AHA 2012 Resuscitation Update

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brendan c. -

There is a move towards an increase in out of hospital termination of efforts where I work. I would love to use CO2 levels to help guide us in making that decision but am not clear if they are dead, but have an esophageal tube, what their level would be. Thoughts?

Zachary S. -

You raise several important points. First, an esophageal intubation would likely give you a low ETCO2 and thus push you to terminate a patient that may be salvagable. An interesting question then becomes what is the chance of survival in a patient with a prolonged esophageal intubation? Probably low as well. I do use ETCO2 as a piece of information in deciding the prognosis of cardiac arrests, but only as a piece of the whole picture.
Termination of Resuscitation (TOR) rules include ROSC, shockable rhythm and witnessed arrest, but there has been several studies looking at ROSC alone to decide to transport. Several of these report <1% survival. So the question then becomes in the patients with a shockable rhythm or witnessed arrest, do you transport? I use the combination of ETCO2, downtime, age, comorbidities to decide some of these cases.
Like I said on the segment, I am pro TOR but there's a big downside to this. TOR assumes there's nothing in the ED you can't do in the field. Where I work we use ECMO on selected arrests and it works! Obviously not on everyone, but the <1% survival quoted with TOR does not include the possibility of ECMO as a resus tool. If I hear the story over the radio and this represents one of those patients I think we should throw everything at, I will transport.

Sean G., M.D. -

I seriously want to move toward the AED shock continue code, no shock call code.....I am so tired of the ACLS Merry Go Round.

Dallas H. -

Just a comment on clopidogrel and PPIs, there was a study in the New England Journal of Medicine that documented a greater than 50% decrease in gastrointestinal events when clopidogrel was combined with omeprazole and showed no greater adverse cardiac outcomes in the clopidogrel/ omeprazole group. The study has some limitations that don't make it practice changing but certainly suggest that the advisory against PPIs and clopidogrel should be reconsidered.


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