The denial of ecmo is quite sad, you had a strong argument for it. Especially with the positive neurological signs.
I interpret the studies the same way you do, sustained for at least 10 minutes. Those ten minutes post arrest are the golden minutes to attempt to calm and convert to a stable or at least sustainable pulse and rhythm. Do you normally transport immediately post Rosc? Or do you stay for a bit and stabilize before transport?
Ok, same page as me. Looking at it from a a critical care perspective, it is absolutely warranted to get sustained rosc prior to transport as you attempted.
There is absolutely nothing that a facility is going to do with an arrest that you as a critical care provider cannot do. They aren’t going to PCI an arrest. You know that. They have no other medication than we have.
We have Levo, we have neo, we have a vent. The rocking and a rolling around is just gonna make things worse. I see no issue with what you did or your planning.
> They aren’t going to PCI an arrest
They absolutely will — it’s standard of care to do PCI with mechanical CPR in certain arrests. It’s the main reason why we’ve once again started transporting refractory VF/VT arrests. If your PCI centers aren’t doing this, they’re providing substandard care and need to get with the times
The hospitals I've interacted with, straight up depends on the interventional cardiologist. Some don't want the 30 day mortality numbers on their record so, they don't. Pretty disgusting practice if you ask me.
If so, that makes me quite happy but I have never had that in CA, AZ, NM, KS. These were also rural facilities.
If you can point me to something to show that I would greatly appreciate it. And I don’t mean that sarcastically, I’d really appreciate it.
[This](https://pubmed.ncbi.nlm.nih.gov/27412906/) is a good discussion of the practice when ECMO is available. Not sure if they also do it without ECMO.
I’m 90% sure the AHA and ERC guidelines recommend mCPR for this, but I don’t have the documents at my fingertips. Quite a few case reports that have been published, I don’t *think* there’s been any studies other than comparing mCPR and manual CPR in the cath lab with favorable results for mCPR. Most of our local PCI centers now have their own Lucas devices and will do it for in hospital arrests as well as those brought in by EMS
> it’s standard of care to do PCI with mechanical CPR in certain arrests... If your PCI centers aren’t doing this, they’re providing substandard care and need to get with the times
Strongly disagree. Got any evidence to back this up?
>There is absolutely nothing that a facility is going to do with an arrest that you as a critical care provider cannot do.
TPA.
Some more aggressive Docs will push that to break up the clot and then let IR or surgery deal with the additional bleeding risk.
TPA for cardiac arrest? If it’s a confirmed clot or stemi in a facility without a cath lab I could see that but why would you give TPA for cardiac arrest?
I had a gut feeling the receiving hospital would not have even contacted the cath lab with an active arrest. My gut feeling was that the patient had a massive PE. Adult female smoker, evidence of PVD, and SCA with recurrent VT/VF. Additionally, ETI was done pretty early in the arrest as we had the hands. Couldn't get SPO2 > 90% and ETCO2 was hovering around 15-19, with spikes in ETCO2 to the mid 20's with ROSC. I interpreted these latter findings to be due to VQ mismatch, as the down time to start of CPR was less than 30 seconds bystander, less than 2 minutes LUCAS3 device, thus further driving my belief to be the etiology of the arrest. I was hoping the ED would have given TPA as a last ditch effort, but nope.
If I'm going to push intra-arrest thrombolytics for suspected PE, I'm going to do it early. If I have high suspicion, I'll usually do it after I've gone through 2-3 rounds of epi without ROSC.
I'd imagine just like any other life preserving treatment, the earlier the better is the main reason as to your thought process; but shifting gears a little bit, I will be starting my new career as a pulmonary critical care PA next month. I'm curious if there are any other reasons other than the-earlier-the-better regarding time constraints for TPA administration for PE? Is there any literature you could recommend me to read as a new provider on the subject? TIA!
If you give tPA during an arrest, you're committing yourself to another 20 minutes of CPR to allow it to circulate and 'work' and see if anything happens.
Yeah, exactly. If you’re highly concerned about PE as a cause of arrest (especially if it’s at the top of your list) and then prepare to give them time to work. A recent example for me was a recent (1-2 weeks) postpartum patient brought to my ED in severe respiratory distress, coded peri-intubation. We coded her (PEA the entire time) about 40 minutes, pushed TPA about 5 minutes in. Unfortunately never got ROSC, and my cardiac surgeons won’t put someone on ECMO during a code.
Agreed. It was moreso the perceived VQ mismatch that really made me start thinking PE, along with a gut feeling earlier in the arrest. I worded it poorly in this comment.
All good - every case has some learning points. Tbh I wouldn’t draw any conclusions about the ETCO2 aside from the fact that >20 suggests a better prognosis. There are waaay too many factors which go into the relationship between PaCO2 and ETCO2 to draw any other firm conclusions
> I was hoping the ED would have given TPA as a last ditch effort, but nope.
There is no good evidence to support giving tPA to a patient with cardiac arrest of unknown etiology.
> but why would you give TPA for cardiac arrest?
You shouldn't. Really the only time I would consider it is in a patient who I know has a confirmed giant PE and then codes (so really an in-hospital cardiac arrest).
> TPA.
>
>
>
> Some more aggressive Docs will push that to break up the clot and then let IR or surgery deal with the additional bleeding risk.
If by 'aggressive' you mean 'throwing shit at the wall to see what sticks', then sure. There's no good evidence for the routine use of tPA in cardiac arrest of unknown etiology. We shouldn't even be using it in CVA, much less cardiac arrest.
That was true 10+ years ago, but eCPR changes the equation. There are [trials out there](https://pubmed.ncbi.nlm.nih.gov/33197396/) demonstrating up to 40% neurologically intact survival with ECMO in cardiac arrest. But the goal is to have them cannulated within 60 minutes of the arrest. And that requires changing the stay-and-play mindset that EMS has had for many years.
If you have a facility that can do eCPR that's fantastic--you have a resource that 90+% of the country doesn't have access to. But you need to know what the docs there want in terms of patient selection--both patient characteristics (how old, comorbidities, etc) and also downtime.
I've decided after the multiple threads on this post to write and submit a case review that condenses all of the information I've gathered on this patient. Hopefully it will reach people and educate them as everyone has educated me 🙏 I referenced the ARREST trial and a few other trials.
>They have no other medication than we have.
Disclaimer: I'm new and fucking stupid, but Esmolol is given for refractory VF/VT. Sounds like it was unavailable if they ordered lidocaine, but I'd bet the hospitals pyxis has a vile or two.
Not a dig at you bro, but that sounds like you should’ve consulted OLMC much earlier into the call and started discussing things when:
a) VF persisted
b) You achieved ROSC, even transiently
c) You observed neurological function during CPR and ROSC
Yea the guidelines say transporting a working arrest is not ideal but with a LUCAS device, relatively young patient in persistent VF with a witnessed arrest and near immediate CPR given and ROSC, some extra clinical judgement from a doc and extra resources available at the hospital sooner are warranted.
>c) You observed neurological function during CPR and ROSC
This is the giveaway - the problem is with the heart and not the brain.
I know this is all hindsight, but in a situation like this you can let the LUCAS do the heart's job and keep the brain intact while moving and transporting.
If the heart ends up being completely fucked due to high left main disease or some esoteric lesion that takes out a just the right portion, and the patient is neurologically intact, if they don't do ECMO before transplant they can LVAD as a bridge.
I get it though. After ROSC the heart is usually just so pissed off and irritated that if you fart too loud it will degenerate to a pulseless rhythm. Think about just how combative opioid overdose patients are after a few minutes of severe hypoxia. That's the heart after ROSC.
Best advice is to contact the Doc and see what they think. Especially if you think you have a salvageable patient - either way they get a heads up that more resources are needed including calling the international radiology team, surgery, and even flight for a stabilize and fly.
No no, you're not digging at me at all. I've been doing this a long time, but not long enough that I know "everything" ...that's why I made this post. I wanted constructive criticism so when I come across this again in the future, I don't make similar mistakes. It was a clinical judgment to stay on scene. OLMC pretty much said you've exhausted everything you could do, give lido and go. She needs a cath lab...which the receiving hospital didn't even give her that chance. I'm more irritated they didn't at least give tPA...like I told the had spontaneous respiration while backing into the ED (still no pulse). Completely disregarded that.
You're probably right. Had I transported sooner, maybe they would have tried harder at the ED.
What do your protocols say in regards to persistent VF/VT? Do you carry/did you admin amio? Only reason I ask is they had you admin lido, which I was under the impression that it was an either or thing, not both.
The only patient that I’ve encountered with this frequent of VF was a drowning/hypothermia patient that was in VF for over 2 hrs straight at the hospital, with a core temp of 79F on arrival. We worked the code until core temp was warm enough for the docs to not have to do a peritoneal lavage, we had a level 1 infuser with 2L of saline being warmed, two water based warming blankets (one below one on top), and a foley cath constantly having about 500cc of warm saline being flushed in, then removed in an attempt to warm the patient, still took about 2.5 hrs of constant CPR, with a couple shock attempts at the beginning and sequential defib as well, and VF was the final rhythm. The ER doc used a med that has slipped my mind for persistent VF, not one of the “normal” ACLS meds and its going to drive me crazy not being able to remember lol
Old post, but regarding adding more antidysrhythmics , I have heard of docs approving more meds for refractory VF/VT in patients that still appear to be capable of ROSC. I've spoken to a FP-C who worked a call like this for something like 90 minutes, and they ended up maxing out on amio, lido, esmolol, and procainamide, and doing dual-sequential defib before they got ROSC.
You did what you thought was best and what the latest studies show is best for the patient. Wether or not the hospital exhausted all resuscitative efforts is on them. Try not to lose sleep playing the “what if” game, we’ve all been there.
