Baby Paramedic with a question regarding pacing

[Hillbilly Medic]

A few of us were discussing this, and I wanted some opinions. I work in a very rural setting, minimum transport time is 60-80 minutes to an ER. Sometimes, you can't get an extra hand onboard during bad calls. So....if you're working an arrest alone, and you're just to tired to do more compressions, is pacing a feasability? Isn't it still going to circulate, providing you get capture?

[Jwade]

A few of us were discussing this, and I wanted some opinions. I work in a very rural setting, minimum transport time is 60-80 minutes to an ER. Sometimes, you can't get an extra hand onboard during bad calls. So....if you're working an arrest alone, and you're just to tired to do more compressions, is pacing a feasability? Isn't it still going to circulate, providing you get capture?

Well, Short answer, NO and it depends....

First, to answer your question accurately, please " qualify" arrest?

If the patient is in V-Fib or Pulseless V-tach, the answer is NO.

If your patient is in symptomatic bradycardia, refractory to medication , then obviously pacing and or CPR are indicated. ( This is also making the assumption one has figured out WHY the patient is in arrest and is instituting specific TX modalities.

Respectfully,

JW

[Hillbilly Medic]

Well, Short answer, NO and it depends....

First, to answer your question accurately, please " qualify" arrest?

If the patient is in V-Fib or Pulseless V-tach, the answer is NO.

If your patient is in symptomatic bradycardia, refractory to medication , then obviously pacing and or CPR are indicated. ( This is also making the assumption one has figured out WHY the patient is in arrest and is instituting specific TX modalities.

Respectfully,

JW

Partner, and fellow new medic, was working an asystolic patient. Glucose WNL, 3 rounds of cardiac meds onboard, amp of bicarb. Minimal history of current condition. Went through the list of possible causes. MCP wouldn't let him DC resuscitation. he was just exhausted, and no available units to help, as none of the VFD's roll on medical patients, just MVC's etc. He was wondering if an attempt to pace would've been successful. I didn't think so, but it was an interesting discussion that just had me curious. I'm not afraid to say that I just didn't know, but I was willing to ask.

[Jwade]

Partner, and fellow new medic, was working an asystolic patient. Glucose WNL, 3 rounds of cardiac meds onboard, amp of bicarb. Minimal history of current condition. Went through the list of possible causes. MCP wouldn't let him DC resuscitation. he was just exhausted, and no available units to help, as none of the VFD's roll on medical patients, just MVC's etc. He was wondering if an attempt to pace would've been successful. I didn't think so, but it was an interesting discussion that just had me curious. I'm not afraid to say that I just didn't know, but I was willing to ask.

Well, you will see two schools of thought from people on this, some will say yes try it, others such as myself will say no...

In my 19 years experience in EMS, the PROBABILITY of pacing working is NOT statistically significant. Also, there is case law to support the medic D/C compressions based on sheer exhaustion......

Respectfully,

JW

Edited April 27, 2010 by Jwade

[paramedicmike]

Well, you will see two schools of thought from people on this, some will say yes try it, others such as myself will say no...

In my 19 years experience in EMS, the PROBABILITY of pacing working is NOT statistically significant. Also, there is case law to support the medic D/C compressions based on sheer exhaustion......

Respectfully,

JW

I'm with JWade on all of the above. Pacing is probably not going to work. Will it hurt to try? Probably not. Will it be effective? Probably not. Do I recommend it? No.

In an effort to understand the larger situation I do have a couple questions, though.

Why initiate transport on a cardiac arrest patient when you have a minimum 60-80 minute transport time? CPR is not effective in a moving vehicle just as it isn't effective when the person providing compressions is exhausted. You're not doing anything to help the patient at this point. What will it take to change your local culture to work a cardiac arrest on scene and transport only if you see ROSC?

Does your MCP not understand the time and distances involved? Since s/he wouldn't let you discontinue it would appear not. You need to make this point crystal clear to him/her when you call in your request.

Please think back to your CPR training, too. One of the endpoints of CPR is when the provider is too exhausted to continue. If one physically can't provide compressions are you really going to risk harming yourself for the benefit of a dead person who is going to stay dead?

Good luck.

[Kiwiology]

I agree with Mike

[Mateo_1387]

A few of us were discussing this, and I wanted some opinions. I work in a very rural setting, minimum transport time is 60-80 minutes to an ER. Sometimes, you can't get an extra hand onboard during bad calls. So....if you're working an arrest alone, and you're just to tired to do more compressions, is pacing a feasability? Isn't it still going to circulate, providing you get capture?

