Why not shock a trauma code?

FlightMedicHunter

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That is a loaded question, who is in vfib for 27 minutes in a traumatic arrest?

Furthermore, would the opinion be different if it was a doctor?
The argument is not whether a physician can safely make this decision. It is whether a paramedic on an ambulance can make the decision on his own without a protocol or written orders directly saying to withhold defibrillation. Your argument is that if they were hypovolemic that you would withhold shocking and do rapid transport with fluid resuscitation. You said you would do this because shocking would be futile as a normal heart rhythm would not be perfusing anyway due to the hypovolemia.

I will make an honest attempt to get impartial opinions from ED physicians as well as my school medical director and several medical directors on the state board. I will update this thread when I get their opinions.

Don't go running from you argument now.....;)
 

Veneficus

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We are getting way off base here. There is something that is worth pointing out here though. There are many progressive EMS folks out there who preach about critical thinking and understanding pathophysiology. I am one of those folks. Veneficus, you also sound like one of those folks.
Yea, I see a bit of value in pathophys ;)

I don't think we are off base at all.

The OP specifically stated his protocols direct traumatic arrests should not be defibrillated.

He then asked why.

After explaining it to him there is an ongoing debate on the value.

However, there also seems to be a group out there who wants medics to be freelancers and operate however they see fit....as long as they can justify it. I find a major fundamental flaw in this argument:
I don't find this to be the case. I think there are people out there who rightfully require liberal enough guidlines so that the treatments available to EMS providers can be more appropriately selected for a given patient.

I have coined the term "surgical resuscitation" to more accurately describe it. Specifically selected therapy for specific conditions and presentations.

I think it is a bit overreaching to call that similar to paramedics doing whatever they want. There are still finite therapies available to them.

In the case of defibrillation of traumatic arrest, withholding treatments based on presentation has been a part of EMS for as long as I can remember. (which is a long time)

A simple example is medication allergy. You wouldn't give a medication to a patient who claimed an allergy would you? Why? You could just predose him with some epi and benadryl and get the desired effect anyway.

You don't do it, because at that point the complexity of the therapy and the amount of side effects outweigh the benefit derived from the original medication.

So you or any reasonable paramedic would select another available and indicated treatment or forgo treatment entirely if that option didn't exist.

We are not physicians. As much as we want to learn and move ahead we are simply not physicians and therefore cannot act outside of standing orders or medical direction.
You are not a physician, got it. :)

But I am not suggesting acting outside of medical direction. I do suggest that medical direction needs to be more than simple an if:then statement. Such rigidity simply doesn't function well in medicine.

a good example is compartment syndrome of the lower extremity secondary to edema in dialysis patients.

If you have clinical signs and symptoms of compartment syndrome in the lower extremity, the indicated surgical treatment is 4 compartment fasciotomy.

Here is where if:then breaks down. If you have an elderly, heart failure, diabetic, renal failure patient like many in this population, when you cut their legs open, those wounds may never heal. Creating complications, decreasing quality of life, increasing costs.

It may be better to try increased dialysis first. Which is not indicated medically in the treatment of compartment syndrome.

Granted, this is more of a surgical/nephro debate, but if I think about it long enough I could probably find an EMS example.


Yes, we must teach critical thinking but just teaching somebody critical thinking does not forfeit the fact that we operate under a physician's license.
Didn't ay it did.

As much as you and I hate it, we DO have to teach how to protect yourself from legal action. We do it all the time. Yes, CYA is a part of EMS. Legal knowledge is part of all EMS curricula.
You can teach legal aspects of EMS without invoking fear from the constant threat of litigation.

litigation is part of modern medicine, it is not really a question of if somebody brings legal action, but when. Anytime gettng sued takes precedent in your mind over doing the right thing, it might be time to find another career or get some medication for anxiety or other relevant psychosis.

Education should remove fear, not install it. That is what seperates it from indoctrination or brainwashing.

Any instructor who teaches that it is okay to withhold defibrillation without having a protocol or orders is doing the student a disservice.
I beg to differ.

What if there is no protocol addressing defibrillation in traumaic arrest?

How many times have you given nitro to someone that you knew was not having cardiac ischemia? Everyone has. Even though they knew it wouldn't help. They did it to cover their ***.
They didn't do it as a diagnostic procedure to help differentiate a more specific diagnosis of ACS?

If they did it to cover there ***, they administered an unindicated medication to a patient. That is a medical error.

