A few tweets sparked a debate (big surprise there) and suddenly there was a storm of opinions on whether OOH cardiac arrests should be transported or terminated in the field. Well, since I do not debate on twitter anymore, I needed a person to speak with on the topic–and there is no better than Howie Mell.
Steel-Man Rules for this Debate
- Any time you want to contradict the other discussant, you must first restate the views they have just stated and confirm with them that you are understanding correctly. If you can bolster their point even more strongly before contradicting, this is even better.
- No ad-hominem attacks (i.e. attacks on the person, not their views. Feel free to politely destroy the views)
- Logical fallacies should be pointed out
- Try to state whether a viewpoint is based on evidence, and what quality or based on your clinical practice
Accepted as Given?
- We are dealing with Adults
- Asytole without signs of life should be run and terminated in the field
- There are EMS services and EDs where EMS does a better job running the arrest than the ED, in those venues EMS should run almost all codes to field termination
- There are some venues where nothing (nothing!) additional gets done in the ED beyond what EMS can do, in those venues EMS should run almost all codes to field termination
The Questions
- What is a public health view of EMS vs. a medical view?
- What is the best approach to <75 y/o vfib/vtach/PEA patient without end-stage comorbidity?
- Can we safely get these patients to the ED?
Cardiocerebral Resuscitation (CCR)
- Watch Ben Bobrow's vid
- Search for Pit Crew CPR to see amazing coordination and perfect, continuous hand cpr
Beam Me Up Scotty?
if we had teleporters…
Can We Safely Transport?
Take Out 1-2 Shocks from the Field Success Rates
and everything changes!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
why is this cheaper?
Things I Can Do in the ED
- Ultrasound
- TEE
- Arterial Lines
- Esmolol
- DSD
- Multiple Antidysrhythmics for Electrical Storm
- Cath Lab
- ECMO
- Blood
- Pericardial Drainage
- Thrombolytics
3 Scenarios for when a Resus Center can make a difference
Vfib shocks to Sinus and then Regresses
these patients almost always have a coronary lesion and there is NOTHING the field management can offer these patients. Even if they don’t you don’t have the monitoring to keep these patients in sinus. multiple pressors/varied pressors
Electrical Storm
there is nothing the field is going to accomplish in these patients
PEA
- what you can fix—hypoxemia
- what you can’t accurately diagnose
- tension pneumo
- what you can’t
- bleeding
- pericardial tamponade
- PE
- SAH
- what you sort of can
- hyperk
- toxicology in most protocols
Additional New Information
More on EMCrit
Additional Resources
You Need an EMCrit Membership to see this content. Login here if you already have one.
- EMCrit 373 – Mike Weinstock with another Critical Care Bounceback: “Asymptomatic Hypertension” - April 18, 2024
- EMCrit Wee – Ross Prager on 10 Heuristics for the New ICU Attending - April 13, 2024
- EMCrit 372 – FoundStab Intubation SOP - April 5, 2024
Another element you should list as Accepted as Given: you are talking about US EMS.
Almost everything you mention as “can only be done in ED” can also be done out of hospital with a properly trained Physician/Nurse team. Most of Europe already does this: after moving the ICU to ED you should start to move the ED to the street… 😉
See, and here is where I’ll disagree again on the numbers game. This is a public health cost issue. How many people could be saved by a doctor/nurse team responding to every cardiac arrest versus CCR by medics? What is the cost per QALY (quality adjusted life year)?
The European Health Systems that provide advanced ALS teams all have health costs much much much much lower than US… it can definitively be done without breaking the bank. Italy, France, Germany, Sweden and many more are all testimony to it.
Agreed.
Trials/Practice Guidelines ongoing outside the United States evaluating prehospital POCUS, Esmolol, DSD by Paramedics as well as prehospital ECMO, pericardiocentesis by Physicians.
I feel the system in Ontario Canada where I am is navigating both sides of this debate fairly well. – Focus is on good CPR/CCR above all else (acls, airway) – Primary care medics (No ACLS) shooting to be off scene with viable cardiac arrest patients in 8-12 minutes, terminating resuscitation for non-viable arrests – Advanced care medics (ACLS trained) making a transport/terminate decision with online medical direction after 3rd dose of EPI with all the factors described in the debate considered with said medical direction. – Fact of the matter: very few true “resuscitation centers of excellence” exist outside… Read more »
Fantastic discussion . . . I agree with most but disagree on a few points. The MaineCrit podcast tackled this issue a few years ago – link is attached. We offered 7 specific considerations for a transport (or not) decision. Face shield down : ). In a nutshell, I believe that viable patients with a suspected underlying cause that cannot be corrected in the field should be transported if the ED can address their pathology (Tamponade, PE, and certain metabolic/tox patients come to mind right off). The trick is that EMS must identify possible causes right off, not stay on… Read more »
I agree, to transport a cardiac arrest patient to hospital means moving them from the scene into the back of the ambulance. Often this takes a good few minutes of carrying them down some flight of stairs, or through the house etc. on a board or carry sheet where CPR quality is horrendous. Poor quality CPR during this extrication could be deadly. Have a look at his great new paper comparing CPR in different locations (stretcher, floor, loading etc.) https://ajp.paramedics.org/index.php/ajp/article/view/563
Many EMS don’t have LUCAS, and should not move patients from scene.
Great debate and a fun listen, thanks. One question/thought: you referenced a study on CCR without naming it, were that you were referring to the Nichol, et al ROC study?
I always get worried when I hear those results being thrown around. Their methods for performing CCR is NOT what’s going on in Arizona and elsewhere. Instead of passive oxygenation in the continuous compression group, they instead just forced ventilations through an unprotected airway with a BVM, which discounts a lot of the potential benefits of CCR (decreased intrathoracic pressures, less gastric bloat, etc.).
Fantastic debate gents and I think you honed in the best answer, that it depends, I work in a very progressive EMS system, but we’re smack dab in the middle of the Rock mountains, and the closest cath lab is at best an hour away on a good day, regardless of the transport modality. Our local level 4 at best will do an ultrasound… at the end of the day, I think public health cost issue/utilitarian model is where we need to rest our laurels on. I’d love to see the concept of a resuscitation center within an appropriate amount… Read more »
Scott – always been a big fan and enjoy hearing your stuff. Wish I hadn’t heard you diss a huge percentage of your colleagues, many of whom have given 30-40 years of their lives to work all hours on the disadvantaged, sick with no apparent cause: generally the vast majority of people that need our care, because: a) they are not as cool as you, b) they struggle to keep up with the pace of advances in our field and can’t do it all and feed themselves and/or c) work in smaller places with limited resources I am fortunate to… Read more »
What time frame would consider a good time frame to transport. Say for instance I’m in city a we have no echo around us, the nearest one is 30-40 min in the middle of the night. Rush hour is just stupid long. Is 30min transport worth ir? Is 40 min or an hour? What time would you go for. Now I agree any vfib/vtach pat should be transported. Pea/asystole let the medics play.
if you can get them there in less than 65 minutes from arrest, you are right in the ballpark for the positive trials in VF/VT