Refractory V-Fib to cath lab #2

cruiseforever

cruiseforever

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My last thread got locked. I will answer questions asked there on this thread.

From DEmedic - That's interesting... is double sequential defibrillation anywhere in that protocol? No it is not.

Is this for any patient who remains in sustained VF, or patients that regain an organized rhythms and then revert to VF? The protocol goes into affect after the third shock. Our treatment strays away from the ACLS guidelines once we contact with Med Control. The biggest change that I have heard of so far is giving less epi. Our medical director tries to be Med. Control on all our arrests at this time.
 
From medicsb -This is one of those things that I find interesting (and promising), but I'm also quite skeptical. ECMO takes time to set-up (from equipment to final placement), and it generally requires a cardiothoracic surgeon. Though some EM docs have trained to do it (E.g. Sharp Memorial Hosp in San Diego), they are exceptions and it would be exceedingly hard to train every EM doc to do it. In my opinion, this is something that should only be done as part of a study. At least with prospective data gathering (though ideally, it would be randomized). I heard mention of a system implementing a similar protocol but sans ECMO, and I'm still skeptical. The hospital that has started this program is a heart transplant hospital. The first crew that transport an arrest pt. there was very impressed on how quick and smoothly everything went. I am sure there will be issues that arise.

At this point, I'd rather see energy and money put toward improving pre-hospital care - increasing bystander CPR rates, public access defib, increasing compression fraction by human compressors (mechanical is no better and more expensive), etc. before throwing more gadgets and expensive personnel into the mix. There is very little additional cost to the ambulance service. Almost every Fire Department in our service area has a mechanical compression device. Public access to AED is improving every year.
 
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From triemal04 - I would be curious to know if it would really be worth it when all things are considered, or if the time/money wouldn't be better spent on upping the numbers for citizen CPR, dispatch aided CPR, public access AED's, AED's in police cruisers, and better performance by EMS agencies.

The two services that I work for are always looking at ways to educate the public in CPR. We do mass CPR classes in schools every year. Set up a CPR education stations at fairs and other large events. Dispatch aided CPR is being done now.

All the squad cars do carry AED's. We are trying to develop a program were people register their AED and when 911 is called the AED nearest to the location will be displayed on the 911 screen.

Better performance by EMS agencies is hard to gauge. Most think they do it the best. There is always room for improvement.

 
From teedubbyaw - Better hope you're close to the hospital. Better survival rate? Sure. Neurological outcome? No. Especially with manual compressions? Shoooot.

It will be interesting to see the data.
 
In my department our goal is patient's side-to-first shock in less than 60 seconds (let's call it 1 minute). We deploy suction, assemble the BVM, attach to capnogrpahy and oxygen, and insert an appropriately sized OPA during the first 2-minute cycle after the first shock, then we shock again and switch to 30:2. According to your "refractory" VF policy the patient would be loaded for transport after the next 2-minute cycle! That's really fast. Less than 10 minutes. I know from analyzing close to 100 cases in CODE-STAT that much of what we call refractory VF is actually recurrent VF (meaning we successfully terminate VF and recurs during CPR). A refractory protocol should be for true refractory VF and not seriously considered until after at least 20 minutes of High Performance CPR, with a "good story" (young-ish patient with witnessed collapse) and persistent good ETCO2. I'd be furious if you loaded up my loved one after the 3rd shock. I'd probably end up in handcuffs. There's a good chance I would pursue legal action.
 
TomB said:
I'd be furious if you loaded up my loved one after the 3rd shock. I'd probably end up in handcuffs. There's a good chance I would pursue legal action.
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On what grounds? CPR in-route to a higher level of medical care with a mechanical device in place is not sub-standard of care. If it was my family member, you're damn sure I would want them getting to that ECMO facility as fast as possible. At my facility, there is a 60 minute code clock in place as a "soft" guideline for emergency ECMO. If you take 5 minutes to respond, and then you **** around on scene for 25 minutes before transporting for 15, that's already 45 minutes gone. By the time you get to the receiving facility, you're period of viability to perform ECMO is fast slipping away. Usually, the ED doc will have to see the pt. and call to assemble the ECMO team. By the time they get here and cannulate, you've probably going to be over that 60 minute mark.
 
