Cite this post as:
Scott Weingart, MD FCCM. Podcast 82 – Mind of the Resuscitationist with Cliff Reid. EMCrit Blog. Published on September 17, 2012. Accessed on January 20th 2025. Available at [https://emcrit.org/emcrit/mind-resuscitationist-reid/ ].
Financial Disclosures:
The course director, Dr. Scott D. Weingart MD FCCM, reports no relevant financial relationships with ineligible companies. This episode’s speaker(s) report no relevant financial relationships with ineligible companies unless listed above.
CME Review
Original Release: September 17, 2012
Date of Most Recent Review: Jul 1, 2024
Termination Date: Jul 1, 2027
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thanks guys for an awesome podcast. v helpful. its not easy to share challenging cases in public so appreciate the effort! Asystolic arrest with cardiac standstill on echo..tough case right off the bat! Cliff, sounds like you gave excellent care from a clinical and human factors viewpoint. I understand your agonising. it means you care about what you do. You have passion and fire for clinical excellence. thats cool! Scott, about your question regarding smaller hospitals and transferring to larger tertiary ones, the evidence suggests benefit in severe trauma and STEMI. For cardiac arrest of uncertain origin, zero evidence area… Read more »
agree with all of that my friend
Thanks for such a great podcast. Sorry I have nothing to add. As a young doctor all I can say is that I truly appreciate the work you guys do and the fact you guys share it with us to learn and improve the care we give our patients.
thanks brother!
I would love to hear more on no external compressions in Traumatic arrest.
Minh……we participated in the “Aspire” trial and used the Autopulse years ago. Simply put it did great CPR……….however the trial was suspended early due to safety measures and some data that in the V-fib arrest it had worse out comes. We as field staff never understood that but alas the Autopulse machines disappeared from our rigs early in the trial.
the ext compressions discussion was in podcast 81 with karim brohi. i can’t wait for 1 of the ext compression devices to bear out in safety tests. human cpr is a joke and a relic.
The problem with the ASPIRE trial was having survival to discharge as a secondary endpoint…a primary endpoint of “survival to 4 hours” does not help resus research in the long run.
Really enjoyed this Scott, engaging and thought provoking, with a few pearls as always. I think the “mind of the resuscitationist” reflects Cliff’s caring and striving for an optimal outcome, rather than just unthinkingly following an algorithm. That demonstration of “care factor” would have been a great learning point for his team, and now for us too.
Cliff radiates caring with his every word and action. truly a great guy!
Such a great discussion. Thanks Cliff and Scott for bring to light some great resuscitation pearls. I wanted to add a few comments. 1. As far as lines in cardiac arrest: I have completely gone to using IO lines. I place humoral IOs in all our cardiac arrests and have moved away from any central line use. It’s faster, cleaner and less likely to have a complication. We’ve been doing this for a while with enormous success as far as getting faster lines with fewer complications. The nurses are also more willing to hang pressors with the IO lines vs… Read more »
great comments. Cliff and I actually discussed adding intra-arrest hypothermia for this case. Cut it b/c of time. I too would offer it in these cases.
As to CPAP, I feel the ultimate intra-arrest ventilation would be a NC at 15 lpm, an impedance threshold device with a face mask hooked up to CPAP between 10-15 cm H20
Scott,
My understanding of the work that led to the impedence threshold device is that applying a CPAP or PEEP to a pt in cardiac arrest is exactly what you should NOT be doing. The ITD creates a larger negative intrathoracic pressure with chest recoil by limiting airflow into the lungs, thus improving venous return to the heart. PEEP will apply a positive pressure to the lungs and thus impair venous return.
In cases where I leave a pt on the vent in a cardiac arrest, I turn the PEEP to 0.
Do you have a different understanding?
Sean Agree that is why the ITD must be there. But now I am thinking the ITD would not impede the CPAP in its current form. So I’d actually want the ITD to block the CPAP except for 10 episodes/per minute. My whole thinking is to eliminate the need to time breaths.
Haha, I think you just spun full circle… An intermittently delivered CPAP is exactly the same thing as a pressure control breath with 0 peep.
The design of the ITD is such that you give a positive pressure breath with O2 delivered during that breath and in between breaths you give no gas flow at all. If you buy into the ITD concept, you have to abandon the passive oxygenation idea, the jury may be out but my reading of the literature suggests that’s the smart bet.
Sorry, Let me clarify my question: the use of CPAP in the intubated patient or with a supra-glotic device. Not in the unintubated or secured airway.
