Working the arrest on scene

[Medico]

What are some of the studies you guys have suggesting that working an arrest on scene is better for ROSC than 'load and go'?

My search yielded opinion articles rather than any peer reviewed study.

AHA suggests minimally interrupted compressions, which can be translated to staying on scene. I am looking for studies that are blunt and stay to remain on scene until ROSC can be achieved.

I am in favor of staying on scene, and do practice that philosophy. However, I am trying to show a co worker the 'light'. No pun intended

 

[LondonMedic]

I suspect that you're unlikely to find a single high-quality piece of research supporting this. As we all know, doing any form of prospective research on OOHCA is fraught with difficulty.

I've found a few bits that, I think, added together, form a reasonable evidence base;
http://www.ncbi.nlm.nih.gov/pubmed/22334218
http://www.ncbi.nlm.nih.gov/pubmed/19477573
http://www.ncbi.nlm.nih.gov/pubmed/17728039

But on the other hand;
http://www.ncbi.nlm.nih.gov/pubmed/18653495

 

[mycrofft]

No articles??

This appeared when I googled "CPR survival in field versus in hospital"
http://www.cdc.gov/mmwr/preview/mmwrhtml/ss6008a1.htm

===========

The phrase "working the arrest on scene" may lack some detail to more-readily match it with studies. Presumably "worked on scene" means or could mean trying until expiration then declaring death (whether officially or simply by stopping efforts), or trying until the pt regains a viable rhythm and spontaneous respirations, or starting care on scene and at some undetermined point picking up and moving to the ambulance and then the hospital.

In your experience, what is the recovery rate of arrests "worked on scene"?

Here's a study from Texas:

http://www.ncbi.nlm.nih.gov/pubmed/22834854

I however think they "want more cowbell" (i.e., they think return of ROSC [as in the techs "returning" the ROSC to its owner] is necessary for survival in-hospital, when it is probably more likely that anyone well enough to achieve ROSC is going to do better).

An article from CNN with some citations of sorts, but a well-written piece for a lay publication:
http://www.cnn.com/2013/07/10/health/cpr-lifesaving-stats/
Some of the comments are interesting to read.
==================

I think there is often confusion, sometimes purposeful due to politics, between the types of patients; the definition of recovery; the iatrogenic elements of resuscitation versus the presenting and continuing status of the patient (apparent versus actual) linked to outcome.

I fell that, since the outcome for true confirmed arrests in any setting are so bad, unless there is motivation to look more closely, the outcome for "staying and playing" (versus "snatch and run", both sarcastically inappropriate) is accepted as "one of those things", "Que serra, Sirrah", "kismet" etc. Which may be the more rational course in the face of sixty years of CPR.

But remember, no one was ever discharged from a hospital to an ambulance to receive superior care.

 

[Christopher]

What are some of the studies you guys have suggesting that working an arrest on scene is better for ROSC than 'load and go'?

My search yielded opinion articles rather than any peer reviewed study.

AHA suggests minimally interrupted compressions, which can be translated to staying on scene. I am looking for studies that are blunt and stay to remain on scene until ROSC can be achieved.

I am in favor of staying on scene, and do practice that philosophy. However, I am trying to show a co worker the 'light'. No pun intended

The evidence clearly points to high quality, minimally interrupted CPR. This precludes transport until ROSC. Services which transport earlier very likely introduce long periods of no flow or low flow time. Studies using mechanical CPR devices (claimed you can use it to transport) have shown that the application takes longer than providers think and they're introducing long no flow times with no known benefit to the patient.

Your coworker needs to put down the Mother, Jugs & Speed and join us in the year 2014

 

[mycrofft]

Need a study of one service which stays til ROSC or declared dead, versus one which gets IV and drugs and electricity going and goes to a hospital.

 

[Christopher]

Need a study of one service which stays til ROSC or declared dead, versus one which gets IV and drugs and electricity going and goes to a hospital.

It's been done before.

 

[Christopher]

But on the other hand;
http://www.ncbi.nlm.nih.gov/pubmed/18653495

19 patients in 15 years and an all rhythms 6% survival to discharge? Not a favorable setup at all, less than half what our area considers reasonable.

They didn't detail anything they do different for those patients, which means they would have likely achieved ROSC in the field had they just waited a bit longer.

Now, if we're talking systems that transport for ECMO or CPR+PCI, then I'll consider discussing how we can add favorable outcomes.

 

[Christopher]

I've found a few bits that, I think, added together, form a reasonable evidence base;
http://www.ncbi.nlm.nih.gov/pubmed/22334218

(adding this for folks who may not have access to read what Protocol C entails)

Protocol C:

• No ventilations for the first 1 minute
• Rhythm interpretation during middle of the 2 minute cycle
• Shock at traditional end of cycles immediately after last compression

 

[EpiEMS]

(adding this for folks who may not have access to read what Protocol C entails)

Protocol C:

• No ventilations for the first 1 minute
• Rhythm interpretation during middle of the 2 minute cycle
• Shock at traditional end of cycles immediately after last compression

More RCTs to this end would be awfully useful, I would think. Why not do them?

