Transporting a Cardiac Arrest?

[Aprz]

What is the etiology of arrest?

A massive LCA occlusion isn’t going to get fixed outside of cath lab.

A kidney patient with a K of 11 isn’t going to live without emergent dialysis.

A uterine rupture or ruptured eptopic isn’t going to survive without emergency surgery.

A ductal dependent heart that is closing isn’t going to live without PGE.

There are many arrest calls that are clearly non-survivable, and there isn’t a good reason to transport those. Some arrests however are only viable in the presence of a major hospital, and pretending that the handfull of resuscitation medication on the ambulance is equivalent is quite presumptuous.

How high is too high of a potassium to treat it with calcium chloride? I don't think I've seen the ER do dialysis during an arrest.

I am not knowledgeable on catherization during cardiac arrest. Do most STEMI facilities do this or just some? While the the arrest may have been caused by the occlude MI, it is possible to treat the arrhythmia without having to treat for the MI further? I know it wouldn't work in all cases, and sometimes an arrhythmia isn't the cause of the arrest from an MI, but wouldn't that work in some cases? Would it be reasonable to work the patient for 20+ minutes before making the decision to transport, if the cause is an MI?

 

[Peak]

It certainly cannot be done safely for the providers. Also:

A Comparison of Chest Compression Quality Delivered During On-Scene and Ground Transport Cardiopulmonary Resuscitation - PMC

American Heart Association (AHA) guidelines recommend cardiopulmonary resuscitation (CPR) chest compressions 1.5 to 2 inches (3.75–5 cm) deep at 100 to 120 per minute. Recent studies demonstrated that manual CPR by emergency medical services (EMS) ...

www.ncbi.nlm.nih.gov

https://www.ahajournals.org/doi/10.1161/JAHA.118.011189

How many 911 EMS providers actually wear their seatbelts correctly on routine calls?

 

[Peak]

How high is too high of a potassium to treat it with calcium chloride? I don't think I've seen the ER do dialysis during an arrest.

I am not knowledgeable on catherization during cardiac arrest. Do most STEMI facilities do this or just some? While the the arrest may have been caused by the occlude MI, it is possible to treat the arrhythmia without having to treat for the MI further? I know it wouldn't work in all cases, and sometimes an arrhythmia isn't the cause of the arrest from an MI, but wouldn't that work in some cases? Would it be reasonable to work the patient for 20+ minutes before making the decision to transport, if the cause is an MI?

I wouldn’t expect for emergent HD or CRRT to be imitated during arrest, however what methods are available on 911 ambulances to check a basic chemistry?

We cannot correct hyper K simply by giving calcium. In fact if you give too much calcium and we can’t pull off the K quick enough then you end up with irreversible contracture of the myocardium.

More importantly the function of potassium isn’t just relative to calcium outside the cell but also to the level of potassium inside the cell. Giving more calcium does not change that. We can temporize patients by things like continuous albuterol or giving insulin and dextrose both of which are not available to the vast majority of 911 providers.

If you recover an arrest without addressing the underlying pathology the chance of rearresting is essentially guaranteed. The hyperkalemic is likely to arrest in the bus again once en route and then the point of working on scene becomes moot.

Reperfusion codes are common the the cath lab during and after procedures, working a code in the cath lab isn’t uncommon or particularly difficult.

We certainly wouldn’t take a code to the cath lab without knowing that they need an appropriate intervention whether that be Dilation/stenting, placing a pacer, placing impellas, or whatever else.

While a large number of adult arrests are the result of MI we can’t take every undifferentiated arrest to the cath lab. The prevalence of MI in cardiac arrest is the largest driver of why we immediately get 12 lead if we get ROSC. Time is muscle, and a MI that has caused enough damage and irritability to cause ectopy leading to a fatal rhythm is extremely time dependent.

If a patient is known to have a high risk cardiac history like multiple prior stents and/or CABGs with a witness stating he reported chest pain or other associated symptoms and had a witnessed arrest with immediate bystander CPR then I would hedge on immediate transport if you have a cath lab within 30 minutes or so.

