Stairs + Cardiac Arrest

[medicdan]

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.

The measure of the viability of an arrest is ETCO2 in the presence of good compressions. That is our universal answer, or universal measure of chance of ROSC, especially when you're 30 minutes into ACLS.

 

[EMT B]

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.

Every unstable rhythm will eventually deteriorate into asystole

 

[mycrofft]

See posts recently about Trendelenberg.

Besides that, think physics. Lying flat, circulation is basically gravity-neutral. Tilt anything up or down, and the blood is harder to get into or out of that sector.
Try lying with your head over the edge of the bed for long. Now think that the pump sending blood down into your head is working at 30% (or less) capacity. Blood needs to circulate, not just "go" someplace.
And of course (go back to first sentence) and all physiologic effects side, mechanically Trendelenberg and effective CPR are ineffective together, unless you have an effective automatic thumper which will wowk traveling down a staircase at 30 deg. inclunation.

 

[Akulahawk]

See posts recently about Trendelenberg.

Besides that, think physics. Lying flat, circulation is basically gravity-neutral. Tilt anything up or down, and the blood is harder to get into or out of that sector.
Try lying with your head over the edge of the bed for long. Now think that the pump sending blood down into your head is working at 30% (or less) capacity. Blood needs to circulate, not just "go" someplace.
And of course (go back to first sentence) and all physiologic effects side, mechanically Trendelenberg and effective CPR are ineffective together, unless you have an effective automatic thumper which will wowk traveling down a staircase at 30 deg. inclunation.

If Trendelenburg positions were all that effective, wouldn't we then be rocking our patients thirty degrees head up and head down instead of doing CPR?? Hmmm, my patient is in full arrest... I wonder which playground has a teeter-totter...:wacko:

 

[chaz90]

Every rhythm will eventually deteriorate into asystole

Fixed it for you

 

[phideux]

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.

I worked for a little over a year on an ambulance with an Autopulse, never got a chance to use it, all our arrests that whole time were too big for it.

 

[Mariemt]

I worked for a little over a year on an ambulance with an Autopulse, never got a chance to use it, all our arrests that whole time were too big for it.

Our service has one in each ambulance. I've seen it used a handful of times.
Once took a patient to am er where the doc had never seen one. He was so impressed by the rhythm and quality of the compressions he bought one for his local ambulance team.

 

[Carlos Danger]

if you can't get rosc on scene, what can the er do that paramedics can't?

ecmo

 

[billydunwood]

ecmo

True, but there has to be limited or no brain damage for it to be effective and not many hospitals/er's have that capability.

 

[NomadicMedic]

ecmo

Ha. I needed a laugh today.

 

[VFlutter]

If you can't get ROSC on scene, what can the ER do that paramedics can't?

Transvenous pacing, thoracotomy / aortic cross clamp, rapid infusers with central lines, diagnostic imaging, Echo, pericardiocentesis, blood products, thrombolytics.

Not that any of those will improve surivival in most cases.

 

[EMT B]

dont forget the good ole Intracardiac drugs!

 

[billydunwood]

Transvenous pacing, thoracotomy / aortic cross clamp, rapid infusers with central lines, diagnostic imaging, Echo, pericardiocentesis, blood products, thrombolytics.

Not that any of those will improve surivival in most cases.

Yes, that's what I meant. What can they do that will improve their survival(most cases)? Not much more.

 

[Handsome Robb]

ecmo

Bro, paramedics could totally be trained to do cutdowns and start ecmo in the field, bro.

:lol:

 

[Carlos Danger]

Ha. I needed a laugh today.

You do know that ECMO for primary cardiac arrest is being done in some centers, right?

There are only a few places right now that do emergent ECMO in the ED, but from what I understand the outcomes are excellent. I think we will see the practice spread to other tertiary hospitals before long, if the data that is being gathered continues to support the practice.

 

[Carlos Danger]

Bro, paramedics could totally be trained to do cutdowns and start ecmo in the field, bro.

:lol:

Man, don't give anyone any ideas.....

 

[NomadicMedic]

Oh yeah, I understand it's a thing. I was more laughing at the idea of one of the hospitals HERE adding ECMO to the Charlie Foxtrot that accompanies anything other than a straightforward "ACLS style" resus.

"Hey Bob, wanna give some vasopressin? And bicarb? Hell, howzabout some injectable kitchen sink?"

"Sure. Why not. Can't hurt, might help. And let's get that Ekk-Moe thing in here too..."

Yikes.

 

[HMartinho]

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

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.

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.

double sequential defibrillation for VFiB. If you can't get ROSC on scene, what can the ER do that paramedics can't?

Oh yeah, I understand it's a thing. I was more laughing at the idea of one of the hospitals HERE adding ECMO to the Charlie Foxtrot that accompanies anything other than a straightforward "ACLS style" resus.

"Hey Bob, wanna give some vasopressin? And bicarb? Hell, howzabout some injectable kitchen sink?"

"Sure. Why not. Can't hurt, might help. And let's get that Ekk-Moe thing in here too..."

Yikes.

The video has 18 minutes, but it's worth it.
Everyone, especially young and healthy people, should have a chance.

http://www.youtube.com/watch?v=vDHUBu_Kl6k

 

[chaz90]

The video has 18 minutes, but it's worth it.
Everyone, especially young and healthy people, should have a chance.

Great story, but totally different scenario than what we're talking about. It's not like any of us are saying we would have worked the hypotensive semi-responsive syncope patient on scene and not transported her. Believe me, I'm not someone whining that we can do everything the hospital can do. I'm fully aware that there are plenty of potentially life saving interventions that are outside my knowledge, skill, and scope that can be performed in a hospital. I am saying that OHCA has a different set of rules than the witnessed arrest in an ED with a surgeon and ED doc available.

We do give every single person a chance. If we have a viable patient, we'll do whatever we can to provide appropriate care that gives the patient the best chance of survival. Transporting every single cardiac arrest in the mindless hope that the hospital is going to perform a miraculously life saving thoracotomy is anathema to that goal. Again, this is why feel good anecdotes don't create policy. It's great that this patient survived what would seem to be an almost invariably fatal event, but there's a reason this kind of thing makes it on TV.

 

[mycrofft]

If Trendelenburg positions were all that effective, wouldn't we then be rocking our patients thirty degrees head up and head down instead of doing CPR?? Hmmm, my patient is in full arrest... I wonder which playground has a teeter-totter...:wacko:

Used to rock them on a barrel for drowning.