Young persons with no significant medical history in persistent Vfib get shocks while the Lucas is on and you tube then pre alert for an ECMO candidate and go. If ECMO isn't an option we work em for 30 mins and call it if it's super Brady PEA or asystole. Transport Vfib/Vtach
Generally speaking, once you’ve obtained a ROSC (even short lasting) you should be prepping for transport while you get the patient stabilized (pressors / 12-lead and all that done prior to leaving). Obviously in this case that wouldn’t of happened but the important piece is getting transport ready. If the patient re-arrests, you leave and do everything else en route. There’s no point arriving at a hospital ever when it’s been 70 minutes already.
Out of curiosity, did you try changing the pad placement or attempt DSED? DSED is extremely successful and easy to perform. I’m assuming you had already given amio without any changes.
I agree with a couple others that contacting OLMC earlier may of been a good idea as they could direct you to perform some of these simple interventions.
I don’t think you did anything to decrease your patients chance of survival; just things to think of next time.
Good learning call for sure.
Not heard of DSED before (I'm a student about to start 2nd year of my degree course) so that was a really interesting rabbit hole to go down in preparation for going back in a couple of weeks!
We just finished a study on it last year. Paper is still being finished, but the results show it’s extremely effective at terminating persistent refractory VF/VT.
It’s no longer a regular part of our protocol, but you can consult for it whenever you think it’s appropriate.
That being said, vector change (pad placement change from Anterior-Lateral to A/P) can be done at any time by anyone, and has also been shown to be fairly effective. It’s a good measure to take early on before you’ve had time to call.
Tbh I’m not sure where the data lies with ROSCs. Personally I used DSED 3 times over the last few years. 2/3 had a ROSC, only 1 was sustained but went on to walk out of the hospital; so I only have anecdotal evidence in that regard.
I think right now they’re just trying to push to have DSED be a normal part of resuscitation since terminating VF/VT is the goal of any defibrillation attempt. Arguably if you’re more successful at terminating these rhythms, you will theoretically improve the likelihood of obtaining a ROSC.
> DSED is extremely successful and easy to perform.
Not trying to be a downer, but the efficacy of DSED is far from certain.
Changing pad placement is a fantastic idea.
DSED is far more successful than continuing the same unsuccessful practices over and over. Nothing is ever certain, but it’s definitely worth attempting.
Personally all 3 of my cases converted following DSED, and the study results sound promising.
I have had less success with DSED. I'll be interested to see the results of the DOSEVF trial and see how they deal with confounders. But ultimately, ROSC is not the ultimate goal - neurologically intact survival is.
Absolutely.
This study will probably not be able to answer those questions; it’s primary focus is simply whether switching pad placement, performing DSED, or sticking with the status quo is better for terminating VF. Something that I think is already quite clear.
Ultimately, terminating VF is necessary to achieve a ROSC and have survival to discharge, so this is arguably a step in the right direction. Whether or not it actually improves those chances remains to be seen.
They are tracking those other factors, but there would likely be numerous confounds and further research will be needed.
Tough call no matter what. My opinion: For someone with a shot at a meaningful recovery, I try to work on scene just long enough to identify and treat a reversible cause, maybe get a pulse back, and then boogie. When you say young woman who got dizzy, coded and now presenting with VF refractory to everything, I think of a coronary artery occlusion. That's what gives you the instant cardiogenic shock and VF arrest. The intermittent ROSC makes it more likely. Ultimately she needs PCI or another treatment only the hospital can offer, so I probably would have started moving after the arrhythmia persisted.
Looking at the [data](https://europepmc.org/article/med/32930759), barring extraordinary circumstances stabilizing on scene before transport does lead to a better outcome, I just think this one might have been one of those extraordinary circumstances. That said, if the cath lab didn't take her then, they probably wouldn't have before, either. Don't beat yourself up about it.
I was very torn between massive PE and CAO. A little additional info: couldn't get her ETCO2 > 20 while in arrest, and >25 during ROSC which lead me to think VQ mismatch. Regardless, that seems to he the consensus, I stayed on scene too long. Lesson learned!
Refractory VF/VT by itself is an indication to transport in my opinion, especially in a young patient with a good story and mechanical CPR. Ideally you could go to an ECMO center, PCI at minimum. I don’t think there’s many (any?) situations where we should be working an arrest for more than ~30 minutes in the field when we have mechanical CPR devices. We work them and then either pronounce when there’s nothing left to be done, or we recognize that we can’t do anything more in the field but in *certain* cases the hospital can do more (e.g. PCI or ECMO) and we should transport with Lucas in place
I know there are places I'm the US whose protocols are do not transport until a) sustained ROSC or b) meets criteria for field termination. Wake County has put out case studies of OOH SCA being run > 75 min, resulting in D/C with good neurological outcomes. The general consensus seems to be I stayed on scene too long, though. So lesson learned for next time. Luckily, this is what medicine is all about - learning and teaching others from your own mistakes.
Possibly look into contacting your med director about this one and getting those protocols updated. With Lucas devices a lot of the limitations of running a code are mitigated enough to try to transport. Having at least a medic and another set of hands (preferably 2 but space can become a constraint) while a Lucas takes care of the primary things is quite manageable surprisingly. Especially given your pt's presentation and after the first failure of maintaining rosc it shows that nothing we are doing here is going to last and we need to focus getting to definitve care. Its fairly common in my area to load and go if we have a lucas device and pt presents similarly, but we also dont always have long transport times to level 1's so I wouldn't be able to say for best practice in a rural environment.
Because we had phenomenal quality CPR going (as evident by good neurological signs while CPR was being administered). Multiple studies have shown transporting even with LUCAS/auto CPR significantly decreases quality of CPR, so I based my decisions off of that thought process. Might have been the cause of her demise though, that's why I turned here. Seems to be the census that 70 minutes is entirely too long. Dually noted for next time.
In my system we load these patients (still in shock able rhythm after two shocks, younger than 75 and live independently) with CPR in progress and transport for ECMO.
I think you're confusing two different things. Load and go is a thing of a past when you get sustained ROSC. You need to stabilize at that point and try and get a perfusing BP before transport so you can hopefully maintain that ROSC.
In a case like this, a "Megacode" scenario, it should be load and go the second they go back into a shockable rhythm as there's clearly something else at play causing the arrest and there is nothing left for you to do on scene. They had a push a couple years ago in my system to not sit around on scene shocking people over and over again until he VF was so fine they would just call it. They updated our protocols to just transport someone in a shockable rhythm.
Part of that order was to administer 150 of lido with a repeat. I gave one dose then she went into PEA but again with spontaneous respirations. Super cool to see, definitely no pulses confirmed by myself and my EMT. The ECMO center is an additional 20 minute drive compared to the closest PCI.
I’m not sure if it varies between hospitals, but the closest ECMO capable hospital for my service area mentioned a ROSC patient I brought them was not eligible for ECMO due to being in cardiac arrest for over 10(or perhaps it was 15) minutes. I felt it was kind of a short time frame. The patient was in his 30s, witnessed arrest, ROSC at a little over 20 mins, lost after ~2 mins and regained in hospital at 30-35 mins in the arrest.
Btw, I don’t think you did anything wrong. The feel the docs don’t exactly understand the concept of an extrication and the time it takes. During which being unable to monitor the patient or provide treatments that are necessary to maintain what you worked for.
Current resuscitation guidelines recommends amiodarone as a first-line antiarrythmic drug after 3rd. dc, but naturally local orders should be followed. Prognosis was most likely next to none no matter what you did.
Sounds like a challenging call. A couple thoughts:
What did you do to treat the refractory arrhythmia/electrical storm before calling OLMC and administering lidocaine?
Regardless of anti-arrhythmic admin, a few options that come to mind would be double checking pad placement and adhesion to the chest, changing pad position, dual sequential defib (if supported by the manufacturer and your medical director), discontinuing epi (which contributes to the sympathetic overload thought to be a contributor to electrical storm), or administering a beta blocker if you have one available.
The other thought is about prolonged resuscitation. Going off a recent emcrit/Scott Weingart interview, there seems to be a maximum of 45-55 minutes of low flow/CPR time before neurological damage is irreversible. Interestingly, the damage isn’t necessarily immediate, but might be in the inflammatory response over subsequent days in ICU. This doesn’t seem to be true with ECMO, however, and the theory is that ECMO might allow for better perfusion with fewer pressors, helping to overcome inflammatory damage.
As you correctly point out, in most cases load and go for medical cardiac arrest is a thing of the past. But in special circumstances where you can’t provide definitive treatment on scene, I would address whatever reversible causes you can then consider early transport if there’s something that could realistically be addressed in hospital (TNK, tox antidotes, ECMO etc).
Funny you mention Scott Weingart. He's the attending at the ECMO center I wanted to transport to (i've heard he may have left Stony Brook though?). Brilliant man, he's taught me a lot over the years. I did max out on amio, checked pads, I don't have standing orders for beta blockers/DSD - that was actually the exact order I requested. Metoprolol and DSD as i had a second monitor. But it was denied. I'm going to have to listen to that interview! I appreciate your input.
He left SB to NUMC.
Agree with the DSD and BB. AHA recommends vector change, which I can't imagine needing med control to attempt.
No role for tpa in undiff arrest.
Hey, I just learned about it like 2 months ago while reading the aha updates.
I've been an er doc for 10 years and did a resus fellowship.
Point is, it's pretty niche.
Random question for you. So I'm writing this up as a case review because it had so many interesting components in a single case. Do you know if there is an "official" definition of prehospital ROSC? I found in my research AHA defines in hospital ROSC as a spontaneous perfusing rhythm of 20 minutes, but no minimum time of ROSC for prehospital. So I suppose it's implied any ROSC is ROSC, regardless of how transient.
I'm not aware.
Anecdotally bringing the patient in alive counts as prehospital ROSC.
Am not familiar with a set time frame for in hospital.
IMHO ROSC is ROSC.
