The effect of ALS before cardiac arrest

[SeeNoMore]

I've seen a lot of research and studies done around ALS for cardiac arrest, most of it seeming to speak against any appreciable benefit.

I was curious though about whether there is conclusive evidence on the effect Paramedics have on patients experiencing chest pain or problematic rythms before they have a heart attack. Or is this too difficult to determine?

It seems that Paramedics often get judged by the effect treatments have on patients in the most dire situations, which makes some sense. But it seems like ALS might be the most effective as it is used to prevent these situations from occuring.

 

[TomB]

I've seen a lot of research and studies done around ALS for cardiac arrest, most of it seeming to speak against any appreciable benefit.

I was curious though about whether there is conclusive evidence on the effect Paramedics have on patients experiencing chest pain or problematic rythms before they have a heart attack. Or is this too difficult to determine?

It seems that Paramedics often get judged by the effect treatments have on patients in the most dire situations, which makes some sense. But it seems like ALS might be the most effective as it is used to prevent these situations from occuring.

I don't know what it would take to prove it, but I feel certain that we benefit peri-arrest patients. Personally, I think the ALS/BLS distinction is an antiquated way to look at EMS. We need to move away from that kind of paradigm and look at prehospital care much more broadly as we move kicking and screaming into the evidence-based era.

Anecdotally, I'm certain that failure to identify life-threatening hyperkalemia has caused several patients their life. Requiring all paramedics to be educated to the ACLS-EP level would be a nice start.

Tom

 

[mgr22]

One approach is to compare prehospital impressions and care to hospital diagnoses and dispositions. It can get pretty complicated, but it does provide useful feedback once you work out the logic and build the necessary relationships.

 

[usafmedic45]

It's a pain in the *** to do prehospital cardiac arrest research. The issues of case volume, consent, randomization are the major reasons why there is very little on the subject that interests you.

 

[Veneficus]

I don't know what it would take to prove it, but I feel certain that we benefit peri-arrest patients. Personally, I think the ALS/BLS distinction is an antiquated way to look at EMS. We need to move away from that kind of paradigm and look at prehospital care much more broadly as we move kicking and screaming into the evidence-based era.

Anecdotally, I'm certain that failure to identify life-threatening hyperkalemia has caused several patients their life. Requiring all paramedics to be educated to the ACLS-EP level would be a nice start.

Tom

But the EP course is not an "if: then" algorythm, it would require paramedics to have considerably more knowledge than is currently called for, which puts us in the endless education debate yet again.

 

[TomB]

Seriously! So maybe it's not ALS that doesn't save lives, but rather poorly trained paramedics providing substandard ALS care that doesn't save lives. What a mess!

 

[Veneficus]

Seriously! So maybe it's not ALS that doesn't save lives, but rather poorly trained paramedics providing substandard ALS care that doesn't save lives. What a mess!

Welcome to my world.

 

[reaper]

Come on, we dont need to be educmacated. We have these fancy machines that tell us what is wrong with the pt!

 

[mycrofft]

Everything is an "if:then; else:..." deal except for the terminal "yes/no".

It's just that the more you know the more nuanced it gets. And the more you have to work on cutting to the chase.

There is little which could be designed to give a more negative outcome than tabulating how many cinically dead people can be brought back to life after the delays to get field care. When cardiac measures, starting with CPR, were moved out of the hospital, it was recognized that around 70% of people who presented thier cardiac conditions would do so with "sudden death" asystole and the street/field/swamp whatever measures would never be as good as a hospital, but were the victim's only/best chance. One side ratcheted the level of care and public expectations up, the other wants to measure it without accounting for the fact that the majority of cases seen by street ALCS are amongst the greatest-risk patients, along with premature births and drastic traumas.

If ACLS is found lacking, well, ok. Decide what the next step is but refine the mission/expectations and then the measures, don't just condemn the participants (except where they deserve it of course).

 

[MrBrown]

Seriously! So maybe it's not ALS that doesn't save lives, but rather poorly trained paramedics providing substandard ALS care that doesn't save lives. What a mess!

Agreed!

ALS care is not required here (or in Australia) to consider termination of resuscitation efforts. Look at the evidence, the evidence is that amiodarone might help a little and so may adrenaline, but all we're doing is trying to make defibrillation more effective.