Are you suggesting that it is ok to knowingly perform a medical error on somebody to help you avoid getting sued?

You know as an instructor you can be held liable for erroneous teaching. Teaching somebody to give a medication "to cover their ***" as the indication would certainly not be a good idea.

You sound like you work in an ED or trauma environment. Maybe you work on the street as well. But you have to remember that this is a big nation of paramedics and 99% of the time, if someone is going to get roasted, it is going to be the paramedic. If liability arises, most agencies will search for a reason to blame the paramedic for what went wrong. The worker bees are always the scapegoats.
Do you really think if something goes wrong, that the :censored::censored::censored::censored: is going to roll in a direction other than down? You seem way too smart for that. Even if you don't get fired from your agency, the work environment will likely become so hostile you'll quit.

The benefit to the physician in the current way EMS is set up in the US, is they do not bear direct responsibility. If they did, there would be a lot less paper medical directors and absentee medical directors.

The agency with the deepest pockets will be sued, and some little guy will take the fall.

Always.

But how many times have you seen a paramedic get fired for going outside their scope of practice or breaking the rules? It happens every day.
Really? Everyday?

I have seen it happen to 1 EMT-B for administering epi outside her scope in my whole career now spanning 5 countries and starting in 89.

Who told you it happens everyday?

just as you say you would if you had a hypovolemic traumatic arrest.
This is not a risk, it is decision backed by expert recommendation and more than a few scientific studies on the outcome of traumatic arrest.

I am far more likely to be congratulated for my clinical accumen and medical knowledge than I am for any potential negative consequence of performing a futile treatment on a corpse.

Unless this guy is moments away from a trauma center, his injuries caused by a penetrating mechanism, and all the stars lining up just right for him, he is dead. (Not because he wasn't defirbillated)
 

Veneficus

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Your argument is that if they were hypovolemic that you would withhold shocking and do rapid transport with fluid resuscitation. You said you would do this because shocking would be futile as a normal heart rhythm would not be perfusing anyway due to the hypovolemia.
Sorry, i didn't read this properly the first time.

I would also withhold fluid if it was a penetrating mechanism.

I will make an honest attempt to get impartial opinions from ED physicians as well as my school medical director and several medical directors on the state board. I will update this thread when I get their opinions.

Don't go running from you argument now.....;)
I will never run from this argument.

Before you do that though, I don't usually boast my credentials, but in addition to being a paramedic and paramedic instructor, I am 120 days away from my joint MD/PhD degree. My PhD is in pathophysiology and my dissertation and original research are on the pathophysiology of shock.

I would be happy to speak with any physician who would like to debate the matter.
 
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Veneficus

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Let me go out on a limb here, knowing that Vene and FMH are living this stuff and I haven't in years. I've read the arguments pro and con, but am stumbling over the issue of priorities.

My first (possibly naive) thought is, if come across a trumatic incident where my patient presents in V-fib, that calls into question whether what I'm seeing is the result of trauma or electrical dysfunction.

At that point I would have to ask myself "Even though there's trauma here, I might be missing something."

If it's electrical, and I'm not sure why, that is potentially immediately fixable through de-fib. That, at least, is something to work with and it doesn't take much time to do. Naturally you're going to want to stave off blood loss, but in the absence of a functioning heart, it's a moot point, there's nothing to stave.

NOT treating a fibrillating heart guarantees there will be no recovery, period.

All the rest is about time management.

(Please file under "Dinosaur logic, irrespective of litigation fears"!).
It is not dinosaur logic.

In penetrating trauma, if the downtime is not long and aggresive surgical intervention and resuscitation are available, there is a small possibility of restoring enough physiologic function for defib to work.

The key there is restoring physiologic function. It is a similar (not exact) mechanism to having to defib the heart from vtach (usually) or vfib secondary to cardioplegia in various on pump cardio surgeries. You must first restore normal working order.

If you hang around trying to defib, the likely (almost promised) outcome is refractory vfib.

The unknown factor is, we don't know if defib will detract from other therapies.

Hanging around on scene will detract.

What it comes down to is the provider on scene is going to have to make a choice.

As I pointed out, there are even conflicting recommendations.

In the end, the decision will come down to clinical proficency (and as part of that experience) of the provider to determine the best course.

If you think it is vfib secondary to hypovolemia in a penetrating arrest, you need to beat feet defib will not help.

If you think it is vfib secondary to a coronary condition with trauma, you will need to defib.

If it is traumatic arrest due to blunt mechanism, doesn't matter what you do, it's already over.
 