This is all what I was alluding to with my original post though. Many arrests are not viable and should not be transported. Some will need rapid transport to a major center for any chance at survival. The move for systems to make working codes until ROSC or presuming death on scene removes the clinicians decision making and is something I find particularly disturbing. It seems to be another trend in removing the paramedic scope of practice (like with intubation or RSI) rather than increasing education so that those decisions can be made.

 

[Tigger]

How many 911 EMS providers actually wear their seatbelts correctly on routine calls?

That doesn’t somehow just make it ok though. We should be wearing our seatbelts, period. If your ambulance and equipment does not allow you to, that doesn’t make your behavior acceptable.

I’m also not going to try not to do something risky that isn’t shown to even be effective.

 

[Peak]

That doesn’t somehow just make it ok though. We should be wearing our seatbelts, period. If your ambulance and equipment does not allow you to, that doesn’t make your behavior acceptable.

I’m also not going to try not to do something risky that isn’t shown to even be effective.

Does your fire department, old third service, or AMR have a Lucas on every ambulance?

Would you be willing to take the lights and sirens off of every EMS vehicle since running code has been shown to have minimal to no benefit but substance rally increases risk to the public and EMS?

Would you be willing to shut down most flight programs as they rarely change outcomes but are inherently very risky?

 

[Tigger]

Does your fire department, old third service, or AMR have a Lucas on every ambulance?

Would you be willing to take the lights and sirens off of every EMS vehicle since running code has been shown to have minimal to no benefit but substance rally increases risk to the public and EMS?

Would you be willing to shut down most flight programs as they rarely change outcomes but are inherently very risky?

The third service, yes. The others no. The flight programs I have no ability to comment on. The lights, I could care less if we responded non-emergent to most calls. Probably still need some of the lights to avoid getting smoked on the interstate.

This is not the point though. We can fix many dangerous behaviors, while also improving our care. If the hospitals wanted us to transport arrests for intra-arrest PCI (currently they look at you funny when it's brought up), we would need to change how we do things to ensure the care is optimal and safe. We can't just wing it and knowingly do unsafe things just because we take (often unnecessary) risks elsewhere. If we are going to transport cardiac arrests, steps need to be taken to do this properly and safely, which currently we do not do.

For clarity, we know that CPR in a moving ambulance is not effective. We know not wearing seatbelts in the back of an ambulance is risky behavior. We should not be doing those things, just because we do other risky or non-effective things, which we also should not be doing.

 

[E tank]

How many 911 EMS providers actually wear their seatbelts correctly on routine calls?

However many do, it should be a policy with some number of warnings then termination of employment. Not talking about the back of the ambulance.

 

[Tigger]

However many do, it should be a policy with some number of warnings then termination of employment. Not talking about the back of the ambulance.

Frankly we should be looking towards this in the back too. Restraint systems and ambulance designs have come a long way, a properly designed truck can allow you to wear your seatbelt on 90% of calls.

 

[Peak]

I could care less if we responded non-emergent to most calls. Probably still need some of the lights to avoid getting smoked on the interstate.

That’s the deal though. Transporting some arrests provides a benefit, although a small percentage. Why not treat lights the same way. If it only benefits a small number of calls but increases risk every time then why not cut it out completely?

 

[johnrsemt]

For the back of the trucks; we have 2 new ambulances with seats instead of benches; and even with them pulled all of the way out and the seatbelts as loose as possible there is no way you could do compressions while wearing seat belts.
No CPR seat.

 

[wtferick]

So, I just got hired by Doctor's Ambulance my first ever job in EMS which is owned by AMR and they run majority IFT for Orange County, but do 911 in Laguna Beach from what I could find out and I just had had my PAT done today and I go in for orientation on Friday. Kinda a weird question, but I was wondering how do you actually transport a code? I mean obviously you start CPR, AED, ETC. but how would you actually transport them? Do you stop CPR to load them onto the gurney or when you're loading the PT? Just something I've always though about. How would you keep compressions going while also moving them?