When we get our upskilling program finished there will not be a need for an Intensive Care Paramedic (ALS) to attend a cardiac arrest ere because the only additional skill they can bring is intubation (whic isn't really required) and IO.

Dare I say those two minute response times and a Paramedic on every fire truck aren't required? Maybe ALS does not save as many lives as some like to think?

 

[DrParasite]

When we get our upskilling program finished there will not be a need for an Intensive Care Paramedic (ALS) to attend a cardiac arrest ere because the only additional skill they can bring is intubation (whic isn't really required) and IO.

but you got to admit, tubing someone and IV access are pretty important in a cardiac arrest

Dare I say those two minute response times and a Paramedic on every fire truck aren't required? Maybe ALS does not save as many lives as some like to think?

absolutely not!!!! every patient needs a paramedic, only paramedics should be on ambulances, and the more paramedics a system has, the better it is for the patients.

 

[MrBrown]

but you got to admit, tubing someone and IV access are pretty important in a cardiac arrest

No I don't, infact they have little evidence as being effective and neither is required to terminate a resuscitation effort out-of-hospital here in New Zealand.

The endotracheal tube was once considered the optimal method of managing the airway during cardiac arrest...

Studies ...failed to show a link between long-term survival rates and paramedic skills such as intubation, intravenous cannulation, and drug administration.

In retrospective (LOE 5) studies, endotracheal intubation has been associated with a 6%17–19 to 14%20 incidence of unrecognized tube misplacement or displacement. ...

It is important to remember that there is no evidence that advanced airway measures improve survival rates in the setting of prehospital cardiac arrest.

Circulation. 2005;112:IV-51-IV-57

absolutely not!!!! every patient needs a paramedic, only paramedics should be on ambulances, and the more paramedics a system has, the better it is for the patients.

Again, you couldn't be further from the truth.

Systems like Los Angeles and Miami who want to put a Paramedic on every street corner have worse results when it comes to cardiac arrest survival rates.

Cities like Seattle, Tulsa and Boston who limit the number of Paramedics have better numbers.

A zillion paramedics fighting over each other for limited opportunities to use thier skillset leads to rustout and clinical risk.

The it in this case is a five-city study showing that fewer paramedics are associated with higher cardiac survival rates in urban areas..

When procedures are performed routinely, it is reflected in outcomes, said Dr. Slovis, a professor and the chairman of emergency medicine at Vanderbilt Medical Center who serves as Nashville's EMS medical director. The results of the study by Michael Sayre, MD, and colleagues mimic findings across health care, Dr. Slovis said. Conversely, when procedures such as intubation are done more infrequently, success rates are lower, he added.

... "Having a smaller number of paramedics who are very highly
trained is probably a better strategy for delivering good patient
outcomes."

Source

Look at Australia and New Zealand; our Intensive Care Paramedics are very igly trained and there has been a deliberate upskilling program across almost every State in Australia and here in New Zealand over the past decade to ensure they are using thier specialised skills frequently.

Soon, an Intensive Care Paramedic will not be required at a cardiac arrest here anymore because Paramedics will have amiodarone (some already do), they already have adrenaline, IV access, fluid, manual defibrillation etc. They aren't running off to jobs to give a bit of morphine or some GTN because other crews have those competencies.

You need to recognise ALS as being a practitioner of a highly invasive and specalist skillset who needs to frequently use it by giving other crews the tools they need to do what was once considered an "ALS job". Bit of fentanyl and GTN or some fluid and adrenaline don't require ALS and by sending them off to jobs they really don't need to be at limits opportunity for exposue to use thier high level skills.

So no, an ALS Paramedic on every ambulance is not the best answer.

 

[ah2388]

No I don't, infact they have little evidence as being effective and neither is required to terminate a resuscitation effort out-of-hospital here in New Zealand.





Again, you couldn't be further from the truth.

Systems like Los Angeles and Miami who want to put a Paramedic on every street corner have worse results when it comes to cardiac arrest survival rates.

Cities like Seattle, Tulsa and Boston who limit the number of Paramedics have better numbers.

A zillion paramedics fighting over each other for limited opportunities to use thier skillset leads to rustout and clinical risk.



Look at Australia and New Zealand; our Intensive Care Paramedics are very igly trained and there has been a deliberate upskilling program across almost every State in Australia and here in New Zealand over the past decade to ensure they are using thier specialised skills frequently.

