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New EMS Concepts in Cardiac Arrest

Howard Mell, MD and Al Sacchetti, MD
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EM:RAP October 2013 Written Summary 2 MB - PDF

Who does not love "New Concepts"? Hands only CPR is discussed along with other interesting resuscitation techniques.

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Tyler V. -

The pit-crew approach makes a lot of sense (and works) in hospital too, but cardiocerebral resuscitation makes less sense. As Howard said, in the out-of-hospital setting where about 80% of cardiac arrests are cardiogenic CCR makes sense from a public health perspective. Depending on where you work and whether you exclude ED arrests, about 80% of in hospital arrests are NOT cardiogenic. i.e. they are more likely to benefit from intubation. In a very strong system it would be reasonable to use CCR in hospital in select cases that are likely to be cardiogenic.

Martin M. -

Excellent PodCast.......!

Howard M. -

Tyler V. - Thank you for your comments. I agree wholeheartedly. CCR works best to bring folks out of cardiogenic cardiopulmonary arrest during the circulatory phase of arrest (which begins 2-3 minutes after arrest). We know that the majority of out of hospital arrests are cardiac in origin. We further know that the overwhelming majority of them occur at home. CCR is all about public health. It is a system designed to help the most people, most often. It simplifies the EMS response towards aiding those who can be aided when assistance generally arrives >4 minutes after the arrest. But the "in-hospital" is generally different for many reasons.

That said, we do need to be careful in the hospital of two lessons from CCR. First, consider using a BVM instead of a tube in order to minimize interruption to compressions (which are key regardless of etiology). Second, be aware of how frequently the patient is ventilated (8-12 bpm as recommended by the AHA is generally sufficient as artificial respirations do have a "cost" in terms of cardiac circulation) .

Fred L. -

I don’t recall you mentioning how the diagnosis of cardiac arrest was confirmed under the new protocol. If one rapidly starts CCR on every unresponsive patient in whom pulses are not felt, is there a chance that you may over diagnose cardiac arrest which would result in apparently better outcomes?

Yogesh N., Dr -

Why an IO and not just an IV for adrenaline in OOHCA?

Howard M. -

Fred L. - If a patient had CPR ongoing on EMS arrival (the usual state of affairs due to dispatch pre-arrival instructions) and the patient remained unresponsive, then you are correct, an assumption of arrest was made. If no pre-arrival CPR, pulses were checked before compressions initiated. That said, there were no cases that I can recall where a ROSC circulation was documented during the first round of EMS compressions after pre-arrival CPR. Additionally, the rate of OOHCA was not different between the years pre and post the protocol. Lastly, our experience is similar to that which has been previously reported in the literature (in terms of relative percentage increase in survival).

Yogesh - The IO route is preferred as it is generally faster, more reliable (in terms of first attempt success), and can almost always be performed without stopping compressions.

Thanks for the questions!

Michael S., -

Yogesh--We did the randomized trial below here at Mecklenburg EMS Agency. I was very good at getting IV's and EJ's on people in cardiac arrest with one or two attempts, but I'm pretty much perfect at getting tibial IO's on the first attempt. Not a big fan of humeral IO's because there is too much action/movement near the shoulder.

Ann Emerg Med. 2011 Dec;58(6):509-16. doi: 10.1016/j.annemergmed.2011.07.020.
Intraosseous versus intravenous vascular access during out-of-hospital cardiac arrest: a randomized controlled trial.
Reades R, Studnek JR, Vandeventer S, Garrett J.

CONCLUSION:
Tibial intraosseous access was found to have the highest first-attempt success for vascular access and the most rapid time to vascular access during out-of-hospital cardiac arrest compared with peripheral intravenous and humeral intraosseous access.

Toyo T. -

CCR is a concept that is wide spread here in AZ, introduced about 5-6 years ago. We have been doing this in my residency program (in the ED) for the past couple years.

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Episode 145 Full episode audio for MD edition 218:18 min - 103 MB - M4AEM:RAP Resumen October 2013 Español 97:28 min - 67 MB - MP3EM:RAP 2013 October MP3 266 MB - ZIPEM:RAP October 2013 Written Summary 2 MB - PDFEM:RAP October 2013 Board Review Questions 641 KB - PDFEM:RAP October 2013 Board Review Answers 658 KB - PDF

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