Your patient arrests as you pull up to the ER

[BushyFromOz]

It is a reference to the newer AHA guidelines that recommend one shock followed by two minutes of CPR. I suspect the original post was referencing situations back when "stacked shocks" were common practice.

Take care,

chbare.

I took it as meaning 3 stacked shocks in a witness arrest.

[Doczilla]

You people with the grammar thing are making a soup sandwich out of an otherwise average thread.

P3 said it right. If there is something that is immediately correctable, perform the intervention and move the patient inside. If you are sitting out on the ambulance ramp running a code rather than coming inside my ER with the patient, you will have a difficult time hearing anyone yell "clear" over the sound of me chewing your ass.

To say that EMS can run the code better in a cramped space with limited equipment, limited light, and limited help rather than in the ER is arrogant. Thinking that all ER doctors are on the same level as every dentist or FP doc who ever took ACLS is asinine. Medics with that kind of attitude typically fail to see their own limitations, and have no clue how little they know.

'zilla

[akflightmedic]

Dwayne, I have no pecker, so your comparison doesn't apply to me...

Your is still bigger than his.

Anyways, stay on topic please. Doc sums it all up nicely and I think just about everything has been covered.

[chbare]

The following is from the AHA "Circulation" journal prior to implementing the 2005 ECC changes. Off topic; however, good information for those who what to know some of the rationale behind AHA changes.

"The ECC Guidelines 200033 recommended the use of a so-called "stacked" sequence of up to 3 shocks, without interposed chest compressions, for the treatment of VF/pulseless VT. Although no studies in humans or animals specifically compared the 1-shock defibrillation strategy with the 3-stacked-shock sequence, other evidence created the tipping point for a change from a 3-shock sequence to 1 shock followed immediately by CPR.

The 3-shock recommendation was based on the low first-shock efficacy of monophasic damped sinusoidal waveforms and efforts to decrease transthoracic impedance with delivery of shocks in rapid succession. Modern biphasic defibrillators have a high first-shock efficacy (defined as termination of VF for at least 5 seconds after the shock), averaging more than 90%,34,35 so that VF is likely to be eliminated with 1 shock. If 1 shock fails to eliminate VF, the VF may be of low amplitude and the incremental benefit of another shock is low. In such patients, immediate resumption of CPR, particularly effective chest compressions, is likely to confer a greater value than an immediate second shock.

After VF is terminated,36–38 most victims demonstrate a nonperfusing rhythm (pulseless electrical activity or asystole) for several minutes; the appropriate treatment for such rhythms is immediate CPR. Yet in 2005 the rhythm analysis for a 3-shock sequence performed by commercially available AEDs resulted in delays of 29 to 37 seconds or more between delivery of the first shock and the beginning of the first post-shock compression.38,39 This prolonged interruption in chest compressions cannot be justified for analysis of a rhythm that is unlikely to require a shock.

Experts recommend that rescuers resume CPR, beginning with chest compressions, immediately after attempted defibrillation. Rescuers should not interrupt chest compressions to check circulation (eg, evaluate rhythm or pulse) until after about 5 cycles or approximately 2 minutes of CPR. In specific settings (eg, in-hospital units with continuous monitoring in place), this sequence may be modified at the physician’s discretion.

The recommendation for a 1-shock strategy creates a new challenge: to define the optimal energy for the initial shock. The consensus is that it is reasonable to use 150 J to 200 J for the initial shock with a biphasic truncated exponential waveform or 120 J with a rectilinear biphasic waveform. In recognition that many EMS systems may still be using monophasic defibrillators, the consensus recommendation for initial and subsequent monophasic waveform doses is 360 J. The goal of this recommendation is to simplify attempted defibrillation. For children, the consensus recommendation is an initial dose of 2 J/kg (monophasic or biphasic); for second and subsequent biphasic shocks, it is advisable to use the same or higher energy (2 to 4 J/kg). Manufacturers of defibrillators should ensure that each of their products clearly displays the range of energy levels at which each specific defibrillator waveform was shown to be effective at terminating VF. Healthcare providers should be aware of the range of energy levels of the specific device they are authorized to operate."

(Circulation. 2005;112:IV-206 – IV-211.)

© 2005 American Heart Association, Inc.

Take care,

chbare.

[HellsBells]

So, a paramedic gives a patient IV Dextrose, and brings said patient out of insulin shock. A very life threatening condition, that if left untreated, will be sure to lead to death. Now, and EMT Basic, who cannot give IV Dextrose must take said patient to 'definitive care'. When the patient arrives at said "definitive care" the patient will be given IV Dextrose.

Lets look at the equation.

IV Dextrose = Definitive Care.

Paramedics administer IV Dextrose.

So with the rule of substitution, we can conclude that...

Paramedics administer definitive care.

Depends on the situation. If the pt has coded due to a cardiac tamponade ( for the sake of argument). Then definitive care will be given in the ER with pericardial centesis.