MonkeyArrow said:
On what grounds? CPR in-route to a higher level of medical care with a mechanical device in place is not sub-standard of care. If it was my family member, you're damn sure I would want them getting to that ECMO facility as fast as possible. At my facility, there is a 60 minute code clock in place as a "soft" guideline for emergency ECMO. If you take 5 minutes to respond, and then you **** around on scene for 25 minutes before transporting for 15, that's already 45 minutes gone. By the time you get to the receiving facility, you're period of viability to perform ECMO is fast slipping away. Usually, the ED doc will have to see the pt. and call to assemble the ECMO team. By the time they get here and cannulate, you've probably going to be over that 60 minute mark.
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It's substandard care when you interrupt chest compressions during the "sweet spot" of the resuscitation (the 3rd shock should be delivered at minute 5) to apply the LUCAS device (no evidence of benefit) just so that you can (possibly) transition to ECMO or beat some arbitrary "soft" guideline. What is being described here is not refractory VF and that's my problem with it.
 
TomB said:
It's substandard care when you interrupt chest compressions during the "sweet spot" of the resuscitation (the 3rd shock should be delivered at minute 5) to apply the LUCAS device (no evidence of benefit) just so that you can (possibly) transition to ECMO or beat some arbitrary "soft" guideline. What is being described here is not refractory VF and that's my problem with it.
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Who said that they're starting the LUCAS after the third shock. Most protocols I know of utilize the LUCAS immediately upon arriving on scene, instead of transitioning to it at a later time. Additionally, if you want to call refractory VF after 20 minutes of high quality CPR and shocks, where does it matter where it happens? The beauty of mechanical chest compression devices is that they operate consistently irrespective of their environment. Unless you want to argue that chest compressions provided by the LUCAS are less effective in the back on an ambulance or in an ER than on the scene, I don't see how "staying and playing" helps the patient.
 
Ah, the joys of medicine. This is another one of those cases where gospel is overturned. It used to be that no one was dead until they were in the ER. Then it became that there is nothing that can be done in the ER that can't be done in the field so work it to death or ROSC. Now we are moving back to getting to the ER ASAP. We have an ECMO protocol in the works but I don't know the details. It will be interesting to see how this turns out. Maybe ECMO will be the thing that finally improves outcomes and field treatment will be to slap on a LUCAS and run like hell.
 
If you have poor outcomes for witnessed VF arrest the solution is to improve the chain-of-survival, not to "slap on a LUCAS and run like hell."
 
TomB said:
If you have poor outcomes for witnessed VF arrest the solution is to improve the chain-of-survival, not to "slap on a LUCAS and run like hell."
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Is anyone's survival rate 100%? Then, there are patients that can benefit from LUCAS and run and ECMO.
 
So you think that King County Medic One should take it's 62% survival rate for witnessed VF and trade it in for "LUCAS and run" so that the remaining 38% can have a chance at life. Is that a fair statement? I'm looking forward to reading all about your "highest in the world" survival rate thanks to ECMO.
 
TomB said:
So you think that King County Medic One should take it's 62% survival rate for witnessed VF and trade it in for "LUCAS and run" so that the remaining 38% can have a chance at life. Is that a fair statement? I'm looking forward to reading all about your "highest in the world" survival rate thanks to ECMO.
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And in your estimation, how many of those 62% do you think KCM1 didn't get ROSC in after the first 15 minutes?
 
So....that's the absolute pinnacle of resuscitation? That there's absolutely no room for improvement? That continuing to delivery quality chest compressions en-route to higher level medical care is a bad thing?
 
I don't have a problem with transitioning to LUCAS for true refractory VF if there is a chance of saving them with ECMO (a patient with a very poor prognosis and nothing to lose). I am aware of some interesting cases from Minneapolis Heart where this was done. I would not, however, change my entire approach to resuscitation from High Performance CPR to "load and go" with a LUCAS device just in case ECMO is needed without some extraordinary evidence that, epidemiologically speaking, more lives will be saved with this approach. So yes, I think it may be a bad thing to prematurely place a LUCAS device on a patient and transport them to the hospital. The person who started this thread indicated that in their system they consider VF to be refractory after 3 shocks and I pointed out that the 3rd shock is delivered at minute 5 of the resuscitation. I think it's a mistake to bypass the conventional resuscitation. Having said that, it really doesn't matter what I believe or what you believe. What matters is what we can prove. I look forward to seeing your data.
 