Soon, an Intensive Care Paramedic will not be required at a cardiac arrest here anymore because Paramedics will have amiodarone (some already do), they already have adrenaline, IV access, fluid, manual defibrillation etc. They aren't running off to jobs to give a bit of morphine or some GTN because other crews have those competencies.

You need to recognise ALS as being a practitioner of a highly invasive and specalist skillset who needs to frequently use it by giving other crews the tools they need to do what was once considered an "ALS job". Bit of fentanyl and GTN or some fluid and adrenaline don't require ALS and by sending them off to jobs they really don't need to be at limits opportunity for exposue to use thier high level skills.

So no, an ALS Paramedic on every ambulance is not the best answer.

i think you missed something in his response

i believe they call it sarcasm.

Interesting point in the 1st statement though

 

[MrBrown]

i think you missed something in his response

i believe they call it sarcasm.

Interesting point in the 1st statement though

The interent is a bit of a bugger like that

 

[SeeNoMore]

Thanks for the responses.

I am trying very hard to become a truly educated paramedic, but need some reassurance that SOMETHING we do is helpful. Just to justify the 8 hour long study sessions before study group meet ups

As a student I feel like I'm in the twilight zone sometimes learning "skills" in a somewhat haphazard manner.

Anyway, this seemed like one area where ALS would actually prove beneficial, along with respriratory distress etc. But I see why conclusive evidence would be hard to generate.

 

[Shishkabob]

No I don't, infact they have little evidence as being effective and neither is required to terminate a resuscitation effort out-of-hospital here in New Zealand.

Little doesn't mean no.



And even if it raises just 1%, but with no detrimental side-effect, is it not then worth it?

 

[MrBrown]

Anyway, this seemed like one area where ALS would actually prove beneficial, along with respriratory distress etc. But I see why conclusive evidence would be hard to generate.

ALS is useful for the next-level up of analgesia (combination midaz/fent or ketamine) and some advanced pharmacology eg thrombolytics, antiarrythmatics/chronotropes (adrenaline, atropine) and steriods for asthma/anaphylaxis. RSI too if properly done.

Little doesn't mean no.

And even if it raises just 1%, but with no detrimental side-effect, is it not then worth it?

Doesn't mean stop doing it no.

 

[mycrofft]

Five is four.

1. Look at the sampling and statistical method. If I were doing it, I would make four categories for initial categorization of calls deemed cardiac:
1. Clinically dead/at least five minutes asystolic before arrival of EMS. (Bystander CPR would count as 0.85 asystole, since it is ineffective). EMD is asystole, we're gauging circulation/pulse, not electrical activity.
2. Clinically dead, less than five minutes asystole pre EMS (EMS called before pt asystolic).
3. Pt with some sort of viable pulse upon EMS arrival even if it is not sustainable for long and response under five min.
4. Pt with some sort of viable pulse etc and EMS arrival over five minutes.

Just the first one would weed out a bunch of cases deemed unsaved by ALS, because what they needed was a sequel since their first episode walking among us is through! (e.g., "dead is dead").

I wonder if time on scene weighed against measured attempted treatments on scene makes a difference. If you get bogged down at the scene you get past the timeframe where transport- while- treating versus on-scene heroics make sense,and those are the very pts who will weigh your stats down with their death.

 

[EMTinNEPA]

but you got to admit, tubing someone and IV access are pretty important in a cardiac arrest

Actually, endotracheal intubation has been deprioritized in the AHA ACLS. They say if you can manage an airway with a pair of hands, a BVM, and an oropharyngeal airway, then go right ahead. As for IV access, it can be important, but it isn't always. Epinephrine is thought to shunt oxygenated blood to the brain and heart through vasoconstriction, but there's no concrete evidence. The fact of the matter is that early CPR and early defibrillation are what have been proven to make the difference.

I believe ALS prevents more cardiac arrests than it solves. Just look at the infamous "Hs and Ts" and see how many can be managed by BLS and how many can be solved, or at least slowed down, by ALS before cardiac arrest occurs.

 

[Shishkabob]

It depends on your protocols, but most I've seen won't let you terminate a working code without fluid access established, be it an IV or IO... some even allow an ETT if all else fails.