taught in SA. However the team approach is somewhat of a challenge as we are often short of hands on scene. This is obviously relevant to the area you're working, city centre versus rural or residential.
In all the codes I've run it's been continuous compressions as the target of treatment and we've Successfully resuscitated a few patients who've returned to thank us.

 

[DrParasite]

I'm pretty sure our medical director considers AHA standards, but don't follow them to the letter.... actually my new job told me that I will never need another AHA CPR cards for as long as I am employed if I stay with them....

We send 1 engine, 1-2 ALS ambulances, and typically 1-2 supervisory type units to every cardiac arrest. the biggest push is on continuous compressions, and the only time we stop them is when we analyze a rhythm or deliver a shock. any other time (defib is charging, right after delivery, while inserting an advanced airway, etc), compressions are maintained, and the LP15s have this cool metronome feature that greatly helps in the rate of compressions (seriously, I love it, it's amazingly simple and I never saw it until about 3 weeks ago). If you see V-fib or V-tach, defib the person, because electricity saves lives, not any drugs in the ACLS algorithm.

We also DON'T transport medical cardiac arrest patients (for the most part, there are some rare exceptions). work them on scene, whether it takes 10 minutes or an hour, you don't move the patient until you get a pulse back or you are pronouncing them. As a general rule, we don't intubate codes either, but some people like to intubate once ROSC is obtained; BIADs are the preferred method, but BVM and OPA/NPA works find too. we also use ETCO2 on every arrest.

and for some reason, we have a ridiculously high cardiac arrest save rate.

 

[Akulahawk]

Did anyone mention upstroke ventilation?

Mention upstroke ventilation? I didn't... but I was doing it 15 years ago. It just seemed the way to decrease the amount of time between compression pauses. Of course this was back when the ratio was 15:whatever...

 

[Household6]

and the LP15s have this cool metronome feature that greatly helps in the rate of compressions (seriously, I love it, it's amazingly simple and I never saw it until about 3 weeks ago)..

I like that feature too, just press the CPR button. I was a little nervous the first time I used it, because I know everything is recorded in the LP15, then transmitted back to the MD for review. I was worried about not doing everything perfectly.

We also carry Lyfetymer LED metronomes for our BVMs. I love those.

 

[TimRaven]

Didn't someone on another sub-forum mentioned that there is a pilot program of AHA in a number of counties practicing upstroke ventilation?

 

[chaz90]

Didn't someone on another sub-forum mentioned that there is a pilot program of AHA in a number of counties practicing upstroke ventilation?

I think a lot of this is a misunderstanding of what AHA does. They provide a set of guidelines that are intended to be based on best evidence to improve outcomes in cardiac arrest patients. Unfortunately, they're only updated every 5 years and are frequently even slower than that to change. They don't serve as a protocol or any kind of rules set in stone, and any medical director is free to adjust them (or ignore them) as he or she feels fit. Watch an ERP run a code in the ED some time. They rarely (for better or for worse) follow AHA guidelines to the letter.

With the support of our medical directors, we have been using continuous chest compressions with a LUCAS and concurrent upstroke ventilation for a while now. There are likely hundreds of agencies across the country that practice various variations of AHA CPR guidelines. There's simply no reason to wait for AHA updates to adjust when reasonable evidence suggests there may be a better way to do things now.

 

[Rick Tresnak]

Simply put no we do our best, use an autopulse and intubate. We run a two man crew, typically one paramedic, and an EMT-B The one thing that we found that helps is the ArrestPAC. It is great for services that only run a few calls a year and it organizes the code pretty well. Here is a link I found to it. http://irs4you.com/index.php/arrestpac.html The thing I like it can be customized to fit your protocols. I think there are several services that use them. It kinda takes the place of your third rider running the code. (I know small town, but you know I like it that way)

 

[mycrofft]

We used to call "upstroke ventilaion" by another name: inerpolated breaths. The second a compression ended we would "blow the hands back up". This made for very energetic inflations to get in a lungful in about 0.4 seconds and the attendant side effects therefrom, since we had either only positional airway or an OPA.