In response to “The Ethics of Different Capabilities at Geographically Close Hospitals.” I think it is tough to bypass any ED with an asystolic patient in the back of the ambulance even if the trip to a quaternary medical center is 15 minutes further. I am in a metro area where there are several community hospitals < 30 minutes from the university hospital. For trauma, STEMI and stroke certainly bypass the community hospital. I would suggest bypassing for the cardiac arrest patient with prehospital ROSC who remains unconscious. This patient would benefit from hypothermia and PCI not readily available at… Read more »
not sure what these small hospitals have to offer that the medics are not already providing. If these pts are going to make it, they need a center that can provide perfect hypothermia, meticulous post-arrest care, cath, and in a few years ED ECMO.
I agree that in a medical arrest small hospitals don’t have much more to offer.
However in the case of traumatic arrest U.S. medics can perform needle thoracostomy but are unable to perform chest tube or prehospital thoracotomy. A smaller hospital with an ED should be able to provide these procedures. We know CPR and ACLS drugs don’t help the traumatic arrest patient and that is what EMS is offering on the way to the trauma center.
It all depends on the capabilities of the hospital you are considering bypassing and the capibilities of the hospital you would be diverting to. I would argue that small hospitals (really anything under a Level II trauma center) offer little-to-no benefit to trauma/trauatic arrest patients and in most cases actually harm them by increasing the time to definitive care. In fact, every traumatic arrest that I have ever seem brought into any non-trauma center by (ALS) EMS has been called at the door. In most areas of the US, EMS protocols have been updated to reflect these realities, and they… Read more »
http://www.resuscitationcentral.com/circulation/content.aspx?id=2250
DOn, later stuff after ASPIRE indicates benefit with Autopulse . No COI declared here from me.
As for traumatic arrest, if chest compressions help everyone , I think that’s ok . I mean I don’t think they are going to hurt
they hurt by not getting you to do what the patient actually needs. if you can’t do a prehospital thoracotomy, then by all means give chest compressions.
Mate, agree with you on penetrating trauma and witnessed arrest = prehospital thoracotomy.
blunt traumatic arrest = evidence base the same as CPR and epinephrine = not much evidence for traumatic arrest benefit.
clinical equipoise = CPR as good as thoracotomy in blunt traumatic arrest
I challenge you to the case of Princess Diana. When she arrested on extrication from her car, they gave her CPR which achieved ROSC. Would a prehospital thoracotomy have been a superior technique for her arrest?
the full Scotland Yard report into her accident and prehospital care is here
http://downloads.bbc.co.uk/news/nol/shared/bsp/hi/pdfs/14_12_06_diana_report.pdf
Another interesting issue is the use of atropine. The 2010 guidelines took atropine out of the asystolic and PEA guideline with a IIb recommendation, however most of the medications in ACLS have a IIb recommendation. If you look at the references they used to make the decision to remove atropine from the guideline they were published before hypothermia was routinely utilized. In a number of the studies they say there was greater success of ROSC using epi/atropine than with epi alone but they had a worse neurologic outcome. I wonder if this would still exist in the hypothermia age?
I’m a believer that atropine may be effective for selective cases of asystole in which you are right there and the arrest is the likely result of a surge in parasympathetic tone (https://www.kg-ekgpress.com/acls_comments-_issue_07/#Survival%20Differences%20IN-%20vs%20OUT-%20Hospital ). While not harmful – it sounds like the arrest in this case is not related to enhanced parasympathetic tone – but rather PEA from likely large acute STEMI – in which case atropine is unlikely to have any effect … (Like Cliff said for the question about trying Bicarb – “sure” if you want – though wouldn’t expect atropine to work in this case).
