Would You Work This Code?

[Emtgirl101]

pulse you still keep going , give it your ALL!

[ncmedic309]

Alright, I must have missed something during this thread. It's been my impression that the patient was pulseless and apneic upon assessment. I know that bystanders reported having a pulse after CPR but the original poster remarked that the patient was a "code". That tells me that the patient is without a pulse and without spontaneous respirations - or better known as dead. It's obviously a different case if you have signs of life, of course you would give it your all at that point.

[croaker260]

I agree with you on that end, if your going to make an attempt - make it a good one. But after all that effort, would you not just go ahead and transport the patient? So, let's say the patient is pulseless and apneic, you secure the airway, get large bore vascular access, start replacing volume your going down the road of troubleshooting the PEA (if it remains) and your not seeing any improvements based on your interventions. The time on the clock is obviously ticking away at this point, it's trauma, do we want to remain on scene or are we just doing all this enroute? In my opinion, if your going to make those kind of efforts, you might as well do it enroute to the ED. If your not going to transport, it's probably just the best option to leave the patient as you find them. Does my viewpoint make any sense at all?

Yes it does, completely. Perhaps we are talking around the same view point.

The things that would effect transport descisions are system based ones that vary hugely accros the US.

Example: One of my earliest codes was a horse rollover on a mountain side with a 40 minute hike in. The dude took his last breath as I walked up with my gear, PEA, big belly, the whole bit. Worked him for 15 or so, epi, decompression, ett, etc etc. Working him down a mountain side was impractical. So we worked him, and called him on location.

I work areas in my county where we are 40 minutes away during winter. and areas downtoewn where we are 5 minutes away from our trauma center. the transport descision at that point is based on system variables. But in both cases if I were to work him, I would work him hard.

There is some data, useful data, suggesting CPR sucks in a moving vehicle of any type, and therefore rescusitation in a moving vehicle may be counter productive....but thats another soap box.

OMG! Is this horse dead? or is it in PEA?

[ncmedic309]

I think it's in PEA...

[CBEMT]

Do you transport all your medical arrests too? The survival to discharge rate for out of hospital blunt traumatic arrest is pretty damn close to 0%. You would have much better results working and transporting all your medical asystolic arrests.

I do. Because that's what is required of me.

When they give me another option, I will use it as appropriate.

Edited May 19, 2009 by CBEMT

[DwayneEMTP]

Who here sees agonal respirations as a sign of life?

Just curious...

Dwayne

[AnthonyM83]

In simplest form, it's cardiopulmonary arrest secondary to a traumatic etiology. It may be blunt, penetrating or even environmental. If it's blunt or penetrating it's typically pronounced on scene without attempts at resuscitation. If it's environmental, depending on the circumstances such as lightning strike or cold water drowning then all attempts are to be made at resuscitation with some variance in treatment based on the exact etiology. Does that clarify any better?

Anthony:

That's actually a good question - but yes - even a VFIB arrest secondary to blunt trauma would still fall into that category. I haven't seen a blunt arrest present with VFIB yet, but I have no doubt that other's likely have and that I will eventually see it as well and the urge to defib it will be strong.

I just now saw your reply.

I find it almost criminal to have a patient in VFib and not work it. If I was the patient, I would surely come back to haunt you. If you were working one of my family members, I would surely knock you out (no offense) and defibrillate him.

As was said, there could be underlying medical conditions. Or a rare commotio cordis.

As a side note on penetrating trauma arrests, they have the best survival chances in ERs due to potential for correctable causes. And you won't be able to determine all those in the field (such as pericardial tamponade).

[tniuqs]

Who here sees agonal respirations as a sign of life?

Just curious...

Dwayne

Ataxic or Agonal breathing pattern(s) are basic brain stem function (~ level of Pons) under the Harvard Criteria on death any attempt(s) of breathing are a sign of life, this criteria is often quoted in courts and used in determination of death for discontinuation of Life Support with ventilated patients in ICUs.

Ok say for example that a large subdural is the cause of herniation and possible cause, this can be salvageable situation if one has rapid access to a trauma center and neurosurgery, that said situational awareness is key BUT if we continue to call ALL psuedo arrests at scene, well the evidence based medicine stats will continue to be 0 % chance of survival.

And I must agree with Antony's last post, to assume that ones Vfib arrest is 100% due to MOI is an error, many Trauma "involved" patients just happen to have a "Medical History" that should never be factored out of the equation.

Look to the future as well .. just who is to say that in 30 years we as EMS providers will NOT be putting Chest tubes in routinely or doing bur holes or inserting ICP or using volume expanders that CAN carry O2 ... hence my stanch perspectives on this topic look to the future no the past to give up hope for your patients. Hell 30 years ago having the capability of defib or being capable of ETI was called "insane" yet another example in medicine was the neonatal born with diaphgramatic herniation there survival rate was also 0 % .. now with ECMO its a 87 % survival rate.

cheers

[msenecal]

The patient is dead. I would not have worked the code but I would not fault someone who did unless they let another patient die while using resources on him.

I also am making that decision with 18 years experience.

[HERBIE1]

The patient is dead. I would not have worked the code but I would not fault someone who did unless they let another patient die while using resources on him.

I also am making that decision with 18 years experience.

It's all about your local protocols. If you don't work someone, you had better be darn sure they meet your standards for a DOA and you document your arse off. In my system, agonal breathing is still technically alive- even with some grey matter protruding. Wrong- maybe, but I don't write the policies.

Obviously agonal respirations are not a good sign and generally not compatible with life, but you also need to know their cause. Is this personal terminally ill with cancer, or do they have a potentially "fixable" problem? Is it an airway issue we can treat, or is it because their brain is herniating? It's not up to us to make calls like that unless, as you say, it's a multivictim triage situation. If you are presented with several critical patients and not enough resources, and one is agonally breathing, yes, that person is a black.