Stopping CPR w/ V-fib?

[medicdan]

I don't think we carry enough epi for 10+ rounds, or a 50 minute code. We would need another als truck or to transport. Do the dynamics change if you have a Lucas or Autopulse?

 

[NomadicMedic]

You don't have a big 30mg vial of Epi 1:1000? There's enough epi there to run 4 or 5 codes.

 

[Veneficus]

I don't think we carry enough epi for 10+ rounds, or a 50 minute code. We would need another als truck or to transport. Do the dynamics change if you have a Lucas or Autopulse?

If you give somebody that much epi, they probably won't have blood flow to the kidneys or brain anyway so it is not like you are missing out.

 

[Christopher]

If you give somebody that much epi, they probably won't have blood flow to the kidneys or brain anyway so it is not like you are missing out.

I wish we had some stopping point for how many saline flushes...I mean epi...we give during a code. Alas, no such luck. Some neighboring services have gone with normal saline drips...I mean epi drips...after 3 mg.

 

[NYMedic828]

I wish we had some stopping point for how many saline flushes...I mean epi...we give during a code. Alas, no such luck. Some neighboring services have gone with normal saline drips...I mean epi drips...after 3 mg.

:rofl::rofl::rofl:

God forbid there was some weight based dose we could use... but thats crazy talk.

 

[mycrofft]

Not to detract from pride and talent, but...

I was thinking just the other day, it's been a while since the "I can do what an ED does" theme had been around.

If all goes well, the mobile unit can do the basic initial measures and do them extremely promptly, barring problems with equipment, supplies, heat/cooling, lighting, power, and the decreased mobility of people working around the patient which delays care when the patient is being prepped or intubated (lain supine, stripped of enough clothing, sometimes shaven a bit, ECG leads placed effectively, etc.).

Once measures are started, the crew and pt are tied down on scene for physical and physiological reasons, not to mention protocols above. This is not significant if patients are cured by ambulance care.

In-hospital, you have a lab, radiology, anesthesiology, surgery, and an ICU etc to backstop your play, and when they are needed, they aren't needed after five minutes, twenty minutes, or an hour on the road.

Beyond those, you have people and room to rapidly position, reposition, prep, and otherwise manipulate the patient, versus in a cramped (and moving) ambulance or someone's front room or bathroom.

Yes, on-scene ACLS and effective layperson bystander CPR ARE essential to a successful conclusion, and yes, sometimes you get into the coffin corner of immobility just because that's the way the case went. But to equate a mobile unit to a hospital can lead to hitches in the thought processes which guide care.

Sidebar: another reason protocols state you transport patients with any activity because they are a hot potato. If they die in the ER, your stats look better than in your ambulance, and if there is any chance at all, it's there; but, if they are declared in your ambulance, the hit is on you and you have to talk to the coroner etc.

5=4. I never heard of a patient being referred from a hospital to an ambulance except for transport.

 

[NomadicMedic]

While your points are well taken, let's not forget the point of THIS conversation, which is resuscitating a cardiac arrest.

As you well know, in the case of the usual "medical arrest", the first 20 minutes will set the tone for the outcome. Good, early CPR and electricity, followed by antiarrythmics and hypothermia when it's going well... A call to pronounce and consolation for the family when it's not.

I don't ever equate what I do in the field to the capabilities of a hospital, unless its the precision of a well orchestrated "pit crew" style resuscitation of SCA. Then, in most cases, we do it as well, if not better, then it's done in the ED.

 

[Veneficus]

:rofl::rofl::rofl:

God forbid there was some weight based dose we could use... but thats crazy talk.

Epi in cardiac arrest is like oxygen in other patients.

There are some times that it helps, most often it hurts, and it helps much less often than people think.

 

[NYMedic828]

Epi in cardiac arrest is like oxygen in other patients.

There are some times that it helps, most often it hurts, and it helps much less often than people think.

I imagine the goal, and the problem, is finding a happy medium behind the theory of increasing blood flow to vital organs while at the same time not restricting blood flow to vital organs.

Seems like a bit of a conundrum to me... We don't exactly have a way of determining if it is or isn't indicated without knowing the cause of arrest. We may as well give 1 of every drug in the toolbox (which is almost what we do anyway)

While your points are well taken, let's not forget the point of THIS conversation, which is resuscitating a cardiac arrest.

As you well know, in the case of the usual "medical arrest", the first 20 minutes will set the tone for the outcome. Good, early CPR and electricity, followed by antiarrythmics and hypothermia when it's going well... A call to pronounce and consolation for the family when it's not.

I don't ever equate what I do in the field to the capabilities of a hospital, unless its the precision of a well orchestrated "pit crew" style resuscitation of SCA. Then, in most cases, we do it as well, if not better, then it's done in the ED.

In my experience, the first 2-5 minutes is what sets the outcome. The only patients I have had survive a cardiac arrest and walk out of the hospital back to their lives had CPR initiated by a bystander almost immediately upon arrest.

I think the best thing we can do as a society is continue to educate EVERYONE on CPR. That high school kid who starts CPR on the old lady at the football game as soon as she collapses is the real hero if she survives. By the time EMS arrives it is usually atleast 5 minutes into arrest usually more. I believe the marker for neurological death is roughly 6 minutes? I would be willing to be the survival rate of out of hospital, witnessed arrests with no bystander CPR is exceptionally low.

My volunteer department offers free CPR training to the community. They currently train national safety council which is garbage. Last year I went and got certified as an AHA BLS instructor but apparently expecting people to show up to a 2-4 hour CPR class instead of a 30 minute one was just too much to ask...

I have taught one class... I don't even remember my login for AHA.