TheGodfather

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If you think it is vfib secondary to hypovolemia in a penetrating arrest, you need to beat feet defib will not help.

If you think it is vfib secondary to a coronary condition with trauma, you will need to defib.

If it is traumatic arrest due to blunt mechanism, doesn't matter what you do, it's already over.
can i get a hallelujah?! amen!
 

Brandon O

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One brief thought, playing devil's advocate for a moment.

Even cardiac failure due to clearly traumatic etiologies, such as hypovolemia, may deteriorate into VF due to irritability, prior to the point where it becomes totally non-pumping due to asystole or PEA. In that case, if defibrillation could return a circulating rhythm (which is admittedly far from certain), you would be restoring some amount of perfusion for some amount of time. Even if the output is poor and brief it would almost certainly be vastly better than compressions and could potentially temporize until the underlying cause could be fixed.

Furthermore, if a traumatic cause does precipitate VF, and you correct an underlying cause, you may still need to shock to restore sinus rhythm.

This is all a stretch and I'm not suggesting it changes the basic concept that arrest due to squishing is generally a lost cause. But if you're asking why could it ever help, there's a theoretical example.
 

Aidey

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Vene (or anyone else)

Wasn't there someone doing a study on withholding defib in certain types of arrest in favor for continued CPR until the cause of the arrest could be fixed?
 

Veneficus

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One brief thought, playing devil's advocate for a moment.

Even cardiac failure due to clearly traumatic etiologies, such as hypovolemia, may deteriorate into VF due to irritability, prior to the point where it becomes totally non-pumping due to asystole or PEA. In that case, if defibrillation could return a circulating rhythm (which is admittedly far from certain), you would be restoring some amount of perfusion for some amount of time. Even if the output is poor and brief it would almost certainly be vastly better than compressions and could potentially temporize until the underlying cause could be fixed.
I think you are overlooking something very important in this theory.

In an MI arrest, a part of the heart is affected by ischemia, there is still working and perfusing parts.

In the hypovolemic arrest, the entire myocardium has failed. It begins in the compensating phase when endogenous endophine constricts endocardial capilary beds in order to shunt more blood to the epicardial arteries.

When delivery of o2 is so inadequete, eventually you have anaerobic metabolism. The tissue is trying to sustain itself, not work properly. (contract)

If it has already reached a level of vfib, (irritability) then the cellular level metabolism is insufficent. (caused by lack of oxygenation of the total heart) At this rather small moment in time, a couple of minutes, if you were to defib, and the heart were to return to an organized rhythm, it will still be unable to carry out any function.(contraction from ATP depletion, required for muscle contraction) The atp production in anaerobic metabolism cannot hope to make up for the loss of beta oxidation or even aeorbic glucose metabolism.

Since you cannot deliver what is needed (oxygen) to return normal metabolism, because part of either the hematocrit, circulatory volume, or both are depleted, there still will not be contractility.

So your clinical outcomes are only going to be recurrent vfib, pea, or aystole.

This is witnessed after cardioplegia in cardiac surgery. When sufficent circulating volume is restored, the vtach, vfib is defibrillated and a perfusing rhythm returns.

When the circulating volume is still insufficent, the rhythm does not convert. After waiting a few minutes, it is attempted again, with the idea that bypass rig returned more volume with sufficent circulation and gas exchange occured to allow return to normal metabolism. (there is also some time for return of more normalized temperatures when hypothermia is used) After this second attempt, volume resuscitation is increased prior to yet another defib attempt.

This last step is then repeated until it works. (I have not seen or heard of it failing)

But in this setting you can actually watch how the whole volume resuscitation concept works. Not only on the EKG, but directly observing the heart.

Furthermore, if a traumatic cause does precipitate VF, and you correct an underlying cause, you may still need to shock to restore sinus rhythm..
Yes you will. But this restoration of underlying cause is going to require either surgical hemostasis,and/or restoration of circulating volume and hematocrit. In class 3-4 shock, when arrest happens, the pt is unresponsive to crystaloid. Which means there is nothing EMS brings to the party that helps except a ride.

But the unknown quantity is, would restoration of a normal looking rhythm via defibrillation force an attempt at function, which likely would increase acidosis and cause cellular failure in the entire organ?

Would the electrical current cause direct cell injury to the already long struggling cells?

Even an injured cell can go into an apoptosis cascade.

What are you willing to bet on no damage?

