The paramedic call comes in, “We’ve got a patient with witnessed cardiac arrest, now in asystole.” What do you do? Keep the code going, call it there and stop the resuscitation?
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The numbers quoted for survival of out of hospital cardiac arrest cannot be correct, or at least they are poorly stated: This segment states, "The rate of neurologically intact survival with resuscitation between 40-45 minutes is 8%, 6% between 45-50 minutes and 5% at 50 minutes. At an hour of resuscitation, the rate of neurologically intact survival is 2% and this is consistent with medical futility. The rate of neurologically intact survival is 20% at 25 minutes of resuscitation. " As stated, this suggests that out of 100 people who have an out of hospital arrest, 20 of those coded for 25 minutes or less will survive and be neurologically-intact, and that of individuals who have already been coded 45 minutes, 1 out of 20 will survive and be neurologically intact. These numbers clearly fly in the face of extensive data about cardiac arrest survival, even when the arrest occurs in hospital. See for reference the recent IOM report that of all out of hospital arrests, less than 6% survive to hospital discharge.
I *think* what was meant, maybe, is that in a retrospective analysis of a sample of patients who HAD survived an out-of-hospital cardiac arrest, 20% has ROSC in under 25 minutes, 5% had ROSC between 45-50 minutes into the code, etc, but that is a very different statement than the one presented.
Abigail, Thanks for listening and for the response. At the point he was presenting these survival numbers Dr. Myers was talking specifically about patients in PEA of greater than 60 bpm and ETCO2 above 20. These are definitely not the survival numbers for all-comers with out-of-hospital cardiac arrest. Hope that helps. Darren
I would love to read/watch/listen more about the finer points of pad placement, whether it be for defibrillation, double sequential defibrillation, cardioversion, or pacing. Any suggestions? Best, Nathan.
Nathan, ACEPNow has a recent article (November 2015) with some illustrations available for free. If you search google for "anterior-posterior pad placement" you will find several resources including manufacturer information. There was also a recent case series of double-sequential defibrillation by Merlin et al in Prehospital Emergency Care that includes some literature review. Hope that gets you started. If you find a great review please let us all know here!
I'm not sure what was meant by the emphasis section discussing patients in asystole. It isn't consistent with either the literature or what Dr. Myers said. It sounded like the emphasis said that resuscitation was futile and didn't need to be initiated for a patient with an unwitnessed arrest found in asystole. Hopefully, I misunderstood.
Aside from this point, I thought this was an outstanding segment. I'm a bit biased as an EMS physician, but I'd love to hear more like this!
Jeff, way to pay attention. I completely agree that the emphasis did not reflect what Myers said - he advocates 20 minutes of resuscitation for asystole - thought it does actually reflect my own practice. In my EMS system we do not initiate resuscitation for adults with unknown downtime, no bystander CPR and asystole - a combination that makes up 20% of our cardiac arrest population. If we do initiate, usually because of witnessed arrest and/or CPR, we work it for 10 minutes and terminate if the patient remains in asystole.
Nice buzzkill Jessica! Really though, that is why we currently save DSD for refractory Vfib where we have nothing to lose and why we clearly need more research. I have had traditional "low dose" defibrillation convert many patients right into asystole as well. I suspect we will look back on our current management in 10 years and be appalled by how little we knew. Thanks for listening and the comment.
Hi Laura, I would love to help you out but it has been a few years since we recorded this and we talked about a lot of numbers. Which time/survival number specifically are you looking to reference? Darren
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Abigail H. - February 17, 2016 11:11 PM
The numbers quoted for survival of out of hospital cardiac arrest cannot be correct, or at least they are poorly stated: This segment states, "The rate of neurologically intact survival with resuscitation between 40-45 minutes is 8%, 6% between 45-50 minutes and 5% at 50 minutes. At an hour of resuscitation, the rate of neurologically intact survival is 2% and this is consistent with medical futility. The rate of neurologically intact survival is 20% at 25 minutes of resuscitation. " As stated, this suggests that out of 100 people who have an out of hospital arrest, 20 of those coded for 25 minutes or less will survive and be neurologically-intact, and that of individuals who have already been coded 45 minutes, 1 out of 20 will survive and be neurologically intact. These numbers clearly fly in the face of extensive data about cardiac arrest survival, even when the arrest occurs in hospital. See for reference the recent IOM report that of all out of hospital arrests, less than 6% survive to hospital discharge.
I *think* what was meant, maybe, is that in a retrospective analysis of a sample of patients who HAD survived an out-of-hospital cardiac arrest, 20% has ROSC in under 25 minutes, 5% had ROSC between 45-50 minutes into the code, etc, but that is a very different statement than the one presented.
Darren B. - February 26, 2016 12:48 PM
Abigail,
Thanks for listening and for the response. At the point he was presenting these survival numbers Dr. Myers was talking specifically about patients in PEA of greater than 60 bpm and ETCO2 above 20. These are definitely not the survival numbers for all-comers with out-of-hospital cardiac arrest. Hope that helps.
Darren
Nathan G. - March 4, 2016 11:07 PM
I would love to read/watch/listen more about the finer points of pad placement, whether it be for defibrillation, double sequential defibrillation, cardioversion, or pacing. Any suggestions? Best, Nathan.
Darren B. - March 7, 2016 10:18 AM
Nathan, ACEPNow has a recent article (November 2015) with some illustrations available for free. If you search google for "anterior-posterior pad placement" you will find several resources including manufacturer information. There was also a recent case series of double-sequential defibrillation by Merlin et al in Prehospital Emergency Care that includes some literature review. Hope that gets you started. If you find a great review please let us all know here!
Jeff - March 9, 2016 4:54 PM
I'm not sure what was meant by the emphasis section discussing patients in asystole. It isn't consistent with either the literature or what Dr. Myers said. It sounded like the emphasis said that resuscitation was futile and didn't need to be initiated for a patient with an unwitnessed arrest found in asystole. Hopefully, I misunderstood.
Aside from this point, I thought this was an outstanding segment. I'm a bit biased as an EMS physician, but I'd love to hear more like this!
Thanks,
Jeff
Darren B. - March 16, 2016 9:22 AM
Jeff, way to pay attention. I completely agree that the emphasis did not reflect what Myers said - he advocates 20 minutes of resuscitation for asystole - thought it does actually reflect my own practice. In my EMS system we do not initiate resuscitation for adults with unknown downtime, no bystander CPR and asystole - a combination that makes up 20% of our cardiac arrest population. If we do initiate, usually because of witnessed arrest and/or CPR, we work it for 10 minutes and terminate if the patient remains in asystole.
Jessie M. - May 4, 2016 5:03 AM
Awesome review. I have tried the double sequential defibrillation 2 times. Both times, the pt promptly came out of vfib...to asystole. No ROSC.
Darren B. - May 5, 2016 7:06 AM
Nice buzzkill Jessica! Really though, that is why we currently save DSD for refractory Vfib where we have nothing to lose and why we clearly need more research. I have had traditional "low dose" defibrillation convert many patients right into asystole as well. I suspect we will look back on our current management in 10 years and be appalled by how little we knew. Thanks for listening and the comment.
Laura M. - September 28, 2018 3:10 PM
Where is the reference for the numbers quoted for survival based on time of resuscitation. Thanks in advance.
Darren B. - October 3, 2018 12:57 PM
Hi Laura, I would love to help you out but it has been a few years since we recorded this and we talked about a lot of numbers. Which time/survival number specifically are you looking to reference? Darren