I also eagerly await more data for the feasibility and survival of E-CPR (Extracorporeal CPR). You seem to continue differentiating "High Performance CPR" and "'load and go' with a LUCAS device" and I don't see the difference. I also do agree with you that through RCTs, we will eventually start retrospectively identifying subgroups in which ECMO was most beneficial for and start having better guidelines to institute. I, however, do also contest that ECMO isn't a bad last ditch effort for multiple reasons: 1. it is extremely resource intensive and cost-prohibitive and 2. total arrest time prior to cannulation may be a key factor in survival and therefore waiting until everything else is exhausted in the properly identified subgroup of arrest patients may be detrimental to an otherwise survivable event had people gone to ECMO sooner.
 
Very interesting protocol, will definitely be interested in seeing what information can be seen after a few years of trying the protocol.
 
TomB said:
If you have poor outcomes for witnessed VF arrest the solution is to improve the chain-of-survival, not to "slap on a LUCAS and run like hell."
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And what's to say that improving the chain of survival doesn't include a LUCAS device which can perform better compressions than a person, run like hell and have ECMO waiting at the door? I never said it was a panacea, I was more putting out a 'what if' type statement. There is not enough evidence yet to judge one way or another. I think you are also comparing apples to oranges. We are talking about refractory vfib, you are talking about someone with ROSC. Someone with ROSC is not going to need ECMO.
 
My department owns a LUCAS device. We do not apply it until after 5 cycles of Pit Crew CPR (we call these patients "non-responders to Pit Crew CPR") but we don't apply the LUCAS during the sweet spot of the resuscitation.

Whether or not the LUCAS can be applied quickly is a matter of opinion but I prefer evidence. Our CODE-STAT data shows that the average application causes not one, but two interruptions in chest compressions (to reposition the plunger), sometimes totaling 30 seconds between "last manual compression" and "first effective mechanical compression" and yes, we have trained extensively on the device.

Regardless of all that, there are patients who have a "good story" who are still in cardiac arrest at the 20 minute mark, with an ETCO2 of 40 and SpO2 of 100 (on the LUCAS). So I think it would be great if we could offer these patients something other than extended resuscitation (which is better than nothing -- Wake County EMS's data shows that we save more patients when we work the arrests longer).

I differentiate between High Performance CPR and the LUCAS device in back of a moving ambulance because there is more to High Performance CPR than high quality chest compressions (airway management, leveraging team experience, and so on). My neighboring EMS system places patients on LUCAS as soon as they arrive at the scene, and while they are not part of the CARES registry, I have some insight because my wife handles outcomes research for our receiving hospital.

Anyway, I have no problem with using LUCAS and ECMO for true refractory VF (or even recurrent VF due to unstable LAD occlusion or something like that). We don't need to beat a dead horse but obviously I am not in favor of immediate application of LUCAS and moving a patient with witnessed VF arrest. I understand that others believe they can do an equal job with the LUCAS device in back of a moving ambulance but it would take a lot for me to believe that (like a review of CODE-STAT data and the annual CARES report).

I wouldn't necessarily agree that there's "not enough evidence" to judge one way or the other. There are too many EMS systems saving 40-60% of their witnessed VF patients by working them in place until ROSC and delivering them to hospitals with cardiologists and intensivists who will actually follow through with appropriate post-resuscitation care. I'm not saying that ECMO does not have a place. I'm saying that if the current system is only saving 10-20% of their witnessed VF patients then ECMO is the wrong focus.

I hope this clarifies my position. You are welcome to have the last word. I suspect we will be hearing a lot more about this topic in the next 5-10 years as different systems start to employ such different approaches to resuscitation. I hope everyone publishes their data to allow apples-to-apples comparisons because "ECMO saves" must be viewed in the context of overall system saves.

Merry Christmas!
 
TomB said:
I wouldn't necessarily agree that there's "not enough evidence" to judge one way or the other. There are too many EMS systems saving 40-60% of their witnessed VF patients by working them in place until ROSC and delivering them to hospitals with cardiologists and intensivists who will actually follow through with appropriate post-resuscitation care. I'm not saying that ECMO does not have a place. I'm saying that if the current system is only saving 10-20% of their witnessed VF patients then ECMO is the wrong focus.
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Excellent post, Tom - mirrors my thought process exactly. Especially the part that I bolded.
 
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