Do I understand your question to be...

1, Can pacing replace CPR to circulate blood?

Or

2, Is it acceptable to pace during the cardiac arrest treatment sequence?

Number 2 has definitely been answered. I have the impression number 1 is your question, and, if it is, the answer is No. Pacing is not a substitute for CPR. It is possible to have 'capture' but have no heart beat. Without contraction of the heart, there is no circulation of the blood.

Matt.

[speedygodzilla]

I have seem few try pacing in cardiac arrest, and it has never worked. I really wonder if anyone has seen it work?

I figure you can always try pacing, but chances are it is not going to circulate or get capture. Is the capture a femoral pulse or just capture on the monitor?

I have to agree with Mike. Even here in the city where I work we work the cardiac arrest for 20 minutes with a few other basic criteria but do not transport if no ROSC after calling medical control. There is more criteria to it than that but that is the basic of the protocol.

[Hillbilly Medic]

I'm with JWade on all of the above. Pacing is probably not going to work. Will it hurt to try? Probably not. Will it be effective? Probably not. Do I recommend it? No.

In an effort to understand the larger situation I do have a couple questions, though.

Why initiate transport on a cardiac arrest patient when you have a minimum 60-80 minute transport time? CPR is not effective in a moving vehicle just as it isn't effective when the person providing compressions is exhausted. You're not doing anything to help the patient at this point. What will it take to change your local culture to work a cardiac arrest on scene and transport only if you see ROSC?

Does your MCP not understand the time and distances involved? Since s/he wouldn't let you discontinue it would appear not. You need to make this point crystal clear to him/her when you call in your request.

Please think back to your CPR training, too. One of the endpoints of CPR is when the provider is too exhausted to continue. If one physically can't provide compressions are you really going to risk harming yourself for the benefit of a dead person who is going to stay dead?

Good luck.

Now I remember why it's not a good idea to post at 0300. Nowhere NEAR enough clarification. My fault. Ok, the pt was in severe resp distress upon transport, went into arrest approx 30 minutes into transport. He (the medic) was able to successfully defib twice, but was unable to convert the last cycle of v-fib. Continued epi and compressions. We both know that CPR is most effective, but that we're human and that, eventually, you get tired. As for changing the dynamic in our area? We've tried, but the only things the VFD is willing to roll on is trauma, or LZ setup, IF it's during reasonable hours. This was around 0240. The particular MCP referenced has done that several times. Why? I can't give you an answer. I know what I asked probably sounded stupid, but the discussion that lead to my post was if it was possible, physiologically, to gain any kind of contraction from pacing. My own opinion was/is that you'll merely be manufacturing PEA. However, I was willing to ask, more out of curiosity than anything. Strange things happen in the field, and I wondered if it had ever been tried, or if anyone had ever seen it work. That's all. I can completely see the reasoning behind it not working. Chalk it up to a "what if" type of scenario. But thanks for the replies, I appreciate it.

[Jwade]

I have seem few try pacing in cardiac arrest, and it has never worked. I really wonder if anyone has seen it work?

I figure you can always try pacing, but chances are it is not going to circulate or get capture. Is the capture a femoral pulse or just capture on the monitor?

I have to agree with Mike. Even here in the city where I work we work the cardiac arrest for 20 minutes with a few other basic criteria but do not transport if no ROSC after calling medical control. There is more criteria to it than that but that is the basic of the protocol.

Speedy,

Can you clarify the above for me please? Not sure I understand? Femoral pulse checks are pretty worthless. See below...

Respectfully,

JW

(Circulation. 2005;112:IV-78 – IV-83.)

© 2005 American Heart Association, Inc.

2005 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care

8. Connick M, Berg RA. Femoral venous pulsations during open-chest cardiac massage. Ann Emerg Med. 1994; 24: 1176–1179.

Assessment During CPR

At present there are no reliable clinical criteria that clinicians can use to assess the efficacy of CPR. Although end-tidal CO2 serves as an indicator of cardiac output produced by chest compressions and may indicate return of spontaneous circulation (ROSC),1,2 there is little other technology available to provide real-time feedback on the effectiveness of CPR.