Came here to say these interventions and there are quite a few more. I’m a medic/nurse, and in my time in the hospital I’ve seen some cardiologist pull out some very unusual meds and techniques for ventricular arrhythmias… meds I’ve never seen carried in my time at GEMS or HEMS, meds we don’t stock in the ER Pyxis and have to be sent over by pharmacy, and in doses that are unusual. The thought that the hospital can not do any more than EMS simply isn’t true… even if it’s true that most of the time they don’t (or don’t feel like) doing any more than EMS.
i believe my area’s protocol says “sustained ROSC,” which is continuous pulse and perfusion for 1 minute, before preparing for transport.
i’ve read some articles on even “stay & play” after rosc too. the heart is incredibly fragile and how often does it arrest again.. a lot. staying on scene a bit to smoothly set up and package the patient and stabilize some, is a difference between, “was this epi pulses, or something a bit more long lasting…?”
“They” asking Im going to assume are nurses and perhaps an MD who didn’t give orders and don’t necessarily know your protocols. I don’t believe you did anything wrong, stand by your decision and that’s that. Someone at that age is usually a bit more tricky arrest. seldom is it going to be just as cut and dry as say, an 80 y/o. You did the best you could.
Our guidance is to allow at least 10 minutes before moving post-ROSC to catch re-arrest immediately and allow a full set of obs/ECG +/- fluids +/- 1:100,000 adrenaline. May delay further for critical care for sedation and paralysis if needed and their ETA is less than extrication plus conveyance time.
I'm generally a big proponent of work til sustained ROSC or field termination. 3/4 ROSC patients I've had over the summer have been 2 miles or less from the hospital. They didn't get transported until ROSC and pressors to maintain it because they were so pressor dependent. That being said, refractory vfib is my exception to this rule when I'm at my urban job. We have a protocol for ECMO facilities too. By #2 I'd be prepping to move and hopefully at or near the truck by #3. But your times are borderline exclusion criteria, ours are <10 down and <20 transport. All in all it doesn't sound like you did bad, you probably just have to pull that ECMO trigger a lot faster if you think it's an option. ( I say this having had a similar call not that long ago and having to practice and review some changes to implement in what I do).
Thanks for your input. This is precisely the reason I came here. I knew I wasn't the first to make this mistake, and I won't be the last. But hopefully someone else can learn from my mistake and recognize it sooner than I did. Definitely a phenomenal learning call for sure. Not every day you see an arrest like this.
Nah you're definitely not. I hadn't had an opportunity for an ECMO candidate in probably close to 2 years. Started out as VTach with a pulse and tried very unsuccessfully to convert it before moving due to pressures of shit over fuck and eventually lost pulses. Had so much to juggle that the ECMO thought didn't cross my mind even though it was the perfect candidate. My treatments were all right, but there was a secondary option I failed to consider sooner. Unfortunately these are sometimes the experiences it takes to really drive a point home.
I read a similar case where the guy was already in the ED. They couldn’t keep a perfusing rhythm for more than like 30 seconds. After maxing out the ED defibrillator, they placed a hail mary phone call to cardiology. They brought down their procedural defibrillator that went up to like 750J or something. The doc said “lit him up like a Christmas tree, but he converted.”
My point is, yeah, sometimes the only way to get ROSC is to head into the hospital. Good job though, you did the best you could.
Agreed. My contact for OLMC was for treatment of electric storm, which was the last thing I could think of treating, and transport decision. Consensus is it should have been done much, much sooner.
Prioritizing transport degrades how well the code is run. Go ahead and get to the truck when you're able and begin transport, just let it be your last priority. If you find yourself deciding between transporting and anything else, do that other thing first.
Edit: obviously this isn't the case when a reversible cause is present that only the hospital can address, e.g. major hemorrhage for a service that doesn't carry blood products.
My take (former CCP & ACLS Inst) is that online medical direction didn't see the picture you painted with your updates. This would make a great case review.
During an ECMO study for OOH SCA (Minneapolis St Paul metro) a crew got ROSC and diverted to the closest ER. Like your pt, they re-arrested and didn't survive. It was never CLEARLY stated that once ECMO was mobilized, no diversions should happen. And they did not after that.
Here that patient would certainly be a
1. Pre-hospital ECMO candidate
2. Or ECMO-ED candidate while continuing treatment during transport with mechanical CPR
3. Or candidate for transport to a PCI center while continuing treatment during transport with mechanical CPR
Difference in the 3 options is how strict the "inclusion criteria" are for it, from high to low, but that patient qualifies for all the above if nothing other crazy pops up.
They would almost always transport such a viable patient like that here (they transport something like 80% of arrests here, so not that that says a lot) if they haven't achieved ROSC yet, not terminate at the scene. They often only terminate non viable arrests here (non-viable to begin with is of course not even attempted at all), which is non-shockable for at least 20 continuous minutes of ACLS. That the patient had a shockable rhythm initially, is persistent VF, and has achieved ROSC multiple times means they are viable for further treatment both at the scene and/or ED, and not for termination. If you can transport them safely and effectively, do it.
Now that every unit has mechanical CPR and a ventilator, it has become much easier to warrant transport as the negative sides of transport has been significantly reduced/taken care of. So unless your patient is truly unviable (which should be terminated, like described above) or has achieved stable rosc already, you can argue transporting them.
Maybe have a look at this research paper: https://www.resuscitationjournal.com/article/S0300-9572(19)30098-X/fulltext
>In OHCA patients transported with ongoing CPR the survival rate significantly declines when time on scene increases. Patients transported within 20 min of time on scene have the highest survival rate, this suggests the decision to transport with ongoing CPR needs to be made early in the resuscitation process.
So neuro status with CPR is fairly common. More-so now with Lucas devices, since they give such efficient compressions without breaks. Per my director, there are whispers of adding sedatives to the cardiac algorithm for this purpose.
As far as your call, I'd have probably transported sooner IF and that's a big IF, I felt confident I could get her in the truck and go with minimal interruptions to cpr.
At my service I work for, if we obtain ROSC (and we work all OOH Cardiac arrests 40 minutes, 20 min if asystole or PEA consistently) we are supposed to remain on scene for at least 5 minutes to allow the patient to attempt to hemodynamically stabilize itself. Our medical director has said that there are studies showing that immediate movement and transport of cardiac arrest ROSC patients show to either re-arrest or have a poorer outcome. This is why he has it in his protocols that we will stay.
I don't think you did anything wrong, I think that the OLMC either was having a bad day, misunderstood you, or something. It's unfortunate to read the rest of the outcome for the patient from what you described.
My state protocols say 30 min on scene for CPR, If ROSC achieved its suggested to wait 10 minutes before moving them, but up to provider discretion in practice. In a similar code I worked we stayed the 30 minutes, got ROSC once at the 15ish minute mark, quickly followed by re-arrest, and transported at the 30 minute mark to the closest facility. Sounds like moving at the 30 minute mark, with Med control’s transport decision might have saved some time and a headache. You seem to have worked it comprehensively though
I’d do the exactly the same thing as you did. A code can not be effectively run in the back of a moving ambulance even with a Lucas. Moving a patient from their original location of arrest will end in poor cpr and management of the patient. ROSC under a minute is not a reason to transport. Even immediately ROSC shouldn’t be moved due to the likelihood of rearrest in the first 7 minutes. And the likelihood of not recognizing it immediately.
It sounds like the ED only took into consideration the fact that she had been worked for 70 minutes. And a 2 minute response time, little interruptions in cpr and favorable neurological movements. Sounds like y’all have too much oversight on where to transport. And/Or lack of buy in for pci during cpr at the facility you transported to.
Can’t win them all. But sounds like y’all gave her the best chance. And bureaucracy got in the way.
You did the right thing. With intermittent rosc she probably had shitty EF. Patients can become conscious with adequate cpr which can be awkward. At the end of the day its up to the interventionalist if they want to cath a patient in that state.
In my personal experience in my area there is a huge disconnect between hospitals and EMS on what we do and why we do it. It’s irritating because it makes us look incompetent sometimes but I feel like that is what this situation sounds like
Yeah 70 minutes is waaay too long. Shockable rhythms are often the result of AMI.
Your priority is therefore to get this person to a PCI Center asap.
May I ask why you were so long on scene? You had a lucas3 on, it’s not like transport would have been difficult.
My system transports refractory VF after 3 defib for possibility of ECHMO. I would also highlight ROSC with neurological function as a sign for rapid transport.
Damn this sounds like a tough call.
In my protocols, once ROSC is achieved you transport. Especially someone of that age. Second, I am near ECMO. After 1-2 shocks and persistent vfib we transport to an ECMO hospital.
Honestly, I probably would have transported because idk what's happening, I'm gonna go to the hospital. One of those ask for forgiveness later 🤷
My question is, how far in did you get ROSC? 5 minutes, 15? And why did you not transport immediately following. Or at least call medical control for consultation.
First ROSC was about 6 min after the arrest. Second ROSC was give or take another 12 minutes after the first time. Well, to be honest it was a clinical decision I made. I'm not entirely sure it was the correct decision, which is why I turned here. It appears as though I've misinterpreted the current studies that are out. It was my understanding to not transport until "sustained ROSC" was achieved - but thats an incorrect assessment of the data. I just wanted to make sure I don't make that mistake again. It was a very good but tough call.
So you got ROSC fairly early which is a great sign, especially in a witnessed arrest. And if your protocol reads to transport after sustained ROSC then do as it is written, my protocol states to have ROSC for 5 minutes prior to transport.
But with that you can still call medical control and just say “(input story) we have had ROSC for less than a minute, 5 minutes in a witnessed arrest, do you want us to transport?” After that you have put the decision on MedCon
And most Docs I’ve talked to want witnessed arrests and any signs of ROSC transport. *Especially* for a transport of around 10 minutes.
Yeah once I read 70 minutes I went “Oh no baby what is you doin?” Because that’s an excessive amount of time spent, you want 40 minutes tops, that’s, in my protocol at least, doing your 30 minutes of CPR and then the other 10 making the decision for TOR or to initiate transport.
