Stairs + Cardiac Arrest

cointosser13

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It seems like every time the EMS have a call for a cardiac arrest, it's a patient who's 300 pounds and is on the second floor. Having to carry all your equipment to the second floor just makes the call that much more "fun". Anyway, I've been thinking about how EMS crews could use the stairs as something of use when we have a cardiac arrest patient. So my thinking has been some what of a crazy idea... but I really want everybody's opinion. Not sure if it's realistic. I'm only a EMT-B. Maybe somebody has already thought of this. I don't know. Here's my idea:

Most stairs go up at about a 33 degree incline. That being said, if we do have a patient on the second floor, after doing CPR and artificial ventilations, we have to carry him down the stairs. Instead of carry the patient feet first, shouldn't we carry the patient head first? If the patient is angled down, isn't some of the blood going to be carried to the head, where the blood is especially needed? The brain needs oxygen or it becomes more damaged, right? It's like a kid hanging on a bar, and his head starts to become more red because some of the blood is being brought to his head. I know our goal as ems providers is to put the patient in the ambulance as fast as we can, but sometimes carrying a 300 pound patient down the stairs can take a while. While we're "struggling" to bring the patient down the stairs, wouldn't some of the blood go to the patient's brain? Of course we would have to have somebody still artificially ventilate the patient because that's the only way the patient would oxygen. The oxygenated blood would travel to his brain. The thing that I don't know, does the 33 degree decline not even help, does it matter?
 

Tigger

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Here's an easier solution...don't carry patients undergoing CPR down the stairs. We know that CPR when moving in an ambulance isn't effective, why so we insist on doing it while walking too?

I'm am not suggesting every arrest worked on scene without ROSC should be called as there are outliers. However by and large as a whole EMS continues to transport far too many arrests than we should.
 

Mariemt

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We have paramedics on call that will go to the scene on cardiac arrest. However when we do have to transport during a code by some chance, we are lucky enough to have an auto pulse which will continue all compressions for us as we move the patient as they are on the Zoll and the mega mover
 

Medic Tim

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Here's an easier solution...don't carry patients undergoing CPR down the stairs. We know that CPR when moving in an ambulance isn't effective, why so we insist on doing it while walking too?

I'm am not suggesting every arrest worked on scene without ROSC should be called as there are outliers. However by and large as a whole EMS continues to transport far too many arrests than we should.
This^^^
 

medicdan

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It seems like every time the EMS have a call for a cardiac arrest, it's a patient who's 300 pounds and is on the second floor. Having to carry all your equipment to the second floor just makes the call that much more "fun". Anyway, I've been thinking about how EMS crews could use the stairs as something of use when we have a cardiac arrest patient. So my thinking has been some what of a crazy idea... but I really want everybody's opinion. Not sure if it's realistic. I'm only a EMT-B. Maybe somebody has already thought of this. I don't know. Here's my idea:

Most stairs go up at about a 33 degree incline. That being said, if we do have a patient on the second floor, after doing CPR and artificial ventilations, we have to carry him down the stairs. Instead of carry the patient feet first, shouldn't we carry the patient head first? If the patient is angled down, isn't some of the blood going to be carried to the head, where the blood is especially needed? The brain needs oxygen or it becomes more damaged, right? It's like a kid hanging on a bar, and his head starts to become more red because some of the blood is being brought to his head. I know our goal as ems providers is to put the patient in the ambulance as fast as we can, but sometimes carrying a 300 pound patient down the stairs can take a while. While we're "struggling" to bring the patient down the stairs, wouldn't some of the blood go to the patient's brain? Of course we would have to have somebody still artificially ventilate the patient because that's the only way the patient would oxygen. The oxygenated blood would travel to his brain. The thing that I don't know, does the 33 degree decline not even help, does it matter?
If you're interested in more information about why we are advocating staying in place, do a search for some articles on CCR, Cardiocerebral resuscitation. The systems doing it are staying in place for at least 8-10 minutes with constant CPR, an OPA, NRB, and in some cases, an IO with epinephrine at regular intervals.
 

DesertMedic66

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Or, work them where they are until ROSC. Then move them. If no ROSC, it's the funeral homes problem
What if you are unable to get ROSC but they are still in a shockable rhythm? My last full arrest stayed V-Fib despite meds and shocks.
 

Anjel

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What if you are unable to get ROSC but they are still in a shockable rhythm? My last full arrest stayed V-Fib despite meds and shocks.
My thoughts as well. We can only terminate efforts in asystole.
 