Assessment of Hemodynamics

Coronary Perfusion Pressure

Coronary perfusion pressure (CPP = aortic relaxation [diastolic] pressure minus right atrial relaxation phase blood pressure) during CPR correlates with both myocardial blood flow and ROSC (LOE 3).3,4 A CPP of 15 mm Hg is predictive of ROSC. Increased CPP correlates with improved 24-hour survival rates in animal studies (LOE 6)5 and is associated with improved myocardial blood flow and ROSC in animal studies of epinephrine, vasopressin, and angiotensin II (LOE 6).5–7

When intra-arterial monitoring is in place during the resuscitative effort (eg, in an intensive care setting), the clinician should try to maximize arterial diastolic pressures to achieve an optimal CPP. Assuming a right atrial diastolic pressure of 10 mm Hg means that the aortic diastolic pressure should ideally be at least 30 mm Hg to maintain a CPP of 20 mm Hg during CPR. Unfortunately such monitoring is rarely available outside the intensive care environment.

Pulses

Clinicians frequently try to palpate arterial pulses during chest compressions to assess the effectiveness of compressions. No studies have shown the validity or clinical utility of checking pulses during ongoing CPR. Because there are no valves in the inferior vena cava, retrograde blood flow into the venous system produce femoral vein pulsations.8 Thus palpation of a pulse in the femoral triangle may indicate venous rather than arterial blood flow. Carotid pulsations during CPR do not indicate the efficacy of coronary blood flow or myocardial or cerebral perfusion during CPR.

Assessment of Respiratory Gases

Arterial Blood Gases

Arterial blood gas monitoring during cardiac arrest is not a reliable indicator of the severity of tissue hypoxemia, hypercarbia (and therefore the adequacy of ventilation during CPR), or tissue acidosis. This conclusion is supported by 1 case series (LOE 5)9 and 10 case reports10–19 that showed that arterial blood gas values are an inaccurate indicator of the magnitude of tissue acidosis during cardiac arrest and CPR both in and out of hospital.

Oximetry

During cardiac arrest, pulse oximetry will not function because pulsatile blood flow is inadequate in peripheral tissue beds. But pulse oximetry is commonly used in emergency departments and critical care units for monitoring patients who are not in arrest because it provides a simple, continuous method of tracking oxyhemoglobin saturation. Normal pulse oximetry saturation, however, does not ensure adequate systemic oxygen delivery because it does not calculate the total oxygen content (O2 bound to hemoglobin + dissolved O2) and adequacy of blood flow (cardiac output).

Tissue oxygen tension is not commonly evaluated during CPR, but it may provide a mechanism to assess tissue perfusion because transconjunctival oxygen tension falls rapidly with cardiac arrest and returns to baseline when spontaneous circulation is restored.20,21

End-Tidal CO2 Monitoring

End-tidal CO2 monitoring is a safe and effective noninvasive indicator of cardiac output during CPR and may be an early indicator of ROSC in intubated patients. During cardiac arrest CO2 continues to be generated throughout the body. The major determinant of CO2 excretion is its rate of delivery from the peripheral production sites to the lungs. In the low-flow state during CPR, ventilation is relatively high compared with blood flow, so that the end-tidal CO2 concentration is low. If ventilation is reasonably constant, then changes in end-tidal CO2 concentration reflect changes in cardiac output.

Eight case series have shown that patients who were successfully resuscitated from cardiac arrest had significantly higher end-tidal CO2 levels than patients who could not be resuscitated (LOE 5).2,22–28 Capnometry can also be used as an early indicator of ROSC (LOE 529,30; LOE 631).

In case series totaling 744 intubated adults in cardiac arrest receiving CPR who had a maximum end-tidal CO2 of <10 mm Hg, the prognosis was poor even if CPR was optimized (LOE 5).1,2,24,25,32,33 But this prognostic indicator was unreliable immediately after starting CPR in 4 studies (LOE 5)1,2,32,33 that showed no difference in rates of ROSC and survival in those with an initial end-tidal CO2 of <10 mm Hg compared with higher end-tidal CO2. Five patients achieved ROSC (one survived to discharge) despite an initial end-tidal CO2 of <10 mm Hg.

In summary, end-tidal CO2 monitoring during cardiac arrest can be useful as a noninvasive indicator of cardiac output generated during CPR (Class IIa). Further research is needed to define the capability of end-tidal CO2 monitoring to guide more aggressive interventions or a decision to abandon resuscitative efforts.

In the patient with ROSC, continuous or intermittent monitoring of end-tidal CO2 provides assurance that the endotracheal tube is maintained in the trachea. End-tidal CO2 can guide ventilation, especially when correlated with the PaCO2 from an arterial blood gas measurement.