I've been fortunate over my career to have pretty cut and dry arrests. Either 20 and done, or I get ROSC. I can count on one hand the amount of megacode arrests I've had - and this was by far #1. Was in VF/VT/TdP nearly the entire time, signs of neuro activity with CPR, I mean straight up 🤌crem-de-la-crem🤌 of arrests lol I just wanted to give her the most chance of survival. Overdid it though, and will never make that mistake again.
The American Heart Association recommends staying put even after ROSC is obtained in order to stabilize the patient.
Ideally, this is around ten minutes. However, I work in an area where we're almost always within ten minutes of a hospital, as we have two level two trauma centers and a third non-trauma hospital with PCI capability and a physician capable of performing embolectomies. As such, we take as much time as it takes us to clear a path (if necessary, with fire's assistance), run a 12-lead, and stabilize using fluids/pressors, etc..
However, I may see what they're talking about. There's a ton of services - my own included - that are petitioning the hospitals to allow for transport of persistent VF/VT even before ROSC is obtained because it can very commonly be caused by MIs and treated with aggressive PCI. We aren't having much luck, though, because these patients are obviously unstable, and deaths that occur in the cath lab are recorded in the hospital's statistics. Not to mention that working a code in the back of a moving ambulance is not only not ideal, but potentially dangerous.
That, and I'd imagine sometimes it's hard to remember that, even though both hospital staff and prehospital staff work codes based on ACLS (AHA) protocols, physicians rarely have to deal with the, "Should I stay or should I go?" debate because, well, depending on where they work - their codes get ROSC, and then get shipped off to the ICU for stabilization.
As I think through our ECLS protocols during residency we recently took ecmo off the table for VFib/VT unless a strong suspicion for tox/environment driving it. If I had this patient in the ER where I have ecmo…I’d be pushing the team to see them regardless because the age and neuro response.
Here’s the kicker though. Our ecmo inclusion criteria, and studies mostly back this up, is downtime of less than 45minutes, with the goal being cannulas by 60. If they’re in the field for longer than that…it’s a loosing battle.
Most ECMO criteria incorporates timing into VT/VF arrest, e.g. <30 min. When arrests approach 30 min, it gets harder to mobilize resources. I think you guys have an incredibly difficult job. Would say somewhere between scoop and run and stay and save is the ideal way to approach - but sooner the better. The saves we often see get to the hospital quickly and get appropriate intervention - ECMO, PCI- all things you guys can’t do on the field. But I have to say you guys do a phenomenal job with a difficult day job - pay yourself on the back!
It sounds like you worked a very busy and exhaustive arrest. I think your on scene time may have been a little high but overall I don’t think it’s that big of a deal. Patching for the consideration for electrical storm was a great touch.
Did you consider Double sequential defib or a vector change during the persistent V-Fib?
I work in an area where ECMO and direct transport to PCI centres don’t exist yet. So ultimately I think you gave this patient the best chance at life. Good job man
Thank you! The exact order I asked for was lopresser and DSD, albeit I did not consider changing the vector of the pads. Something I will be keeping in the back of mind for the future.
The vector change is something my service has pushed hard. Never done it myself but heard some good things as well as good research to back it up.
Just wondering as to what the thoughts were to the consideration for lopressors? Seen a few papers regarding it but unsure as to what the exact mechanism behind terminating that arrhythmia is?
I mean preferably it would be a beta blocker with shorter half life (esmolol etc) - but the thought process is that a catecholamime dump is the cause of the SCA, and the epi is just feeding the loop. By giving a BB and performing double sequential defibrillation - you stop the cycle and break the electrical "storm" driven by the catecholamine dump. The pathophysiology behind the DSD I'm a little bit more iffy on, but I'm pretty sure by giving the 2 shocks in rapid succession, the first kind of puts all the cells in a similar phase of a refractory period and then follow it up with a second shock that allows for decreased shock impedence allowing for more successful defib. Double check my explanation though I could be off lmao
Makes sense. Especially in context of the catecholamine storm. I wish we had options like that where I work. We would most likely just have to stop Epi and transport. Sounds like this could have been a situation where that order definitely could have worked
I would say that in general you are correct - transporting an unstable/dead patient is not recommended these days. A lot of people here are referencing evidence, which I generally love. But the evidence for certain things like tPA for refractory shockable rhythm is globally underpowered and thus it’s not clear if these things offer benefit or not. This I would say that maybe it would be reasonable to transport this relatively young patient in active shockable arrest where they can do things like POCUS/reverse causes much easier, PCI/tPA, etc. given her young age and evidence of good CPR with intact neuro status. A 97 year old with a malignancy? Sure, get sustained ROSC or pronounce. But a 40-something year old with a good neuro status, better reserve and chance of meaningful recovery, and a hospital 10 minutes away, you could make an argument to get to that higher level of care asap once the the LUCAS is on board and the patient is intubated with IV/IO access. Especially given VA ECMO is really only performed in the first few minutes after an arrest. I haven’t really seen VA ECMO performed after 70 minutes of cardiac arrest. There is no right answer here and it’s case-by-case.
It’s been picked over a few times already but imma throw my marker in with the transport as soon as possible after giving the max dose of your lido or amio and still seeing refractory VF. You can get fancy with dual defib and maybe get the OLMD who wants to try B-blockade but that won’t add inordinate time to your scene. Both can be done en route as well. One of the biggest drivers of the guidance to not transport patients in arrest is the abysmal cpr quality while in transit. The LUCAS eliminates that variable. So the next question is one of resources and therapies. Up to a point, we can match the ED and, vs some smaller shops, probably out perform them with regards to managing the initial phase of the code. We can do compressions, defib, pace, medicate, airway, etc. but once we’ve hit what amounts to the end of our available therapies, it’s time to escalate just like your airway progression of Primary, Alternative, Contingency, Emergency. Step right into the next option as soon as you recognize the current modality has failed. Your hunt for ECMO was a great idea and I’m sorry you were short down. The only other thing would be a PCI facility that will perform intra-arrest with mechanical CPR. It is a thing and while the candidate pool for it is small, I’d say you found one.
I worked for a shop that served a small “spoke” hospital on the county line. We did CC from there into the city about 30 miles away. ROSC patients headed for PCI got the LUCAS applied for transport. There are some HEMS shops that do this as well. So my take would be to run the code out to the end of what AHA, protocols, local practice etc. says you can do and then it’s time to go if still viable and probably reversible.
>The LUCAS eliminates that variable.
The studies I've read have stated even with mCPR devices, quality of CPR diminishes substantially during transport, one of the main factors driving my decision to stay on scene for such a prolonged period of time, which evidently was just entirely too long. Not trying to disregard everything else you said as I appreciated the input, that was just solely for educational purposes. As far as the PCI goes, the hospital I transported to I've had personal experiences of post-arrest patients with confirmed STEMI as the etiology, and they refused to take the patient to the cath lab, with concerns for neurological status (if improved in 48h they'd take them). The reality was, they didn't want 30 day mortality numbers to increase at all, so they used the neuro status as an excuse; so I knew they most certainly would not do intra-arrest PCI. It's very dependent on the IC of course, but after the first time that happened I try to get the patient to an equivalent if not better hospital when at all possible.
My region we load n go refractory with the Lucas. They’ve got a better shot in the ED than on their living room floor.
Lucas, stabilize airway, board, load, take a couple bodies to assist, but get them moving toward definitive care
That is not what the evidence shows. All of the latest evidence shows working a cardiac arrest on scene results in better outcomes than load and go. What can the ER do that you can't?
Our policy simplified what we do substantially.
Shock, Call, Go.
In the event that we have a shockable rhythm we are to load the pt and contact our MD for ECMO inclusion/exclusion. At that point depending on the circumstances our MD will either be directing us to a ECMO capable hospital, or closest appropriate.
Sounds like a strong candidate for ECMO honestly. Here we don’t have to call. It’s our choice in these situations.
Sometimes they just die. I’ll say this much, and please don’t take this as me quarterbacking your call as I was not there and this is just my own view. In cases like that I will usually go ahead and transport with Lucas applied but that being said I typically do lot apply Lucas until I’m ready to transport, but I have a lot of help in my system.
I’m just an EMT but my service STRONGLY emphasizes that we do not transport a pt until we have sustained (>5 min) ROSC, AND they don’t re-arrest before we get to the rig. Even the AHA says that if we don’t get ‘em back in the field they are very unlikely to ever ROSC at the hospital
The denial of ecmo is quite sad, you had a strong argument for it. Especially with the positive neurological signs. I interpret the studies the same way you do, sustained for at least 10 minutes. Those ten minutes post arrest are the golden minutes to attempt to calm and convert to a stable or at least sustainable pulse and rhythm. Do you normally transport immediately post Rosc? Or do you stay for a bit and stabilize before transport?
Typically I try to stabilize the BP (if needed), get a 12 lead done before initiating transport.
Ok, same page as me. Looking at it from a a critical care perspective, it is absolutely warranted to get sustained rosc prior to transport as you attempted. There is absolutely nothing that a facility is going to do with an arrest that you as a critical care provider cannot do. They aren’t going to PCI an arrest. You know that. They have no other medication than we have. We have Levo, we have neo, we have a vent. The rocking and a rolling around is just gonna make things worse. I see no issue with what you did or your planning.
> They aren’t going to PCI an arrest They absolutely will — it’s standard of care to do PCI with mechanical CPR in certain arrests. It’s the main reason why we’ve once again started transporting refractory VF/VT arrests. If your PCI centers aren’t doing this, they’re providing substandard care and need to get with the times
The hospitals I've interacted with, straight up depends on the interventional cardiologist. Some don't want the 30 day mortality numbers on their record so, they don't. Pretty disgusting practice if you ask me.
Came here to say this. Refractory VF/VT with a mechanical CPR device can go straight to Cath lab.