As for the argument that good CPR cannot be given while moving to the ER, hogwash. How far is the ER from your ambulance bay? If its more than 10 seconds away, then I guess you'll just have to take frequent breaks to ensure there is minimum interruptions to compressions.

[mobey]

So, a paramedic gives a patient IV Dextrose, and brings said patient out of insulin shock. A very life threatening condition, that if left untreated, will be sure to lead to death. Now, and EMT Basic, who cannot give IV Dextrose must take said patient to 'definitive care'. When the patient arrives at said "definitive care" the patient will be given IV Dextrose.

Lets look at the equation.

IV Dextrose = Definitive Care.

Paramedics administer IV Dextrose.

So with the rule of substitution, we can conclude that...

Paramedics administer definitive care.

Actually on the contrary......

Definitive care would include a thourough look at diet, excersice, and lifestyle. Not to mention an in-depth overview of the patients use of insulin/oral hypoglycemics. There is no reason for a diabetic to hit such a lifethreatening state. Although we can "fix" the immediate problem, it is only a bandaid. Perhaps the patient needs recomendations on diet? change of meds? different insulin dosage? You get the drift.

[akroeze]

You people with the grammar thing are making a soup sandwich out of an otherwise average thread.

P3 said it right. If there is something that is immediately correctable, perform the intervention and move the patient inside. If you are sitting out on the ambulance ramp running a code rather than coming inside my ER with the patient, you will have a difficult time hearing anyone yell "clear" over the sound of me chewing your ass.

To say that EMS can run the code better in a cramped space with limited equipment, limited light, and limited help rather than in the ER is arrogant. Thinking that all ER doctors are on the same level as every dentist or FP doc who ever took ACLS is asinine. Medics with that kind of attitude typically fail to see their own limitations, and have no clue how little they know.

'zilla

I appreciate your response Doc and tend to agree with what you have said. May I ask a follow up question of you then?

Where do you weigh in in the "house next door to the ER" scenario? Should these people be transported too? I guess what I'm trying to get at is where do people draw the line on what is acceptable to run into the ER and what is acceptable to work in the field?

[Just Plain Ruff]

It's a judgement call on every single call. You make that determination at the time of the call. do you transport or not.

We had a 37 year old code at 3am today(tuesday). Asystole throughout. If we werent' 25 minutes to the hospital we would havce worked her until we got to the hospital.

I suspect that if you are just across from the hospital I think it would be a bad decision not to load them up and take em to the ER. Hell, why not just wheel em there. It's less than a block. I think that many physicians would be pissed at us if we worked a patient who lived less than a 10th of a mile from the ER and didn't bring them in. I think the courts might have something to say about this also.

You had a fully stocked ER with plenty of resources available less than a minute away might be considered negligent care on your part.

I don't have the statistics or evidence to back it up but I just think you might see a deposition in your future if this scenario happened to you.

[Doczilla]

Where do you weigh in in the "house next door to the ER" scenario? Should these people be transported too? I guess what I'm trying to get at is where do people draw the line on what is acceptable to run into the ER and what is acceptable to work in the field?

Distance is less important than time. If the patient arrested in the house next door prior to extrication, it would make sense to work in place so long as you can secure the airway and vascular access (IV or IO). These people are not simply a stroll down the street. You have to load them up on the board, then the cot, strap in place, carry [down stairs] [out door] [through yard] to the ambulance and load, then make sure you got all your stuff. In that case, it's wise to stabilize the patient first, secure the airway, and begin working them. If the opportunity presents to get a break and move to the truck, go for it.

If the patient is already in the ambulance and is on the pad and 10 seconds from the ER door, just go in. As Ruff said, it's a judgement call.

Also, there is the question of the nature of the arrest. If it's a trauma arrest, there is very little benefit to treatment in the field other than stopping the bleeding, ventilating them, and decompressing the chest, and so less is more. We basically have 5 minutes to crack the chest from the time the patient arrests in penetrating trauma if a thoracotomy is going to be of any benefit.

As long as you can secure the airway and obtain vascular access, and are properly equipped to run a code, there is potentially some benefit to working a patient in the field, even relatively close to the hospital. Once transport has begun, don't hold the patient in the ambulance longer than necessary.

From the legal perspective, out-of-hospital is out-of-hospital once you cross the property line. Once you get onto the hospital's grounds, legal precedent has established (with a good boost from EMTALA) that the hospital has some duty to the patient. This could be interpreted to mean that if you're in the truck under my canopy screwing things up rather than bringing them in, we could be held liable.

'zilla

[Arizonaffcep]

Now granted, I've been skipping around on this thread, but I would hope that this "arresting" patient wasn't a "surprise" arrest...in that the extreme majority of the time, anyone who codes in back should have been expected to possibly code, thus having all the "toys" at the ready. Now...there is the very rare times when an otherwise healthy patient codes on you in back (acute onset MI--the "big one--, etc.). But, I would start the code...defib if called for, if not, establish an airway, IV's etc., and maybe 1st round of drugs walking down the hallway. Oh...and contact the hospital in some fashion just to let them know the patient just "crumped."