OUT OF HOSPITAL CARDIAC ARREST
The day you get to look up at Reaper and say "Not today", is one of the most amazing parts of this job. We have to understand the goals and the science in order to be successful. One of most challenging parts in resuscitation is staying up-to-date with the information and not letting new and shinny affect tried and true. One example of evidence based practice today shows that EPI saves the heart at the expense of the brain, and we love EPI in rural EMS. Getting providers to limit or avoid EPI can be a real challenge. It’s best to provide this information at reviews or staff training. Not in the moment.
There are so many variables. Load and Go vs Stay and Play. Ami vs Lido vs Proc, Intubate vs Igel. In our limited resources and rural locations we should be very conscience of practice vs modern development. EZ-EMT has compiled a list of suggestions for rural EMS to consider and discuss with you Medical Director. These are middle ground ideas that can potentially change outcomes for the better.
Load and go nowhere. Getting a patient to a stable spot to resuscitate can seriously delay resuscitation. Multiple studies show CPR on the go decreases survival rates. Rushing to a hospital with a CPR in progress, often delays essential oxygenation to vital organs as the quality of CPR drops while rushed or in motion. Work a Code on scene for the first 2-3 cycles minimum. If you practice high quality resuscitation, then work the code in place and use ETCO2 as your guide. Discuss with your medical director about when its appropriate to cease efforts. If ETCO2 remains under 10 for the first 20 minutes might be a good place to start the conversation.
Try to gain history before administering anti-arhythmic medications. It’s rare but undiagnosed H and T history + Amiodorone can keep dead dead. Routine / doesn’t replace critical thinking. -for now check out these 2 links: https://youtu.be/s78pB-sKI9g / https://youtu.be/M0VG7f3GZEY This does not mean replace Ami on the code, but consider the mechanism of action and how it affects the ventricles. I will often reach for Lidocaine if I have no history over Ami. The destructive effects of AMI are more for a perfusing heart and are nominal in a code setting. My questions to family and bystanders are:
Is the patient on any heart medications?
Any heart surgeries or previous heart attacks?
Any medical history not related to heart such as dialysis, diabetes, transplants, cancer?
Unless you have a video laryngiscope and your team trains extensively to intubate a patient getting their chest pounded. ET tubes should not be attempted. Igel is fast and more reliable with limited ALS resources. Igel can be placed by most any level provider. I train my EMT’s to place and bag. I will often have Airway, Pads, Lucas, and IO placed in 30 seconds of the start of resuscitation.
ETCO2 is a must. Nothing can lead a resus better. Be aggressive with watching trends and spikes. With poor cardiac waveform but perfusing ETOC2 numbers, check pulse. ETCO2 waveform capnography can be used with iGel.
Personal opinion, don’t stop every 2 minutes for a pulse check if your ETCO2 doesn’t change. Delay interruptions in CPR in increase oxygenation and CPP.
Don’t stop CPR for defibrillation. With gloves on, Lucas or autopulse in place, defibrillate on the decompression.
The following is an opinion based clip on OHCA. DISCLAIMER: This is an opinion piece emphasizing that in the rural setting, we should desire to excel but not to exceed expectations of those you work with. High quality BLS care can assist high quality ALS care. As I’ve said before I don’t expect ALL my BLS partners to know how to prep a video laryngeoscopy for ET placement, but I do expect all my BLS partners to know how and when to place a iGel and attached WF ETCO2. This doesn’t stop me from training BLS to assist with VL-ET placement.
There are so many variables. Load and Go vs Stay and Play. Ami vs Lido vs Proc, Intubate vs Igel. In our limited resources and rural locations we should be very conscience of practice vs modern development. EZ-EMT has compiled a list of suggestions for rural EMS to consider and discuss with you Medical Director. These are middle ground ideas that can potentially change outcomes for the better.
Load and go nowhere. Getting a patient to a stable spot to resuscitate can seriously delay resuscitation. Multiple studies show CPR on the go decreases survival rates. Rushing to a hospital with a CPR in progress, often delays essential oxygenation to vital organs as the quality of CPR drops while rushed or in motion. Work a Code on scene for the first 2-3 cycles minimum. If you practice high quality resuscitation, then work the code in place and use ETCO2 as your guide. Discuss with your medical director about when its appropriate to cease efforts. If ETCO2 remains under 10 for the first 20 minutes might be a good place to start the conversation.
Try to gain history before administering anti-arhythmic medications. It’s rare but undiagnosed H and T history + Amiodorone can keep dead dead. Routine / doesn’t replace critical thinking. -for now check out these 2 links: https://youtu.be/s78pB-sKI9g / https://youtu.be/M0VG7f3GZEY This does not mean replace Ami on the code, but consider the mechanism of action and how it affects the ventricles. I will often reach for Lidocaine if I have no history over Ami. The destructive effects of AMI are more for a perfusing heart and are nominal in a code setting. My questions to family and bystanders are:
Is the patient on any heart medications?
Any heart surgeries or previous heart attacks?
Any medical history not related to heart such as dialysis, diabetes, transplants, cancer?
Unless you have a video laryngiscope and your team trains extensively to intubate a patient getting their chest pounded. ET tubes should not be attempted. Igel is fast and more reliable with limited ALS resources. Igel can be placed by most any level provider. I train my EMT’s to place and bag. I will often have Airway, Pads, Lucas, and IO placed in 30 seconds of the start of resuscitation.
ETCO2 is a must. Nothing can lead a resus better. Be aggressive with watching trends and spikes. With poor cardiac waveform but perfusing ETOC2 numbers, check pulse. ETCO2 waveform capnography can be used with iGel.
Personal opinion, don’t stop every 2 minutes for a pulse check if your ETCO2 doesn’t change. Delay interruptions in CPR in increase oxygenation and CPP.
Don’t stop CPR for defibrillation. With gloves on, Lucas or autopulse in place, defibrillate on the decompression.
The following is an opinion based clip on OHCA. DISCLAIMER: This is an opinion piece emphasizing that in the rural setting, we should desire to excel but not to exceed expectations of those you work with. High quality BLS care can assist high quality ALS care. As I’ve said before I don’t expect ALL my BLS partners to know how to prep a video laryngeoscopy for ET placement, but I do expect all my BLS partners to know how and when to place a iGel and attached WF ETCO2. This doesn’t stop me from training BLS to assist with VL-ET placement.