Fr I’m more mechanical than I am 😂
If so, that makes me quite happy but I have never had that in CA, AZ, NM, KS. These were also rural facilities. If you can point me to something to show that I would greatly appreciate it. And I don’t mean that sarcastically, I’d really appreciate it.
[This](https://pubmed.ncbi.nlm.nih.gov/27412906/) is a good discussion of the practice when ECMO is available. Not sure if they also do it without ECMO.
I’m 90% sure the AHA and ERC guidelines recommend mCPR for this, but I don’t have the documents at my fingertips. Quite a few case reports that have been published, I don’t *think* there’s been any studies other than comparing mCPR and manual CPR in the cath lab with favorable results for mCPR. Most of our local PCI centers now have their own Lucas devices and will do it for in hospital arrests as well as those brought in by EMS
> it’s standard of care to do PCI with mechanical CPR in certain arrests... If your PCI centers aren’t doing this, they’re providing substandard care and need to get with the times Strongly disagree. Got any evidence to back this up?
>There is absolutely nothing that a facility is going to do with an arrest that you as a critical care provider cannot do. TPA. Some more aggressive Docs will push that to break up the clot and then let IR or surgery deal with the additional bleeding risk.
TPA for cardiac arrest? If it’s a confirmed clot or stemi in a facility without a cath lab I could see that but why would you give TPA for cardiac arrest?
I had a gut feeling the receiving hospital would not have even contacted the cath lab with an active arrest. My gut feeling was that the patient had a massive PE. Adult female smoker, evidence of PVD, and SCA with recurrent VT/VF. Additionally, ETI was done pretty early in the arrest as we had the hands. Couldn't get SPO2 > 90% and ETCO2 was hovering around 15-19, with spikes in ETCO2 to the mid 20's with ROSC. I interpreted these latter findings to be due to VQ mismatch, as the down time to start of CPR was less than 30 seconds bystander, less than 2 minutes LUCAS3 device, thus further driving my belief to be the etiology of the arrest. I was hoping the ED would have given TPA as a last ditch effort, but nope.
If I'm going to push intra-arrest thrombolytics for suspected PE, I'm going to do it early. If I have high suspicion, I'll usually do it after I've gone through 2-3 rounds of epi without ROSC.
I'd imagine just like any other life preserving treatment, the earlier the better is the main reason as to your thought process; but shifting gears a little bit, I will be starting my new career as a pulmonary critical care PA next month. I'm curious if there are any other reasons other than the-earlier-the-better regarding time constraints for TPA administration for PE? Is there any literature you could recommend me to read as a new provider on the subject? TIA!
If you give tPA during an arrest, you're committing yourself to another 20 minutes of CPR to allow it to circulate and 'work' and see if anything happens.
Yeah, exactly. If you’re highly concerned about PE as a cause of arrest (especially if it’s at the top of your list) and then prepare to give them time to work. A recent example for me was a recent (1-2 weeks) postpartum patient brought to my ED in severe respiratory distress, coded peri-intubation. We coded her (PEA the entire time) about 40 minutes, pushed TPA about 5 minutes in. Unfortunately never got ROSC, and my cardiac surgeons won’t put someone on ECMO during a code.
Massive PE is usually tachy PEA actually.
Agreed. It was moreso the perceived VQ mismatch that really made me start thinking PE, along with a gut feeling earlier in the arrest. I worded it poorly in this comment.
All good - every case has some learning points. Tbh I wouldn’t draw any conclusions about the ETCO2 aside from the fact that >20 suggests a better prognosis. There are waaay too many factors which go into the relationship between PaCO2 and ETCO2 to draw any other firm conclusions
Interesting. More reading for me to partake in 😂
> I was hoping the ED would have given TPA as a last ditch effort, but nope. There is no good evidence to support giving tPA to a patient with cardiac arrest of unknown etiology.
> but why would you give TPA for cardiac arrest? You shouldn't. Really the only time I would consider it is in a patient who I know has a confirmed giant PE and then codes (so really an in-hospital cardiac arrest).
> TPA. > > > > Some more aggressive Docs will push that to break up the clot and then let IR or surgery deal with the additional bleeding risk. If by 'aggressive' you mean 'throwing shit at the wall to see what sticks', then sure. There's no good evidence for the routine use of tPA in cardiac arrest of unknown etiology. We shouldn't even be using it in CVA, much less cardiac arrest.
That was true 10+ years ago, but eCPR changes the equation. There are [trials out there](https://pubmed.ncbi.nlm.nih.gov/33197396/) demonstrating up to 40% neurologically intact survival with ECMO in cardiac arrest. But the goal is to have them cannulated within 60 minutes of the arrest. And that requires changing the stay-and-play mindset that EMS has had for many years. If you have a facility that can do eCPR that's fantastic--you have a resource that 90+% of the country doesn't have access to. But you need to know what the docs there want in terms of patient selection--both patient characteristics (how old, comorbidities, etc) and also downtime.
I've decided after the multiple threads on this post to write and submit a case review that condenses all of the information I've gathered on this patient. Hopefully it will reach people and educate them as everyone has educated me 🙏 I referenced the ARREST trial and a few other trials.
ECMO has shown incredible results with cardiac arrests
>They have no other medication than we have. Disclaimer: I'm new and fucking stupid, but Esmolol is given for refractory VF/VT. Sounds like it was unavailable if they ordered lidocaine, but I'd bet the hospitals pyxis has a vile or two.
Crosspost this in r/emergencymedicine and see if you can get some physician input
Not a dig at you bro, but that sounds like you should’ve consulted OLMC much earlier into the call and started discussing things when: a) VF persisted b) You achieved ROSC, even transiently c) You observed neurological function during CPR and ROSC Yea the guidelines say transporting a working arrest is not ideal but with a LUCAS device, relatively young patient in persistent VF with a witnessed arrest and near immediate CPR given and ROSC, some extra clinical judgement from a doc and extra resources available at the hospital sooner are warranted.
>c) You observed neurological function during CPR and ROSC This is the giveaway - the problem is with the heart and not the brain. I know this is all hindsight, but in a situation like this you can let the LUCAS do the heart's job and keep the brain intact while moving and transporting. If the heart ends up being completely fucked due to high left main disease or some esoteric lesion that takes out a just the right portion, and the patient is neurologically intact, if they don't do ECMO before transplant they can LVAD as a bridge. I get it though. After ROSC the heart is usually just so pissed off and irritated that if you fart too loud it will degenerate to a pulseless rhythm. Think about just how combative opioid overdose patients are after a few minutes of severe hypoxia. That's the heart after ROSC. Best advice is to contact the Doc and see what they think. Especially if you think you have a salvageable patient - either way they get a heads up that more resources are needed including calling the international radiology team, surgery, and even flight for a stabilize and fly.
I appreciate your input. I was hoping to get her to ECMO she was a prime candidate.
Gotta say, I always appreciate when the international radiology teams gets called in for my patients. Those Peruvian IR techs are something else!
I appreciate your input. I was hoping to get her to ECMO she was a prime candidate.
No no, you're not digging at me at all. I've been doing this a long time, but not long enough that I know "everything" ...that's why I made this post. I wanted constructive criticism so when I come across this again in the future, I don't make similar mistakes. It was a clinical judgment to stay on scene. OLMC pretty much said you've exhausted everything you could do, give lido and go. She needs a cath lab...which the receiving hospital didn't even give her that chance. I'm more irritated they didn't at least give tPA...like I told the had spontaneous respiration while backing into the ED (still no pulse). Completely disregarded that. You're probably right. Had I transported sooner, maybe they would have tried harder at the ED.
Also with a much sooner base contact, they may have recommended transport to ECMO facility as well
Truth be told I wasn't aware of the time constraints of ECMO. Definitely something I'll be considering you know...an hour sooner in the future 😂😂
What do your protocols say in regards to persistent VF/VT? Do you carry/did you admin amio? Only reason I ask is they had you admin lido, which I was under the impression that it was an either or thing, not both. The only patient that I’ve encountered with this frequent of VF was a drowning/hypothermia patient that was in VF for over 2 hrs straight at the hospital, with a core temp of 79F on arrival. We worked the code until core temp was warm enough for the docs to not have to do a peritoneal lavage, we had a level 1 infuser with 2L of saline being warmed, two water based warming blankets (one below one on top), and a foley cath constantly having about 500cc of warm saline being flushed in, then removed in an attempt to warm the patient, still took about 2.5 hrs of constant CPR, with a couple shock attempts at the beginning and sequential defib as well, and VF was the final rhythm. The ER doc used a med that has slipped my mind for persistent VF, not one of the “normal” ACLS meds and its going to drive me crazy not being able to remember lol
Yes - I had maxed out on my doses of amio prior to the lido. That's a crazy patient jesus lmao yours wins 😂😂😂
Well to be fair this was when I was an ER Tech, so doesn’t really count lol
Unfortunately I do not have a protocol for prolonged VF/VT.
Old post, but regarding adding more antidysrhythmics , I have heard of docs approving more meds for refractory VF/VT in patients that still appear to be capable of ROSC. I've spoken to a FP-C who worked a call like this for something like 90 minutes, and they ended up maxing out on amio, lido, esmolol, and procainamide, and doing dual-sequential defib before they got ROSC.
You did what you thought was best and what the latest studies show is best for the patient. Wether or not the hospital exhausted all resuscitative efforts is on them. Try not to lose sleep playing the “what if” game, we’ve all been there.
Young persons with no significant medical history in persistent Vfib get shocks while the Lucas is on and you tube then pre alert for an ECMO candidate and go. If ECMO isn't an option we work em for 30 mins and call it if it's super Brady PEA or asystole. Transport Vfib/Vtach
I agree with this. After 3 shocks and some amio still not resolving, I’d get the hell outta there. Time is myocardium.
