Which treatments would you want?

NPO

NPO

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We all know what recent literature suggests about treatments that have long been considered standard.

I am specifically talking about cspine in trauma, and epi in cardiac arrest.

But what about you? If you were in a car accident, would you let the responders place a collar and put you on a board?

If you or a loved one were in cardiac arrest would you want them pushing Epi (and other ACLS drugs if you want to add that too)?
 
Was talking to my AT preceptor about spine boarding just the other day, and explaining how EMS has started to ween away from long boards (ATCEMS recently released new COGs that loosen the grip on boards. Woop!). Personally, I believe in the spine board in cases of (1) cardiac arrest and (2) difficult extrications. Let's go (2 1/2) for any scenario where the Pt being on a board would make life easier for everyone. Basically, I see it as another tool to assist EMS and Fire personnel, and less of spinal immobilization. As you mentioned, in a car accident I believe that a board usually just makes things easier when trying to keep the Pt as still as possible while still effectively extricating. From there I would leave them on the board until arrival to ED to make transferring to the ED bed a bit easier/Pt friendly. If extrication is not applicable, then we look at NSAIDS and experience. If I have a soccer player down after axial loading his/her face into the goal post, but shows no symptoms other than point tenderness at, say, C5, I don't think I would board them. Why should anyone? I can just as effectively put on a c-collar and explain why they need to not be moving. their torso or head.
 
I will punch you if you try to backboard me against my will.
 
I'll let them place a collar but will adamantly refuse any further spinal motion restriction. I fractured my C2-3 spinal processes about 8 years ago and damaged my C6-T2 costovertebral joints last December in a snowmobile accident. It's very uncomfortable for me to lay flat unless I've got my pillow that took like 5 tries to find the right one, laying supine on a hard board would be absolutely excruciating.

I personally would not want epi if I were in arrest.
 
You'd have to RSI me to get me on a board. There is no way I'd allow anyone from my family on a board.

And if one of my loved ones was in arrest, I'd not want Epi administered. Stick with CPR and Electricity. I'd actually only let them work VF/VT. (But, unless I had some advanced directives in place, I don't think anyone would listen to me. )
 
No board. No epi.
 
No board, I'd let them place a collar (and by that I mean I would check the correct size because way to many providers size the collar to big).

I can't really say id refuse Epi because I'm not going to be making my wishes known to anyone at that point
 
Boards are uncomfortable, but not murderous. Yes, I agree with the move away from them, but they are still warranted in some cases. I've been on a board, and while it wasn't the best experience, it didn't kill me. Use 'em when you need 'em.

I can see the argument against epi if you're using mechanical CPR, as those devices can get decent perfusion pressures on their own, but if you're doing manual CPR, epi is a great tool. Granted, there's all kinds of new studies out there that question its efficacy, but until it's debunked, I'm perfectly happy using it.
 
Honestly, I'd want any treatment that I could get if I need epi in a code scenario. Throw the drug box, all the o2 in the world, the electricity, the MAST pants, the kitchen sink at/into me. If I'm in a lethal rhythm, I want you to try EVERYTHING before you call the code.
 
I'll take a cervical collar (+/- KED) and a combi-carrier.

No adrenaline in cardiac arrest. I'll take amiodarone though (not that it has been shown to improve survival to intact neurologic outcomes)

Would definitely take RSI from one of our RSI trained ICPs.
 
I'd have to say no on the long board too. I hurt my coccyx once and laying on it was excruciating. I can imagine the same would hold true with bulging disks on any other part of the spine.
 
Probably not on the long board. Not much data to support benefits and lets face it ... it hurts and is uncomfortable.
As for Epi ... there's a good question ... lots of studies out there on that. Maybe it could be looked at as Epi or help me create natural ATP.
Hospital data from 2005 through 2008:
The odds of return of spontaneous circulation prior to hospital arrival were significantly higher in patients who received epinephrine in the field than in those who did not. However, at 1 month, patients who received epinephrine had significantly lower odds of survival; good or moderate cerebral performance; and no, mild, or moderate neurological disability.
So the question is Epi now and maybe live, and maybe **** my odds later. Or go with recent pushes and hope that the people working on me can help me generate ATP. Natural ATP increases my odds for circulation and is naturally found at the cellular level during life. This is after all a major push for all the CPR guidelines. CPR 1st, build ATP, shock, and you should have better odds.

It's an excellent question and topic.
 
No backboard at all for penetrating trauma, and more than likely no board for anything at all. Go ahead and use a scoop, or use a lsb for auto ex, but once I'm on the cot, remove the board/scoop. Leave the collar on.