 

[TheLocalMedic]

From my personal experience I have the philosophy that codes should always be worked on scene for two reasons:

First, hospitals generally follow the same ACLS protocols that we use in the field. If you're doing it right, there really isn't much more that the hospital can provide that you can't for the cardiac arrest. Sure, there are extra hands and docs have a ton of experience, but all those hands and experience are going to be doing is running through the ACLS cycles like you ought to be doing already (not to mention that it's common for docs to do some eyebrow-raising stuff not proscribed by ACLS... "Let's give epi and atropine! Why? Because we can!"). Also, if you ever watch codes in hospital, look to see how long they pause between compressions. EMS is often more mindful of keeping interruptions in CPR to a minimum while in hospital CPR is often secondary to other procedures (let's stop to intubate, let's stop to get an ultrasound of the heart, oops, someone should really get back on that chest...).

Secondly, have you ever tried doing CPR in the back of a moving ambulance? It's nearly impossible to continue quality compressions bouncing down the road, not to mention switch compressors or work in the confined space. Even using mechanical devices is less effective because moving the patient into the ambulance and the motion of the vehicle has a tendency to make the device slip out of place and necessitate stopping it to get it repositioned.

So that being said, I strongly feel that codes should be worked to completion on scene. Either get ROSC and then boogie or work 'em into the ground.

 

[Bullets]

(adding this for folks who may not have access to read what Protocol C entails)

Protocol C:

• No ventilations for the first 1 minute
• Rhythm interpretation during middle of the 2 minute cycle
• Shock at traditional end of cycles immediately after last compression

This is an infinity loop, how does it end?

 

[LondonMedic]

This is an infinity loop, how does it end?

At 20 minutes or when you get bored.

 

[rugbyguy]

We don't transport dead bodies. We will work it through 4 or so rounds of epi, if we don't get change we call it. We usually work a code 20-30 minutes unless it is obvious death, then we try to not mess up the bodies to much while explaining to the family they have been dead for a while. No one with liver mortis is coming back.

 

[Christopher]

This is an infinity loop, how does it end?

At 20 minutes or when you get bored.

We don't transport dead bodies. We will work it through 4 or so rounds of epi, if we don't get change we call it. We usually work a code 20-30 minutes unless it is obvious death, then we try to not mess up the bodies to much while explaining to the family they have been dead for a while. No one with liver mortis is coming back.

Time alone is unsupported as a stopping point during attempted resuscitations. Wake Co has shown that a number of CPC1-2 survivors came from arrests worked longer than 45 minutes. The optimal "time" is not known, but 20 minutes is far too short and 30 minutes is probably too short as well.

In fact, I highly doubt we'll ever find the "optimal time".

Termination of resuscitation should be driven by quantitative measures such as end tidal CO2, duration of untransitioned asystole, etc.

 

[rugbyguy]

Termination of resuscitation should be driven by quantitative measures such as end tidal CO2, duration of untransitioned asystole, etc.

That is what I meant. We get a ROSC only during half life of the epi then it is immediately back to asystole and ETCo2 stays awful, and we call it. If they are workable, then we work the hell out of them, but if it's obvious deaths we can measure, then no, we work it for the families sake then call it.

We just had a code where he was cold to the touch, had liver mortis, and a potential down time of 6+ hours. We worked it for 20, did a full round of our CCR and had 0 change, so we called it. Protocols for us is no transport unless there is ROSC that maintains after half life of epi has worn off.

 

[Christopher]

We just had a code where he was cold to the touch, had liver mortis, and a potential down time of 6+ hours. We worked it for 20, did a full round of our CCR and had 0 change, so we called it.

Rigor noted yet resus attempted? Color me confused.

 

[chaz90]

We just had a code where he was cold to the touch, had liver mortis, and a potential down time of 6+ hours. We worked it for 20, did a full round of our CCR and had 0 change, so we called it. Protocols for us is no transport unless there is ROSC that maintains after half life of epi has worn off.

Fair enough to terminate resuscitative efforts there, but why bother attempting at all in that case?

 

[rugbyguy]

Rigor noted yet resus attempted? Color me confused.

Yea we tried to explain it to the wife repeatedly but she kept screaming for us to do something, she is a tax payer and wants the full work done. My partners started to work it as I pulled her aside and explained that we will do everything we can, but with the signs we see (cold, liver mortis, rigor mortis, unknown downtime) that it is highly unlikely we will be able to help him. It was my captains call not mine so we worked it, showed her and explained to her everything as we were doing it and how nothing was improving. She was quiet and watched, and when we finally called it we showed her the ekg's and showed how nothing has changed from when we started to when we finished. It helped her I think and she was finally able to accept it. We called it in, got her some water and sat down and talked with her. I think she just needed to be shown he was without a shadow of a doubt dead. Sucks, but had to do what she wanted.

 

[TransportJockey]

Yea we tried to explain it to the wife repeatedly but she kept screaming for us to do something, she is a tax payer and wants the full work done. My partners started to work it as I pulled her aside and explained that we will do everything we can, but with the signs we see (cold, liver mortis, rigor mortis, unknown downtime) that it is highly unlikely we will be able to help him. It was my captains call not mine so we worked it, showed her and explained to her everything as we were doing it and how nothing was improving. She was quiet and watched, and when we finally called it we showed her the ekg's and showed how nothing has changed from when we started to when we finished. It helped her I think and she was finally able to accept it. We called it in, got her some water and sat down and talked with her. I think she just needed to be shown he was without a shadow of a doubt dead. Sucks, but had to do what she wanted.

Show codes are bad practice. Whether they are on pedis or adults.

 

[rugbyguy]

Show codes are bad practice. Whether they are on pedis or adults.

I don't disagree, but as I said, not my call.