What you should really be concerned about is how to get to both your mission hospitals and further trauma centers lol

 

[johnrsemt]

PT job we don't run lights and sirens on the freeway until the last half mile going to a MVC, because our trucks max out at 75-80mph and the freeway speed is 80mph. We definitely don't run L&S transporting cause it is 100 miles either way of speeds like that. We seldom run L&S in town, but we have 5 minutes to mark en route.

 

[Seirende]

I had two recent IFTs as the patient. No interventions. Neither provider wore their seatbelt until I called them out on it.

 

[Jambow]

Depends on where you work, i worked for an agency in Va that did not let BLS transport codes. They had to call and wait for ALS.
otherwise you are correct. CPR will be interrupted to move the patient (for transport, loading and unloading the ambulance) If you are transporting a code (hopefully non-emergent) time the loading and unloading with the breath cycles / pulse checks.
this will give you the least interruptions.
I agree with the other post - where I work, we only transport ROSC. Most get called in the field by ALS.
my thoughts
Code situation
Request ALS
if their response time is longer than the what it would take to get ALS on scene...i could see BLS transport
I worked transport and BLS for several years (many years ago) never had to work a BLS code (got lucky I guesss)
just another thought
i tell all my students (dead is dead, you can not fix dead) Most out of hospital arrest are going to remain dead.
I was never told this as a new medic and it was hard lesson to learn.

 

[FlorianFred]

My comment is more towards the OP's original question, so perhaps my comment is out of date. The TLDR summary is: a patient with no discernible heart activity must be brought to a level of at least a pulse on scene before being transported.

For those who like to read, here's the context of my situation and recent scenario: I'm a Volunteer Firefighter (VF) who recently completed my EMR (or MFR) training and state certification. Our ambulance crews typically run with 1 Paramedic and 1 EMT, and I'm located in a rural area (gravel and dirt roads heavily outnumber paved roads) and the closest small hospital is 30 minutes away; the bigger, more equipped hospitals are 45 minutes to an hour. We do have and use air med. While we have a healthy VF contingent, I would estimate that only 10% will go on a medical call....the *distasteful* joke is that if you're not on fire, don't call us. I don't subscribe to that way of thinking, given the terrain and spread-out nature of our area, I arrive on scene before the ambulance at least 75% of the time, and I'm often there long enough to get through the SAMPLE/OPQRST questions and at least full set of vitals. In some cases I'm able to stop the bleeding or begin CPR....or just keep the PT and family calm as we wait for the ambulance.

So my example case of not transporting a coding PT was early in my "career" with the VF. I was a newly credentialed CPR and MFR, so I had been advised to not go on medical calls without knowing that another, more experienced first responder, would be going. The call was originally for a 40 year old adult male with low blood sugar who was vomiting. The call was located in an area where I knew I would be the only first responder, so I held back. 10 minutes later a second call came out that the ambulance service was requesting CPR help for a coded PT, same address. With the ambulance onsite, I headed that way to assist. I arrived on scene to find a very tired EMT who had clearly been alternating between compressions and bagging, the Paramedic was working on establishing a line in the leg and was having difficulty. PT was on the floor of a tiny kitchen, we were slipping around the vomit on the floor and I immediately took up a kneeling position and took over chest compressions. They had worked on him for about 15 minutes, and after about 5 minutes of me being there the Paramedic asked if any other VF's were coming....I told her no and we continued our work. Luckily a few Sheriff Office deputies showed up and one of them relieved me on compressions and I took over on bagging. The mother was sitting in the living room and began asking why we weren't transporting her son to the hospital. The SO deputy told her that we couldn't move him until we stabilized him, and she seemed to accept that. After 45 minutes of attempting resuscitation (no joy from the AED or Epinephrine), the Paramedic called the local hospital, spoke with the ED Doc and he declared the patient dead.

I'll admit that as a civilian, I always imagined that Air med or an ambulance would immediately transport any PT in any emergency state of health to the hospital, but I understand why that isn't the case; and I suspect sudden cardiac arrest in this particular case (diabetic and recreational drug user), so I'm not optimistic they could've brought this PT back.

It's my first post, so I apologize for the lack of brevity -- I'll try to do better going forward.