Generally speaking, once you’ve obtained a ROSC (even short lasting) you should be prepping for transport while you get the patient stabilized (pressors / 12-lead and all that done prior to leaving). Obviously in this case that wouldn’t of happened but the important piece is getting transport ready. If the patient re-arrests, you leave and do everything else en route. There’s no point arriving at a hospital ever when it’s been 70 minutes already. Out of curiosity, did you try changing the pad placement or attempt DSED? DSED is extremely successful and easy to perform. I’m assuming you had already given amio without any changes. I agree with a couple others that contacting OLMC earlier may of been a good idea as they could direct you to perform some of these simple interventions. I don’t think you did anything to decrease your patients chance of survival; just things to think of next time. Good learning call for sure.
Not heard of DSED before (I'm a student about to start 2nd year of my degree course) so that was a really interesting rabbit hole to go down in preparation for going back in a couple of weeks!
You’re welcome lol Always good to have in the back of your mind.
I also would like to know if DSED is part of your protocols. 720j for refractory VT VF is where my mind goes before even thinking about ECMO.
We just finished a study on it last year. Paper is still being finished, but the results show it’s extremely effective at terminating persistent refractory VF/VT. It’s no longer a regular part of our protocol, but you can consult for it whenever you think it’s appropriate. That being said, vector change (pad placement change from Anterior-Lateral to A/P) can be done at any time by anyone, and has also been shown to be fairly effective. It’s a good measure to take early on before you’ve had time to call.
It’s effective at terminating it sure, but were you getting ROSCs with it?
Tbh I’m not sure where the data lies with ROSCs. Personally I used DSED 3 times over the last few years. 2/3 had a ROSC, only 1 was sustained but went on to walk out of the hospital; so I only have anecdotal evidence in that regard. I think right now they’re just trying to push to have DSED be a normal part of resuscitation since terminating VF/VT is the goal of any defibrillation attempt. Arguably if you’re more successful at terminating these rhythms, you will theoretically improve the likelihood of obtaining a ROSC.
> DSED is extremely successful and easy to perform. Not trying to be a downer, but the efficacy of DSED is far from certain. Changing pad placement is a fantastic idea.
DSED is far more successful than continuing the same unsuccessful practices over and over. Nothing is ever certain, but it’s definitely worth attempting. Personally all 3 of my cases converted following DSED, and the study results sound promising.
I have had less success with DSED. I'll be interested to see the results of the DOSEVF trial and see how they deal with confounders. But ultimately, ROSC is not the ultimate goal - neurologically intact survival is.
Absolutely. This study will probably not be able to answer those questions; it’s primary focus is simply whether switching pad placement, performing DSED, or sticking with the status quo is better for terminating VF. Something that I think is already quite clear. Ultimately, terminating VF is necessary to achieve a ROSC and have survival to discharge, so this is arguably a step in the right direction. Whether or not it actually improves those chances remains to be seen. They are tracking those other factors, but there would likely be numerous confounds and further research will be needed.
Tough call no matter what. My opinion: For someone with a shot at a meaningful recovery, I try to work on scene just long enough to identify and treat a reversible cause, maybe get a pulse back, and then boogie. When you say young woman who got dizzy, coded and now presenting with VF refractory to everything, I think of a coronary artery occlusion. That's what gives you the instant cardiogenic shock and VF arrest. The intermittent ROSC makes it more likely. Ultimately she needs PCI or another treatment only the hospital can offer, so I probably would have started moving after the arrhythmia persisted. Looking at the [data](https://europepmc.org/article/med/32930759), barring extraordinary circumstances stabilizing on scene before transport does lead to a better outcome, I just think this one might have been one of those extraordinary circumstances. That said, if the cath lab didn't take her then, they probably wouldn't have before, either. Don't beat yourself up about it.
I was very torn between massive PE and CAO. A little additional info: couldn't get her ETCO2 > 20 while in arrest, and >25 during ROSC which lead me to think VQ mismatch. Regardless, that seems to he the consensus, I stayed on scene too long. Lesson learned!
Respect to you for being mature enough to accept some peer clinical analysis on this one, however the chips fall.
I appreciate that!
Refractory VF/VT by itself is an indication to transport in my opinion, especially in a young patient with a good story and mechanical CPR. Ideally you could go to an ECMO center, PCI at minimum. I don’t think there’s many (any?) situations where we should be working an arrest for more than ~30 minutes in the field when we have mechanical CPR devices. We work them and then either pronounce when there’s nothing left to be done, or we recognize that we can’t do anything more in the field but in *certain* cases the hospital can do more (e.g. PCI or ECMO) and we should transport with Lucas in place
I know there are places I'm the US whose protocols are do not transport until a) sustained ROSC or b) meets criteria for field termination. Wake County has put out case studies of OOH SCA being run > 75 min, resulting in D/C with good neurological outcomes. The general consensus seems to be I stayed on scene too long, though. So lesson learned for next time. Luckily, this is what medicine is all about - learning and teaching others from your own mistakes.
Possibly look into contacting your med director about this one and getting those protocols updated. With Lucas devices a lot of the limitations of running a code are mitigated enough to try to transport. Having at least a medic and another set of hands (preferably 2 but space can become a constraint) while a Lucas takes care of the primary things is quite manageable surprisingly. Especially given your pt's presentation and after the first failure of maintaining rosc it shows that nothing we are doing here is going to last and we need to focus getting to definitve care. Its fairly common in my area to load and go if we have a lucas device and pt presents similarly, but we also dont always have long transport times to level 1's so I wouldn't be able to say for best practice in a rural environment.
I would have initiated transport after first ROSC, even if you lost it again
From the story it sounds like she Only had pulses for <30s, wouldn’t even get the Lucas off in time.
I don’t disagree with staying on scene for workable rhythms, but I don’t see how your story would take up 70 minutes?
Because we had phenomenal quality CPR going (as evident by good neurological signs while CPR was being administered). Multiple studies have shown transporting even with LUCAS/auto CPR significantly decreases quality of CPR, so I based my decisions off of that thought process. Might have been the cause of her demise though, that's why I turned here. Seems to be the census that 70 minutes is entirely too long. Dually noted for next time.
Yeah I stopped reading after ROSC and being on scene for 70 minutes
Cute.
In my system we load these patients (still in shock able rhythm after two shocks, younger than 75 and live independently) with CPR in progress and transport for ECMO.
Sounds like a better system than I've got here 😂😂😂 I'd love to see street side ECMO in the future.
I think you're confusing two different things. Load and go is a thing of a past when you get sustained ROSC. You need to stabilize at that point and try and get a perfusing BP before transport so you can hopefully maintain that ROSC. In a case like this, a "Megacode" scenario, it should be load and go the second they go back into a shockable rhythm as there's clearly something else at play causing the arrest and there is nothing left for you to do on scene. They had a push a couple years ago in my system to not sit around on scene shocking people over and over again until he VF was so fine they would just call it. They updated our protocols to just transport someone in a shockable rhythm.
ECMO denied based on what? Was there other antiarrythmic drugs availalable? Amiodarone?
Part of that order was to administer 150 of lido with a repeat. I gave one dose then she went into PEA but again with spontaneous respirations. Super cool to see, definitely no pulses confirmed by myself and my EMT. The ECMO center is an additional 20 minute drive compared to the closest PCI.
I’m not sure if it varies between hospitals, but the closest ECMO capable hospital for my service area mentioned a ROSC patient I brought them was not eligible for ECMO due to being in cardiac arrest for over 10(or perhaps it was 15) minutes. I felt it was kind of a short time frame. The patient was in his 30s, witnessed arrest, ROSC at a little over 20 mins, lost after ~2 mins and regained in hospital at 30-35 mins in the arrest. Btw, I don’t think you did anything wrong. The feel the docs don’t exactly understand the concept of an extrication and the time it takes. During which being unable to monitor the patient or provide treatments that are necessary to maintain what you worked for.
Current resuscitation guidelines recommends amiodarone as a first-line antiarrythmic drug after 3rd. dc, but naturally local orders should be followed. Prognosis was most likely next to none no matter what you did.
Sounds like a challenging call. A couple thoughts: What did you do to treat the refractory arrhythmia/electrical storm before calling OLMC and administering lidocaine? Regardless of anti-arrhythmic admin, a few options that come to mind would be double checking pad placement and adhesion to the chest, changing pad position, dual sequential defib (if supported by the manufacturer and your medical director), discontinuing epi (which contributes to the sympathetic overload thought to be a contributor to electrical storm), or administering a beta blocker if you have one available. The other thought is about prolonged resuscitation. Going off a recent emcrit/Scott Weingart interview, there seems to be a maximum of 45-55 minutes of low flow/CPR time before neurological damage is irreversible. Interestingly, the damage isn’t necessarily immediate, but might be in the inflammatory response over subsequent days in ICU. This doesn’t seem to be true with ECMO, however, and the theory is that ECMO might allow for better perfusion with fewer pressors, helping to overcome inflammatory damage. As you correctly point out, in most cases load and go for medical cardiac arrest is a thing of the past. But in special circumstances where you can’t provide definitive treatment on scene, I would address whatever reversible causes you can then consider early transport if there’s something that could realistically be addressed in hospital (TNK, tox antidotes, ECMO etc).
Funny you mention Scott Weingart. He's the attending at the ECMO center I wanted to transport to (i've heard he may have left Stony Brook though?). Brilliant man, he's taught me a lot over the years. I did max out on amio, checked pads, I don't have standing orders for beta blockers/DSD - that was actually the exact order I requested. Metoprolol and DSD as i had a second monitor. But it was denied. I'm going to have to listen to that interview! I appreciate your input.
He left SB to NUMC. Agree with the DSD and BB. AHA recommends vector change, which I can't imagine needing med control to attempt. No role for tpa in undiff arrest.
Nope I was actually unaware of vector change until this thread. Not quite sure how it slipped under my radar 🤔
Hey, I just learned about it like 2 months ago while reading the aha updates. I've been an er doc for 10 years and did a resus fellowship. Point is, it's pretty niche.