can’t disagree in those circumstances
Great discussion – although I almost crashed my car at 6am driving to work because I was so caught up in listening to the podcast! In my corner of the UK, where we have a Physician/Paramedic HEMS team, our policy is to carry out resuscitation at scene until we either get a ROSC or we call it. We don’t transport patients in arrest unless there are exceptional circumstances (e.g. paediatric, severe hypothermia). As Minh points out, human provided CPR in the back of a moving vehicle (land ambulance or worse, helicopter) is really ineffective. Once we’ve achieved a ROSC we’ll… Read more »
Thanks for this one Scott and Cliff. It really brought back memories and feelings a case I had a couple months ago which in my mind mind really pointed out the inequalities in health care distribution between hospitals in close (or not so close) proximity. I work in a metropolitan area that has 2 main tertiary centers and multiple surrounding community EDs. I work at one of the tertiary centers and two of the community EDs. Most higher levels of care (PCI, trauma, stroke…even OB) have been relegated to the larger hospitals leaving the other community EDs with nice shiny… Read more »
Coming from an RN, great show, I love listening to and picking Intensivist minds about cases, it allows me to see your thinking in cases and allows me to broaden my education and thinking to allow better patient care as well. I know in this situation Dr. Reid did not have access to, but if you did what about an implant of bilateral Ventricular Assist Device?? I understand this would be much more work and time consuming and Ecmo would be preferred for oxygenation and decrease workload, but if one was able to sustain this patient to the operating room… Read more »
What a great podcast from a great bloke. Cliff I shared a few chest thud eye wipes during that one….. With the provision of prehospital care being ever more advanced in most developed countries I can’t see the that the argument of going to the nearest holding any water. As Scott said there is nothing worse than dead, and CPR is merely a bridge to definitive care. The caveat is that there is plenty of evidence showing that CPR in a moving vehicle is ineffective and hazardous to the user. I think IPPV with an impedance threshold device, some form… Read more »
Thanks for the great feedback and comments. I had intended to bring up automated CPR in the conversation. We used the LUCAS device routinely in my UK ED for years and it felt really barbaric coming to Australia and watching everyone do it the caveman way. I was used to patients coming into ED having been intubated in the field and the nurses would apply the LUCAS immediately and we’d put the patient on a ventilator. No-one had to think about BLS – it was delivered far more effectively by machines and that way all action and thinking could be… Read more »
Cliff, I would encourage you to please consider recording a podcast on the automatedCPR and your current opinion, either on resusme, here or on my show. I do not normally support the notion that technology should replace basic skills and tactics, for example, I do not believe now that video laryngoscopy should ever replace direct laryngoscopy. However in chest compressions and BLS, I do wonder what benefit we are doing by training people via costly courses and trying to get them to provide excellent BLS in oft difficult conditions. ?…when we have devices that can do it better and longer… Read more »
Thank you for a great podcast
Do you have a autopsy to further learn from?
I had the same questions. Cliff???????
Haha, I think you just spun full circle… An intermittently delivered CPAP is exactly the same thing as a pressure control breath with 0 peep. The design of the ITD is such that you give a positive pressure breath with O2 delivered during that breath and in between breaths you give no gas flow at all. If you buy into the ITD concept, you have to abandon the passive oxygenation idea, the jury may be out but my reading of the literature suggests that’s the smart bet. Not spun around, it just sounds that way b/c I am explaining myself… Read more »
I’m still confused about what you are trying to accomplish, my friend. Re-reading your posts I gather the following: a BLS paramedic crew without training in intubation or supra glottic airways, taking care of a pt in cardiac arrest in the amb en route to your ER. It seems you are suggesting this pt gets15 LPM NP, a tight sealing facemask on top hooked up to the ITD and then a portable CPAP machine, not a BVM. I don’t have first hand experience with the ITD but think I understand the mechanics involved. Depending on whether you set the CPAP… Read more »
Nope, in its current form, ITD allows all ventilations in from above. It doesn’t allow ventilations in from below until you overcome the spring valve. Not talking a CPAP machine, CPAP set-up like the Boussignac or Flowsafe. Cost of the ITD is not to allow for this set-up, it is b/c I believe in the concept of the ITD. Would need only the alteration of only allowing breaths in during the time for breaths, i.e. 1 every 6 seconds for a period of 1 second. Given the ITD already has a timer built in and the valve structure, shouldn’t be… Read more »
Ok, finally with you. The ITD would have to be modified as you mentioned, almost becoming an oxylator in addition to an ITD. But the concept is a good one to me. Would allow for set it and forget it ideal ventilation during a code, allowing personnel to focus attention elsewhere… Now you just need to invent it.
Cheers!
yes I was thinking about the oxylator whilst reading the two of you debate the setup! But currently as Sean says the oxylator would need a modification to avoid delivering positive pressure all the time. To be honest that whole setup you two describe sounds freakin complicated. What Cliff described of using the LUCAS and then a standard ventilator in ED resus sounds much simpler and feasible. Prehospital resus you could still do that if you got a ventilator If not then something like this might be even simpler and doable http://www.harvardapparatus.com/hapdfs/HAI_DOCCAT_1_2/VT46.pdf Note how they used a mechanical chest compression… Read more »
Thanks,- great talk.