As for epi, although the evidence isn't great, give it to me. At best, it works, at worst I'm an organ donor (which doesn't happen w/ field terminated arrests).
Some of that new diastolic bp based epi dosing stuff seems good, give it a try given the other options.
Same with some of the other drugs. Although they may not help, they don't seem to really hurt - and if you don't get ROSC then you don't have any chance of leaving the hospital w/ a functioning brain.

But please: before you mess around w drugs, run a perfect bls code, constant CPR, no hyperventilation. Use mech CPR if you have it.
And if you do get ROSC, for the love of god, lay off the oxygen and dont hyperventilate. Spo2 between 94-98% and normocapnea.

Same with therapeutic hypothermia. I want a minimum of targeted temp mgmt, but I'd likely be OK if you decide to take it down to 33 deg C, at least until other studies are done.
 
I'm glad you brought up hypothermia. Only 2 hospitals (of 5) have standing protocols for it. I want to go there.
 
Exactly. Until this is sorted out/refinements are made, ill still take 33 deg C. Although the ttm trial showed no difference, it also showed that in general, there was minimal to no harm from it either. Hypothermia isn't benign, but one cant just ignore all the previous lab data because the trials haven't shown a benefit. I have a feeling that we will find that some form of it does help, but how and when are the big questions.

As for intra arrest hypo, please sign me up. Look up ischemic preconditioning vs. perconditioning vs. postconditioning. Same thing goes for treatments that act to protect from hypoxic effects.

Preconditioning usually has the best outcomes. I have a feeling (no evidence yet) that intra arrest hypothermia may help at least in some subgroups, but how to do it best may still have to be worked out.

As an example of what can be done in ideal, controlled environments w/ preconditioning, look up deep hypothermic circulatory arrest...
 
Av8or007 said:
Same with some of the other drugs. Although they may not help, they don't seem to really hurt - and if you don't get ROSC then you don't have any chance of leaving the hospital w/ a functioning brain.

Same with therapeutic hypothermia. I want a minimum of targeted temp mgmt, but I'd likely be OK if you decide to take it down to 33 deg C, at least until other studies are done.
Click to expand...

I'm not sure I agree with the first part. While it sounds logical, without research there is no way to know if our efforts to achieve ROSC are the very same things that are preventing survival to discharge. A lot of the medications we give during an arrest stick around for a while and have a variety of side effects that may not manifest themselves immediately.

As for the hypothermia, I was recently provided a study from our medical director showing no change in outcomes between patients at 91 and 97 F. He also added that the intensivist who was the first to implement it in a US ICU has pulled from standard protocols. I do not have a source for this, however.
 
W/ the hypo, that's what i mean. I am aware that the ttm trial showed no difference (i read it) between 33 and 36 deg C. For ME at least (given the op topic) i'd choose 33 degrees if given the choice, but prefer ttm over nothing at all. Wouldn't fight against 36 degrees either, but absolutely insist on active temp management to either normo or hypothermia.

As for meds, look up diastolic bp based epi dosing. I agree that 1 mg q3 min may not be good, but we always seem to be bipolar when writing guidelines, and either go full out one way or full out nothing even though the reality is likely somewhere in between.
But especially for a refractory arrest, give me meds (especially for refractory vf/vt) and consider double external defib if that fails. At that point the options are call it or try something else. Ill take try something else...
 
Av8or007 said:
W/ the hypo, that's what i mean. I am aware that the ttm trial showed no difference (i read it) between 33 and 36 deg C. For ME at least (given the op topic) i'd choose 33 degrees if given the choice, but prefer ttm over nothing at all. Wouldn't fight against 36 degrees either, but absolutely insist on active temp management to either normo or hypothermia.

As for meds, look up diastolic bp based epi dosing. I agree that 1 mg q3 min may not be good, but we always seem to be bipolar when writing guidelines, and either go full out one way or full out nothing even though the reality is likely somewhere in between.
But especially for a refractory arrest, give me meds (especially for refractory vf/vt) and consider double external defib if that fails. At that point the options are call it or try something else. Ill take try something else...
Click to expand...

I don't mean specifically epi. There might be some promise with that research but it has a bit to go I'd say.

My point is that ROSC and neurologically intact survival to discharge are entirely different things. Yes, you cannot have survival to discharge with ROSC, but that does not mean increasing ROSC will have any effect on survival rates, and such things very well could decrease it. It is not enough to say "such intervention increases ROSC rates so we shall do it." If our initial interventions later hamper continued efforts to keep the patient alive, we should not be doing them.
 
No board, no collar unless for comfort. Don't care too much about epi. No oxygen unless short of breath. Don't care too much about tPA if I stroke.

Hook me up with the good stuff if I'm in pain or nauseous, though.
 
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