This is all a stretch and I'm not suggesting it changes the basic concept that arrest due to squishing is generally a lost cause. But if you're asking why could it ever help, there's a theoretical example.
too oversimplified.
 

systemet

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As a devil's advocate (actually, I'm not sure which side of the argument I'd have to be on to be a devil's advocate here), what about the idea that pulseless VF /VT represents a state where cellular energy demand isn't met by cellular metabolism and high-energy phosphate / glycogen stores are being depleted, and the development of lactic acidosis / metabolite accumulation is occuring at an accelerated rate.

I wonder if it's possible that having the hear in pseudo-PEA, true PEA, or asystole might be better from a cellular metabolism standpoint?

[I do agree with the futility of defibrillating someone who has no volume and no hematocrit, if we're talking about producing a beating heart with decent hemodynamics.]

Just wondering what the opinions were about this from a physiology / pathophysiology standpoint.
 

Veneficus

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As a devil's advocate (actually, I'm not sure which side of the argument I'd have to be on to be a devil's advocate here), what about the idea that pulseless VF /VT represents a state where cellular energy demand isn't met by cellular metabolism and high-energy phosphate / glycogen stores are being depleted, and the development of lactic acidosis / metabolite accumulation is occuring at an accelerated rate.

I wonder if it's possible that having the hear in pseudo-PEA, true PEA, or asystole might be better from a cellular metabolism standpoint?

[I do agree with the futility of defibrillating someone who has no volume and no hematocrit, if we're talking about producing a beating heart with decent hemodynamics.]

Just wondering what the opinions were about this from a physiology / pathophysiology standpoint.
I don't understand what you are asking sorry :(
 

Veneficus

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2nd look

As a devil's advocate (actually, I'm not sure which side of the argument I'd have to be on to be a devil's advocate here), what about the idea that pulseless VF /VT represents a state where cellular energy demand isn't met by cellular metabolism and high-energy phosphate / glycogen stores are being depleted, and the development of lactic acidosis / metabolite accumulation is occuring at an accelerated rate.
I am still not sure if there is a question in here or what you are trying to say?

I wonder if it's possible that having the heart in pseudo-PEA, true PEA, or asystole might be better from a cellular metabolism standpoint?
That is what is happening. Cells go into "hybernation" as they try to use the ATP generated to preserve cell integrity.

At some point this integrety is compomised by membrane permiability (multiple mechanisms)

If proper intervention (like restoration of circulation) is undertaken while still in time for the cell to recover from the insult, the acute arrest pathology is corrected and homeostasis can return.

But keep in mind, the inflammatory response to shock has alread been initiated, and there will be a longer term sequele to that. (like delayed cell killing)

Not all cells are affected equally either, so some will die and some will return to function. How many makes a big difference.

If proper and timely intervention is not undertaken, there is a point where injury triggers the apoptosis cascade in a cell. That is irreversible and is largely recognized to take up to 10 days to manifest with clinical signs. (the average being around 4 in the heart)

Hypothermia is the reversible treatment to slow down cell metabolism.

While focusing on the heart in this discussion, let us not lose sight of the insult to other organs. The heart is the very last organ to be affected. So the damage to the rest of the body is already substantial.

I would liken defirbrillating a hypovolemic arrest to kicking a dying animal and expecting that will help.
 

systemet

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I am still not sure if there is a question in here or what you are trying to say?
Sorry. Question: "Is it better to be in a PEA / low perfusion state or asystole for the individual cardiomyocyte, compared with high frequency stimulation during VF/VT?".

Just wondering as a thought experiment. Sorry for the lack of clarity.

That is what is happening. Cells go into "hybernation" as they try to use the ATP generated to preserve cell integrity.

At some point this integrety is compomised by membrane permiability (multiple mechanisms)

If proper intervention (like restoration of circulation) is undertaken while still in time for the cell to recover from the insult, the acute arrest pathology is corrected and homeostasis can return.

But keep in mind, the inflammatory response to shock has alread been initiated, and there will be a longer term sequele to that. (like delayed cell killing)

Not all cells are affected equally either, so some will die and some will return to function. How many makes a big difference.
Agreed / accepted.

If proper and timely intervention is not undertaken, there is a point where injury triggers the apoptosis cascade in a cell. That is irreversible and is largely recognized to take up to 10 days to manifest with clinical signs. (the average being around 4 in the heart)
And this is related to loss of membrane potential (i.e. depolarisation), Ca2+ entry, caspase activation, and loss of mitochondrial membrane potential, and MPTP formation. I'm just wondering if VF/VT accelerates this.