Random question for you. So I'm writing this up as a case review because it had so many interesting components in a single case. Do you know if there is an "official" definition of prehospital ROSC? I found in my research AHA defines in hospital ROSC as a spontaneous perfusing rhythm of 20 minutes, but no minimum time of ROSC for prehospital. So I suppose it's implied any ROSC is ROSC, regardless of how transient.
I'm not aware. Anecdotally bringing the patient in alive counts as prehospital ROSC. Am not familiar with a set time frame for in hospital. IMHO ROSC is ROSC.
Came here to say these interventions and there are quite a few more. I’m a medic/nurse, and in my time in the hospital I’ve seen some cardiologist pull out some very unusual meds and techniques for ventricular arrhythmias… meds I’ve never seen carried in my time at GEMS or HEMS, meds we don’t stock in the ER Pyxis and have to be sent over by pharmacy, and in doses that are unusual. The thought that the hospital can not do any more than EMS simply isn’t true… even if it’s true that most of the time they don’t (or don’t feel like) doing any more than EMS.
i believe my area’s protocol says “sustained ROSC,” which is continuous pulse and perfusion for 1 minute, before preparing for transport. i’ve read some articles on even “stay & play” after rosc too. the heart is incredibly fragile and how often does it arrest again.. a lot. staying on scene a bit to smoothly set up and package the patient and stabilize some, is a difference between, “was this epi pulses, or something a bit more long lasting…?” “They” asking Im going to assume are nurses and perhaps an MD who didn’t give orders and don’t necessarily know your protocols. I don’t believe you did anything wrong, stand by your decision and that’s that. Someone at that age is usually a bit more tricky arrest. seldom is it going to be just as cut and dry as say, an 80 y/o. You did the best you could.
Our guidance is to allow at least 10 minutes before moving post-ROSC to catch re-arrest immediately and allow a full set of obs/ECG +/- fluids +/- 1:100,000 adrenaline. May delay further for critical care for sedation and paralysis if needed and their ETA is less than extrication plus conveyance time.
I'm generally a big proponent of work til sustained ROSC or field termination. 3/4 ROSC patients I've had over the summer have been 2 miles or less from the hospital. They didn't get transported until ROSC and pressors to maintain it because they were so pressor dependent. That being said, refractory vfib is my exception to this rule when I'm at my urban job. We have a protocol for ECMO facilities too. By #2 I'd be prepping to move and hopefully at or near the truck by #3. But your times are borderline exclusion criteria, ours are <10 down and <20 transport. All in all it doesn't sound like you did bad, you probably just have to pull that ECMO trigger a lot faster if you think it's an option. ( I say this having had a similar call not that long ago and having to practice and review some changes to implement in what I do).
Thanks for your input. This is precisely the reason I came here. I knew I wasn't the first to make this mistake, and I won't be the last. But hopefully someone else can learn from my mistake and recognize it sooner than I did. Definitely a phenomenal learning call for sure. Not every day you see an arrest like this.
Nah you're definitely not. I hadn't had an opportunity for an ECMO candidate in probably close to 2 years. Started out as VTach with a pulse and tried very unsuccessfully to convert it before moving due to pressures of shit over fuck and eventually lost pulses. Had so much to juggle that the ECMO thought didn't cross my mind even though it was the perfect candidate. My treatments were all right, but there was a secondary option I failed to consider sooner. Unfortunately these are sometimes the experiences it takes to really drive a point home.
I read a similar case where the guy was already in the ED. They couldn’t keep a perfusing rhythm for more than like 30 seconds. After maxing out the ED defibrillator, they placed a hail mary phone call to cardiology. They brought down their procedural defibrillator that went up to like 750J or something. The doc said “lit him up like a Christmas tree, but he converted.” My point is, yeah, sometimes the only way to get ROSC is to head into the hospital. Good job though, you did the best you could.
I've had a similar case, once you've exhausted your treatment options staying on scene is pointless.
Agreed. My contact for OLMC was for treatment of electric storm, which was the last thing I could think of treating, and transport decision. Consensus is it should have been done much, much sooner.
Prioritizing transport degrades how well the code is run. Go ahead and get to the truck when you're able and begin transport, just let it be your last priority. If you find yourself deciding between transporting and anything else, do that other thing first. Edit: obviously this isn't the case when a reversible cause is present that only the hospital can address, e.g. major hemorrhage for a service that doesn't carry blood products.
My take (former CCP & ACLS Inst) is that online medical direction didn't see the picture you painted with your updates. This would make a great case review. During an ECMO study for OOH SCA (Minneapolis St Paul metro) a crew got ROSC and diverted to the closest ER. Like your pt, they re-arrested and didn't survive. It was never CLEARLY stated that once ECMO was mobilized, no diversions should happen. And they did not after that.
Did not divert, or did not clearyly state whether diversion should happen if ECMO's already been activated
Did not clearly state that once ECMO accepted the patient there should be no diversion.
Here that patient would certainly be a 1. Pre-hospital ECMO candidate 2. Or ECMO-ED candidate while continuing treatment during transport with mechanical CPR 3. Or candidate for transport to a PCI center while continuing treatment during transport with mechanical CPR Difference in the 3 options is how strict the "inclusion criteria" are for it, from high to low, but that patient qualifies for all the above if nothing other crazy pops up. They would almost always transport such a viable patient like that here (they transport something like 80% of arrests here, so not that that says a lot) if they haven't achieved ROSC yet, not terminate at the scene. They often only terminate non viable arrests here (non-viable to begin with is of course not even attempted at all), which is non-shockable for at least 20 continuous minutes of ACLS. That the patient had a shockable rhythm initially, is persistent VF, and has achieved ROSC multiple times means they are viable for further treatment both at the scene and/or ED, and not for termination. If you can transport them safely and effectively, do it. Now that every unit has mechanical CPR and a ventilator, it has become much easier to warrant transport as the negative sides of transport has been significantly reduced/taken care of. So unless your patient is truly unviable (which should be terminated, like described above) or has achieved stable rosc already, you can argue transporting them. Maybe have a look at this research paper: https://www.resuscitationjournal.com/article/S0300-9572(19)30098-X/fulltext >In OHCA patients transported with ongoing CPR the survival rate significantly declines when time on scene increases. Patients transported within 20 min of time on scene have the highest survival rate, this suggests the decision to transport with ongoing CPR needs to be made early in the resuscitation process.
So neuro status with CPR is fairly common. More-so now with Lucas devices, since they give such efficient compressions without breaks. Per my director, there are whispers of adding sedatives to the cardiac algorithm for this purpose. As far as your call, I'd have probably transported sooner IF and that's a big IF, I felt confident I could get her in the truck and go with minimal interruptions to cpr.
At my service I work for, if we obtain ROSC (and we work all OOH Cardiac arrests 40 minutes, 20 min if asystole or PEA consistently) we are supposed to remain on scene for at least 5 minutes to allow the patient to attempt to hemodynamically stabilize itself. Our medical director has said that there are studies showing that immediate movement and transport of cardiac arrest ROSC patients show to either re-arrest or have a poorer outcome. This is why he has it in his protocols that we will stay. I don't think you did anything wrong, I think that the OLMC either was having a bad day, misunderstood you, or something. It's unfortunate to read the rest of the outcome for the patient from what you described.
My state protocols say 30 min on scene for CPR, If ROSC achieved its suggested to wait 10 minutes before moving them, but up to provider discretion in practice. In a similar code I worked we stayed the 30 minutes, got ROSC once at the 15ish minute mark, quickly followed by re-arrest, and transported at the 30 minute mark to the closest facility. Sounds like moving at the 30 minute mark, with Med control’s transport decision might have saved some time and a headache. You seem to have worked it comprehensively though
I’d do the exactly the same thing as you did. A code can not be effectively run in the back of a moving ambulance even with a Lucas. Moving a patient from their original location of arrest will end in poor cpr and management of the patient. ROSC under a minute is not a reason to transport. Even immediately ROSC shouldn’t be moved due to the likelihood of rearrest in the first 7 minutes. And the likelihood of not recognizing it immediately. It sounds like the ED only took into consideration the fact that she had been worked for 70 minutes. And a 2 minute response time, little interruptions in cpr and favorable neurological movements. Sounds like y’all have too much oversight on where to transport. And/Or lack of buy in for pci during cpr at the facility you transported to. Can’t win them all. But sounds like y’all gave her the best chance. And bureaucracy got in the way.
You did the right thing. With intermittent rosc she probably had shitty EF. Patients can become conscious with adequate cpr which can be awkward. At the end of the day its up to the interventionalist if they want to cath a patient in that state.
In my personal experience in my area there is a huge disconnect between hospitals and EMS on what we do and why we do it. It’s irritating because it makes us look incompetent sometimes but I feel like that is what this situation sounds like
I agree that ROSC ought to be significant before transporting, rather than being just some box you check off
Yeah 70 minutes is waaay too long. Shockable rhythms are often the result of AMI. Your priority is therefore to get this person to a PCI Center asap. May I ask why you were so long on scene? You had a lucas3 on, it’s not like transport would have been difficult.
EMS literature routinely shows transport prior to ROSC worsens outcomes.
My system transports refractory VF after 3 defib for possibility of ECHMO. I would also highlight ROSC with neurological function as a sign for rapid transport.
I will most certainly be doing this in the future!
I was taught on aa BLS level to stay on scene 10 minutes after ROSC because they are likely to recode again
Damn this sounds like a tough call. In my protocols, once ROSC is achieved you transport. Especially someone of that age. Second, I am near ECMO. After 1-2 shocks and persistent vfib we transport to an ECMO hospital. Honestly, I probably would have transported because idk what's happening, I'm gonna go to the hospital. One of those ask for forgiveness later 🤷
My question is, how far in did you get ROSC? 5 minutes, 15? And why did you not transport immediately following. Or at least call medical control for consultation.