DesertMedic66

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My thoughts as well. We can only terminate efforts in asystole.
That's always one of my questions when I hear "we either call them on scene or transport if we get ROSC". I don't know of very many services that allow calling a patient who is in V-fib/V-Tach.
 

chaz90

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That's always one of my questions when I hear "we either call them on scene or transport if we get ROSC". I don't know of very many services that allow calling a patient who is in V-fib/V-Tach.
With a medical control consult, I could absolutely see situations in which it would be appropriate to pronounce a patient in refractory V-Fib. No response to many shocks, Epi, amiodarone, and CPR for a prolonged period of time with a long transport ahead? Again, situation dependent, but there is a place for it. I can't see pronouncing a patient in V Tach, but they don't stay in that for long. V Fib eventually deteriorates to asystole anyway. I know there are a few exceptions in the literature with crazy prolonged V Fib, but most codes worked on scene for ~20-30 minutes aren't going to stay in it.
 

billydunwood

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What if you are unable to get ROSC but they are still in a shockable rhythm? My last full arrest stayed V-Fib despite meds and shocks.
double sequential defibrillation for VFiB. If you can't get ROSC on scene, what can the ER do that paramedics can't?
 

DesertMedic66

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double sequential defibrillation for VFiB. If you can't get ROSC on scene, what can the ER do that paramedics can't?
Depends on your area and scope. Paramedics in my area are very limited
 

billydunwood

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Depends on your area and scope. Paramedics in my area are very limited
Well, a paramedic would probably have to get permission from Medical Control to do a double defribillation anyways. But in my opinion(and seems like many here) is that you shouldn't transport dead bodies and if there is no ROSC on scene in a reasonable amount of time, you cease activities.
 

DesertMedic66

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Redacted.
 

unleashedfury

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Or, work them where they are until ROSC. Then move them. If no ROSC, it's the funeral homes problem

This..

I am a huge advocate of field pronouncing patients.

the prognosis for Asystole is poor, and the chance of ROSC after 8 to 10 minutes is possible but the patient returning to normal life is slim to none.

My chief insists we transport all cardiac arrests cause he insists that its all a "fudged effort" to allow hospitals to reduce the deaths in their facility. You can show him every case study that proves how ineffective CPR in a moving ambulance is, the chance of survival of prehospital arrest is poor. So why are we doing this?? Cause in his eyes its still 1990.
 

FiremanMike

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Or, work them where they are until ROSC. Then move them. If no ROSC, it's the funeral homes problem
I guess I should have mentioned I don't generally lay hands on someone until I decide it seems like there's a shot, and I'm also ok with not transporting any calling a code 1.
 

chaz90

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I guess I should have mentioned I don't generally lay hands on someone until I decide it seems like there's a shot, and I'm also ok with not transporting any calling a code 1.
How about the fact that those potentially viable cardiac arrests are the ones that deserve to be worked appropriately on scene? It drives me nuts when people tell me they agree with me that arrests should be worked on scene and not transported unless with ROSC, and with their next breath say "but I'm OK with scooping and running with a young witnessed arrest in a shockable rhythm who had immediate CPR." There's a fundamental misunderstanding here! We don't transport arrests for two reasons.

A. Transporting dead bodies is an unnecessary risk and waste of resources.

B. When a patient is viable, their best chances for survival lie with quality care on scene of the arrest.


When I respond to a cardiac arrest, one of my thoughts is hoping I get there before the BLS ambulance can load the patient and drive to intercept me rather than meet me on scene. That's the only problem I see with CPR assist devices right now. I love the LUCAS 2 my service uses, but some seem to see it as a free license to transport arrests now that we can do CPR during transport.
 

FiremanMike

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How about the fact that those potentially viable cardiac arrests are the ones that deserve to be worked appropriately on scene? It drives me nuts when people tell me they agree with me that arrests should be worked on scene and not transported unless with ROSC, and with their next breath say "but I'm OK with scooping and running with a young witnessed arrest in a shockable rhythm who had immediate CPR." There's a fundamental misunderstanding here! We don't transport arrests for two reasons.

A. Transporting dead bodies is an unnecessary risk and waste of resources.

B. When a patient is viable, their best chances for survival lie with quality care on scene of the arrest.


When I respond to a cardiac arrest, one of my thoughts is hoping I get there before the BLS ambulance can load the patient and drive to intercept me rather than meet me on scene. That's the only problem I see with CPR assist devices right now. I love the LUCAS 2 my service uses, but some seem to see it as a free license to transport arrests now that we can do CPR during transport.
I personally don't find that there can be universal answers to this particular question. Each arrest is different and each has their own set of mitigating factors that will drive the decision making process as to whether transport will happen or not. I will say (for those who have not experienced the joy of the autopulse) that compressions are productive and viable whether you're sitting in their bedroom, carrying them down stairs, rolling down the street, or heck, probably even upside down.
 
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