Hypothermia is the reversible treatment to slow down cell metabolism.

While focusing on the heart in this discussion, let us not lose sight of the insult to other organs. The heart is the very last organ to be affected. So the damage to the rest of the body is already substantial.
It's interesting that much of the discussion in the literature has been so focused on the neurological effects of hypothermia, versus any CV effects. Granted, the neurological outcome is critical, but it's also important to avoid sudden arrhythmic death, especially in the first 24 hours, and have hemodynamic stability.

I would liken defirbrillating a hypovolemic arrest to kicking a dying animal and expecting that will help.
I think you're right, but the discussion got me thinking about the energetic state of the myocardium during VF.
 

Veneficus

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Sorry. Question: "Is it better to be in a PEA / low perfusion state or asystole for the individual cardiomyocyte, compared with high frequency stimulation during VF/VT?".
I don't think it matters. With the membrane permiability, it will be in asystole soon enough.

And this is related to loss of membrane potential (i.e. depolarisation), Ca2+ entry, caspase activation, and loss of mitochondrial membrane potential, and MPTP formation. I'm just wondering if VF/VT accelerates this
I would say VF is a variant manifestation of the above considering PEA and asystole are more common in hypovolemic arrest.

Sort of a "last hurrah" for the heart with the energy it has before it can't go on.

From what I know about hypovolemic arrest, I would also suggest that this course of VF is going to be measured in a few short minutes.
 

zmedic

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The other way to look at all this is to say "forget about what's logical, what should work, what actually happens when there is a prehospital cardiac arrest due to blunt trauma?"

The data I've seen so far say if someone is in arrest from blunt trauma they all die. Doesn't matter if you defib them, do CPR, give fluids, MAST pants, whatever. They all die.

So if I was writing a protocol for what my medics should do if they show up at a blunt trauma cardiac arrest, I'd say don't start CPR. That it doesn't matter how logical it is to defib the patient, that vfib could have caused the crash. If no one is surviving, clearly it doesn't make sense to bring these patients to the hospital.

Old study:
http://ukpmc.ac.uk/abstract/MED/8371308/reload=0;jsessionid=oC2kHQOVkge8WF82wCSU.143

Study from Japan, with agressive treatment including open heart CPR, 3/477 patients who suffered blunt cardic arrest survived to discharge with good neurological outcome. Everyone else died or lived in a vegitative state.

http://www.springerlink.com/content/p634xg356l860q07/fulltext.pdf


Now the last study had a few survivors, but it's hard to tell how well that system translates to a US system.

Now I think there are times when it makes sense to go outside the protocol. I think I would work a 8 year old who was hit by a car, or someone who was talking when I got on scene and coded in front of me after a trauma. But I know that they aren't coming back. I think the best protocols allow some discretion.

I would also point out that the brain's need for oxygen is similar regardless of if the cause of cardiac arrest is trauma or medical. So if the patient isn't getting bystander CPR in a traumatic arrest they have a much lower chance of being saved. I'd guess (though I have no data) that there is less bystander CPR in trauma because the patient is often stuck in the car/under the train/ under the collapsed building or whatever caused the trauma.
 

Brandon O

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... So your clinical outcomes are only going to be recurrent vfib, pea, or aystole.
I suppose my point is that if there's any possibility of a later reversal, "recurrent vfib" may be our best bet. Even if the intervening rhythm is agonal and poor, with weak, poorly synchronous contractions, and even if we go into VF ten times, that cycle is still better than no rhythm at all, and once in a blue moon this might make the difference between salvageable vs. non-salvageable.

... But this restoration of underlying cause is going to require either surgical hemostasis,and/or restoration of circulating volume and hematocrit. In class 3-4 shock, when arrest happens, the pt is unresponsive to crystaloid. Which means there is nothing EMS brings to the party that helps except a ride.
I was thinking a little more about other causes, particularly since penetrating trauma is perhaps the one situation where traumatic arrests still have the most potential for survival. For instance, maybe we've corrected a tension pneumothorax, or maybe there was a primarily hypoxic arrest due to obstructed airway or respiratory depression. (Actually, that last is probably our best bet.) These are things we can remedy.

But the unknown quantity is, would restoration of a normal looking rhythm via defibrillation force an attempt at function, which likely would increase acidosis and cause cellular failure in the entire organ?
I think there is little question that an active heart will have greater metabolic demand. But a non-pumping heart means our window for correction has become truly tiny -- that's clear enough -- so I don't think that "letting it twitch" is ever going to yield the better supply/demand balance. (Unless we come up with a way of really inducing hibernation, such as rapid hypothermia... or hydrogen sulfide, hey.)