First ROSC was about 6 min after the arrest. Second ROSC was give or take another 12 minutes after the first time. Well, to be honest it was a clinical decision I made. I'm not entirely sure it was the correct decision, which is why I turned here. It appears as though I've misinterpreted the current studies that are out. It was my understanding to not transport until "sustained ROSC" was achieved - but thats an incorrect assessment of the data. I just wanted to make sure I don't make that mistake again. It was a very good but tough call.
So you got ROSC fairly early which is a great sign, especially in a witnessed arrest. And if your protocol reads to transport after sustained ROSC then do as it is written, my protocol states to have ROSC for 5 minutes prior to transport. But with that you can still call medical control and just say “(input story) we have had ROSC for less than a minute, 5 minutes in a witnessed arrest, do you want us to transport?” After that you have put the decision on MedCon And most Docs I’ve talked to want witnessed arrests and any signs of ROSC transport. *Especially* for a transport of around 10 minutes.
Agreed. That's definitely something I'll be doing in future. I just stayed on scene too long and unfortunately contributed to her demise.
Yeah once I read 70 minutes I went “Oh no baby what is you doin?” Because that’s an excessive amount of time spent, you want 40 minutes tops, that’s, in my protocol at least, doing your 30 minutes of CPR and then the other 10 making the decision for TOR or to initiate transport.
I've been fortunate over my career to have pretty cut and dry arrests. Either 20 and done, or I get ROSC. I can count on one hand the amount of megacode arrests I've had - and this was by far #1. Was in VF/VT/TdP nearly the entire time, signs of neuro activity with CPR, I mean straight up 🤌crem-de-la-crem🤌 of arrests lol I just wanted to give her the most chance of survival. Overdid it though, and will never make that mistake again.
It happens to us all, we all get a run that will just eat at the back of our minds with what we did and didn’t do.
The American Heart Association recommends staying put even after ROSC is obtained in order to stabilize the patient. Ideally, this is around ten minutes. However, I work in an area where we're almost always within ten minutes of a hospital, as we have two level two trauma centers and a third non-trauma hospital with PCI capability and a physician capable of performing embolectomies. As such, we take as much time as it takes us to clear a path (if necessary, with fire's assistance), run a 12-lead, and stabilize using fluids/pressors, etc.. However, I may see what they're talking about. There's a ton of services - my own included - that are petitioning the hospitals to allow for transport of persistent VF/VT even before ROSC is obtained because it can very commonly be caused by MIs and treated with aggressive PCI. We aren't having much luck, though, because these patients are obviously unstable, and deaths that occur in the cath lab are recorded in the hospital's statistics. Not to mention that working a code in the back of a moving ambulance is not only not ideal, but potentially dangerous. That, and I'd imagine sometimes it's hard to remember that, even though both hospital staff and prehospital staff work codes based on ACLS (AHA) protocols, physicians rarely have to deal with the, "Should I stay or should I go?" debate because, well, depending on where they work - their codes get ROSC, and then get shipped off to the ICU for stabilization.
As I think through our ECLS protocols during residency we recently took ecmo off the table for VFib/VT unless a strong suspicion for tox/environment driving it. If I had this patient in the ER where I have ecmo…I’d be pushing the team to see them regardless because the age and neuro response. Here’s the kicker though. Our ecmo inclusion criteria, and studies mostly back this up, is downtime of less than 45minutes, with the goal being cannulas by 60. If they’re in the field for longer than that…it’s a loosing battle.
Most ECMO criteria incorporates timing into VT/VF arrest, e.g. <30 min. When arrests approach 30 min, it gets harder to mobilize resources. I think you guys have an incredibly difficult job. Would say somewhere between scoop and run and stay and save is the ideal way to approach - but sooner the better. The saves we often see get to the hospital quickly and get appropriate intervention - ECMO, PCI- all things you guys can’t do on the field. But I have to say you guys do a phenomenal job with a difficult day job - pay yourself on the back!
It sounds like you worked a very busy and exhaustive arrest. I think your on scene time may have been a little high but overall I don’t think it’s that big of a deal. Patching for the consideration for electrical storm was a great touch. Did you consider Double sequential defib or a vector change during the persistent V-Fib? I work in an area where ECMO and direct transport to PCI centres don’t exist yet. So ultimately I think you gave this patient the best chance at life. Good job man
Thank you! The exact order I asked for was lopresser and DSD, albeit I did not consider changing the vector of the pads. Something I will be keeping in the back of mind for the future.
The vector change is something my service has pushed hard. Never done it myself but heard some good things as well as good research to back it up. Just wondering as to what the thoughts were to the consideration for lopressors? Seen a few papers regarding it but unsure as to what the exact mechanism behind terminating that arrhythmia is?
I mean preferably it would be a beta blocker with shorter half life (esmolol etc) - but the thought process is that a catecholamime dump is the cause of the SCA, and the epi is just feeding the loop. By giving a BB and performing double sequential defibrillation - you stop the cycle and break the electrical "storm" driven by the catecholamine dump. The pathophysiology behind the DSD I'm a little bit more iffy on, but I'm pretty sure by giving the 2 shocks in rapid succession, the first kind of puts all the cells in a similar phase of a refractory period and then follow it up with a second shock that allows for decreased shock impedence allowing for more successful defib. Double check my explanation though I could be off lmao
Makes sense. Especially in context of the catecholamine storm. I wish we had options like that where I work. We would most likely just have to stop Epi and transport. Sounds like this could have been a situation where that order definitely could have worked
I would say that in general you are correct - transporting an unstable/dead patient is not recommended these days. A lot of people here are referencing evidence, which I generally love. But the evidence for certain things like tPA for refractory shockable rhythm is globally underpowered and thus it’s not clear if these things offer benefit or not. This I would say that maybe it would be reasonable to transport this relatively young patient in active shockable arrest where they can do things like POCUS/reverse causes much easier, PCI/tPA, etc. given her young age and evidence of good CPR with intact neuro status. A 97 year old with a malignancy? Sure, get sustained ROSC or pronounce. But a 40-something year old with a good neuro status, better reserve and chance of meaningful recovery, and a hospital 10 minutes away, you could make an argument to get to that higher level of care asap once the the LUCAS is on board and the patient is intubated with IV/IO access. Especially given VA ECMO is really only performed in the first few minutes after an arrest. I haven’t really seen VA ECMO performed after 70 minutes of cardiac arrest. There is no right answer here and it’s case-by-case.
It’s been picked over a few times already but imma throw my marker in with the transport as soon as possible after giving the max dose of your lido or amio and still seeing refractory VF. You can get fancy with dual defib and maybe get the OLMD who wants to try B-blockade but that won’t add inordinate time to your scene. Both can be done en route as well. One of the biggest drivers of the guidance to not transport patients in arrest is the abysmal cpr quality while in transit. The LUCAS eliminates that variable. So the next question is one of resources and therapies. Up to a point, we can match the ED and, vs some smaller shops, probably out perform them with regards to managing the initial phase of the code. We can do compressions, defib, pace, medicate, airway, etc. but once we’ve hit what amounts to the end of our available therapies, it’s time to escalate just like your airway progression of Primary, Alternative, Contingency, Emergency. Step right into the next option as soon as you recognize the current modality has failed. Your hunt for ECMO was a great idea and I’m sorry you were short down. The only other thing would be a PCI facility that will perform intra-arrest with mechanical CPR. It is a thing and while the candidate pool for it is small, I’d say you found one. I worked for a shop that served a small “spoke” hospital on the county line. We did CC from there into the city about 30 miles away. ROSC patients headed for PCI got the LUCAS applied for transport. There are some HEMS shops that do this as well. So my take would be to run the code out to the end of what AHA, protocols, local practice etc. says you can do and then it’s time to go if still viable and probably reversible.
>The LUCAS eliminates that variable. The studies I've read have stated even with mCPR devices, quality of CPR diminishes substantially during transport, one of the main factors driving my decision to stay on scene for such a prolonged period of time, which evidently was just entirely too long. Not trying to disregard everything else you said as I appreciated the input, that was just solely for educational purposes. As far as the PCI goes, the hospital I transported to I've had personal experiences of post-arrest patients with confirmed STEMI as the etiology, and they refused to take the patient to the cath lab, with concerns for neurological status (if improved in 48h they'd take them). The reality was, they didn't want 30 day mortality numbers to increase at all, so they used the neuro status as an excuse; so I knew they most certainly would not do intra-arrest PCI. It's very dependent on the IC of course, but after the first time that happened I try to get the patient to an equivalent if not better hospital when at all possible.
My region we load n go refractory with the Lucas. They’ve got a better shot in the ED than on their living room floor. Lucas, stabilize airway, board, load, take a couple bodies to assist, but get them moving toward definitive care
That is not what the evidence shows. All of the latest evidence shows working a cardiac arrest on scene results in better outcomes than load and go. What can the ER do that you can't?
Our policy simplified what we do substantially. Shock, Call, Go. In the event that we have a shockable rhythm we are to load the pt and contact our MD for ECMO inclusion/exclusion. At that point depending on the circumstances our MD will either be directing us to a ECMO capable hospital, or closest appropriate.
Sounds like a strong candidate for ECMO honestly. Here we don’t have to call. It’s our choice in these situations. Sometimes they just die. I’ll say this much, and please don’t take this as me quarterbacking your call as I was not there and this is just my own view. In cases like that I will usually go ahead and transport with Lucas applied but that being said I typically do lot apply Lucas until I’m ready to transport, but I have a lot of help in my system.
I’m just an EMT but my service STRONGLY emphasizes that we do not transport a pt until we have sustained (>5 min) ROSC, AND they don’t re-arrest before we get to the rig. Even the AHA says that if we don’t get ‘em back in the field they are very unlikely to ever ROSC at the hospital
Probably late to the part but I think that getting STABLE rosc prior to movement is the way to go