 

[Veneficus]

I imagine the goal, and the problem, is finding a happy medium behind the theory of increasing blood flow to vital organs while at the same time not restricting blood flow to vital organs.

Seems like a bit of a conundrum to me... We don't exactly have a way of determining if it is or isn't indicated without knowing the cause of arrest. We may as well give 1 of every drug in the toolbox (which is almost what we do anyway)

Mycrofft said it best.

EMTechnician vs. clinician.

There are ways to tell. It just requires education and thinking.

 

[Bullets]

I was involved in a resuscitation attempt where the upper 70's year old man arrested in front of one of his children. CPR was started with instructions from dispatch. We worked the arrest for 50 minutes or so, the patient remained in fine v-fib the entire time. He was shocked 6 times, given 7 mg of epi. 1/10000, 450 mg amiodarone, 100 meq. if sodium bicarb, and 2 mg of Narcan, At what point would you have stopped effort to resuscitate (contact med control)?

After 20 minutes if it was actually FVF and not artifact in asystole

I am surprised by how many here still have Bicarb in their arrest protocols.

Not that it matters, once patients get the ACLS prescribed dose of Epi you nuked their brain anyway. I transported a patient the other day, no L&S. Blew everyone's mind but i think we got better compression. Shockingly pronounced at the door of the ER (Sarcasm)

 

[mycrofft]

I wonder if enough epi will cause enough of SOME sort of myofascial activity to generate an ECG somewhat like "fine v-fib".

Yeah, correct and instantaneous CPR in a place luck enough to be accessible and relatively flat makes the first part of the chain of survival. S'truth.

 

[Veneficus]

I wonder if enough epi will cause enough of SOME sort of myofascial activity to generate an ECG somewhat like "fine v-fib"..

Can't say for sure, but from what I do know, I would very seriously doubt it. In fact it would take an almost bullet proof large scale study to convince me otherwise.

 

[mycrofft]

Fishing for a grant?

 

[Veneficus]

Fishing for a grant?

Not for that. I will just stick with guessing "no."

 

[Fish]

How far away from a Hospital are you? Level one trauma?

You can rule out the various causes of cardiac arrest (Hs & Ts) and perform the necessary interventions more effectively than an ER physician? You can relive tamponade in the field? Do you carry blood products? To say that you are faster and more practical than a Level one trauma team is very bold.

I am not advocating transporting every arrest but to say that an arrest will be handled the same in the field as it is in the ER is a little bit of a stretch. Ill take my chances in the hospital.....

Also, you sit on scene for 10 mins post ROSC just incase they code again? What do you do during that time?

This sounded like Medical Cardiac arrest, not a traumatic one, not in need of blood or level one trauma

 

[Fish]

Wait.....whaaaaa...... Come again?

What the heck do you advocate doing? Sitting there and staring at them?

Can you cite your "fact" about re-arresting?

Would you really rather wait 10 minutes on scene with what is, for all intents and purposes, an extremely unstable patient "in case" they arrest again? Wouldn't you want to have them 10 minutes closer to a DOCTOR if they do arrest again?

Or am I totally missing something here?

I will agree with what he said, Patient's are extremely likely to re-arrest in the minutes directly following ROSC. We are required to Monitor our patient's for 5 minutes following ROSC to watch for recrurrent Cardiac arrest. Now with that being said, we do not just sit there for 5 minutes and stare at the patient, we get a 12Lead(If STEMI, call Code STEMI to receiving hosp), get a set of vitals, Obtain two IVs(if we have time and assuming all we had was an IO) and prepare a bag of Dopeamine(incase) since ROSC patients frequently need vasopressors and when they do need them, they need them quickly.

Why wait on scene for 5 minutes instead of load and go as soon as we detect a pulse? Because like stated before, patient's are extremely likely to re-arrest within the first 5 minutes and the best place to work a patient who has arrest is on the ground, not on a stretcher on its way out to the ambulance, and not in the back of a moving ambulance(which studies have shown is ineffective)

 

[ah2388]

Its been a month or two. Ya, 12 years of medical is great. Do the Physicians in your area blindly follow the ACLS algorithms? I rarely see ER physicians run a textbook ACLS code like medics would, they frequently deviate based on clinical judgment and patient presentation.

To say that the physicians in the ED you are referring to blindly follow ACLS algorithms would quite obviously be an insult to their incredible ability as clinicians. With that being said, there are many similarities in the way cardiac arrest is managed in the ED as compared to the field.

With that being said, I pray that if/when I arrest it is in hospital, that is of course should I choose to be resusc.

 

[VFlutter]

To say that the physicians in the ED you are referring to blindly follow ACLS algorithms would quite obviously be an insult to their incredible ability as clinicians. With that being said, there are many similarities in the way cardiac arrest is managed in the ED as compared to the field.

With that being said, I pray that if/when I arrest it is in hospital, that is of course should I choose to be resusc.

Exactly, The comment was made that a code is worked exactly the same, if not better, in the field as it was in the ED and that the physicians would not do anything different. I was trying to argue that ER physicians do much more than blindly follow ACLS algorithms like I have seen many medics do.

Maybe my post came off the opposite way I wanted it to.

 

[ah2388]

Exactly, The comment was made that a code is worked exactly the same, if not better, in the field as it was in the ED and that the physicians would not do anything different. I was trying to argue that ER physicians do much more than blindly follow ACLS algorithms like I have seen many medics do.

Maybe my post came off the opposite way I wanted it to.

I dont think it came out the opposite of the way you intended, I read it as youve explained. With that being said, let us not forget that most often cardiac arrest in the prehospital environment has many similarities to the way the episode is managed in hospital..I suppose that is sort of obvious. It is not as if being a physician causes you ignore the "standard of care....." It is more the reason behind the rhyme that many of us prehospital folks fail to gather