Would the electrical current cause direct cell injury to the already long struggling cells?
Although electrocution is probably not exactly organic granola, so far the literature seems to increasingly find that cardiac damage from defibrillation is minimal...
 

FlightMedicHunter

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So, talked to several physicians today including several from the state medical board, 2 attendings from our level trauma center, and 1 attending from our pediatric ED. I gave them the scenario exactly as it is shown from my earlier post.

All are in agreement that there is accepted standard of care that would allow for a prehospital paramedic to make the decision to withhold defibrillation in a traumatic arrest, regardless of the situation.

I remain in full agreement with them that it is completely unacceptable to make your own decision in the field to withhold shocking vfib/vtach. Veneficus, I understand you are experienced and that you are working on your MD, but just as in my earlier posts I cannot agree that this would be an acceptable practice.

Defibrillating someone takes an additional 3 seconds every 2 minutes while en route to an ED. When we see vfib/vtach, we shock it, simple as that.

You asked earlier "who stays in vfib for 25 minutes?" The answer is no one knows because no one in their right mind would ever sit there and watch someone remain in vfib for more than 1 round of CPR
 

Veneficus

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The other way to look at all this is to say "forget about what's logical, what should work, what actually happens when there is a prehospital cardiac arrest due to blunt trauma?"

The data I've seen so far say if someone is in arrest from blunt trauma they all die. Doesn't matter if you defib them, do CPR, give fluids, MAST pants, whatever. They all die.

So if I was writing a protocol for what my medics should do if they show up at a blunt trauma cardiac arrest, I'd say don't start CPR. That it doesn't matter how logical it is to defib the patient, that vfib could have caused the crash. If no one is surviving, clearly it doesn't make sense to bring these patients to the hospital.

Old study:
http://ukpmc.ac.uk/abstract/MED/8371308/reload=0;jsessionid=oC2kHQOVkge8WF82wCSU.143

Study from Japan, with agressive treatment including open heart CPR, 3/477 patients who suffered blunt cardic arrest survived to discharge with good neurological outcome. Everyone else died or lived in a vegitative state.

http://www.springerlink.com/content/p634xg356l860q07/fulltext.pdf


Now the last study had a few survivors, but it's hard to tell how well that system translates to a US system.

Now I think there are times when it makes sense to go outside the protocol. I think I would work a 8 year old who was hit by a car, or someone who was talking when I got on scene and coded in front of me after a trauma. But I know that they aren't coming back. I think the best protocols allow some discretion.

I would also point out that the brain's need for oxygen is similar regardless of if the cause of cardiac arrest is trauma or medical. So if the patient isn't getting bystander CPR in a traumatic arrest they have a much lower chance of being saved. I'd guess (though I have no data) that there is less bystander CPR in trauma because the patient is often stuck in the car/under the train/ under the collapsed building or whatever caused the trauma.
Excellent post.
 

Aidey

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So, talked to several physicians today including several from the state medical board, 2 attendings from our level trauma center, and 1 attending from our pediatric ED. I gave them the scenario exactly as it is shown from my earlier post.

All are in agreement that there is accepted standard of care that would allow for a prehospital paramedic to make the decision to withhold defibrillation in a traumatic arrest, regardless of the situation.

I remain in full agreement with them that it is completely unacceptable to make your own decision in the field to withhold shocking vfib/vtach. Veneficus, I understand you are experienced and that you are working on your MD, but just as in my earlier posts I cannot agree that this would be an acceptable practice.

Defibrillating someone takes an additional 3 seconds every 2 minutes while en route to an ED. When we see vfib/vtach, we shock it, simple as that.

You asked earlier "who stays in vfib for 25 minutes?" The answer is no one knows because no one in their right mind would ever sit there and watch someone remain in vfib for more than 1 round of CPR

Maybe I'm having a reading comprehension fail, but those two lines seem to completely disagree with each other.
 

FlightMedicHunter

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All are in agreement that there is accepted standard of care that would allow for a prehospital paramedic to make the decision to withhold defibrillation in a traumatic arrest, regardless of the situation.

Oops....this clearly should say:

All are in agreement that there is NO accepted standard of care that would allow for a prehospital paramedic to make the decision to withhold defibrillation in a traumatic arrest, regardless of the situation
 
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