Minh,
Vent is easy to say and hard to use (though it is what I use during arrest). What Sean and I have been going back and forth about is extremely difficult to say and idiot-proof to use. If you think trans-trach is easier still then you are a better man than I.
I’m with Minh on this one, just give me a vent.
Since we are into the increasingly theoretical realm of reimagined equipment already, perhaps we could imagine a “cardiac arrest hotkey” on a ventilator… To instantly change your settings to those appropriate for an arresting pt. This might pass your simplicity test as nicely as your alternative, Scott.
Thanks for listening Henrik and Michael
There are worse things than dead- neurologically devastated with a resuscitated heart comes to mind.
???
Hey Scott, Thanks for the podcast as always, but I’d like to chime in on your question on the thought of regionalized care for patients post-cardiac arrest. Minh pointed out above that regionalization of care has resulted in improved mortality for trauma and it is believed to improve mortality in patients with STEMI. However, the RACE project and data published in Annals of this year suggests that the overall reduction in mortality in pre-hospital transferred patients with STEMI was similar amongst hospitals not involved in the program. Additionally the overall reduction in mortality seen nationwide based on medicare/medicaid data also… Read more »
Regardless of ECMO and PCI, the reason patients do better at cardiac arrest centers is familiarity with the post-arrest syndrome and the ability to respond to it aggressively. While the data are not clear, studies are bearing this out, for instance Carr’s work.
Most small hospitals can’t pass muster for full-bore critical care. There are some that can and these centers should definitely be able to become arrest centers.
Forgive me b/c of my youth (as I’m only a couple years into EM training), but to me resuscitation centers make sense. Why send a patient that needs specialized care to a place that only performs that care a few times a year? My point is that the patients I remember the most are the one’s that I have made mistakes and learned from. Places that only see a “few” cases really can’t get this same experience. I’m not just talking about physicians either. I’m talking nursing, RT, protocols that have been attempted and revised, specialist referrals and expertise that… Read more »
Joe Wrote: “I think it is tough to bypass any ED with an asystolic patient in the back of the ambulance” I think it is tough to justify starting to the ED with an asystolic patient in the back of the ambulance. In an extraordinary case, like the one described by Cliff Reid, yes. But there should be a very good reason. Sure it sucks to pronounce someone dead while you’re looking at their kids’ artwork on the fridge or family pictures on the mantle, but that is part of prehospital medicine. In most cases, field pronouncement is the responsible… Read more »
absolutely agree. AHA’s prehospital termination rules look pretty reasonable as an objective criteria.
I enjoyed podcast and found interesting from academic standpoint. I work in small community hospital, single MD coverage. I would have called code with asystole and cardiac standstill on US regardless of age . Let’s say on case discussed in podcast that ROSC was achieved, in reality is there any chance pt would have left neurologically intact? If not then doing exercise of prolonged ACLS/resusitation, especially in single coverage ER, prevents all other ER pts from receiving care and adds extreme cost to case study pt (say if you got him to ICU for day or two) without return to… Read more »
Steve. With hypothermia, these patients do leave the hospital neuro intact. The rate is ~10%; not great but not nothing.
Sorry I’m a bit late in the discussion, just listened to this podcast. Love the show Scott – makes me think every time. I want to comment on the “travel to nearest hospital” issue. All of the above commentary has focused on possible improved outcomes for the occasional patient. I am an advocate for the nearest hospital because I work in a community hospital and see the problems of ambulances bypassing me with trauma, STEMI, stroke, anyone who might potentially need tertiary care. The big hospital is 45 min away. The issues are: 1. I have 10 consultants (attendings) and… Read more »
Wow Chris – You open a whole “can of worms” in terms of whether to “bypass” the “nearest hospital” or not. In primary care (where I taught and worked for 30 years until recently retiring from practice) – there were similar issues of this “Catch-22” where one becomes very good at what one does – but then gets caught into a vicious cycle being less good when not regularly “doing” a procedure – leading to doing even less and less. As you state – BEST to find that “happy medium” between when to go to the “Big House” vs the… Read more »
Chris, There are 2 ways to run a small shop. You can have the classic community hospital: the ED doc is the only actual doc in the house at night, no tertiary services, ICU is actually seeing what would predominantly be step-down pts in other hospitals, etc. In these places, the ED can be top-notch, but the pt will not do well. We in the ED only provide a small portion of a sick patient’s care. or You can run a small shop with all of the services, but just less of each doc in each dept. For instance you… Read more »
Interesting study from Korea, which I’ve not yet read in detail: Regionalisation of out-of-hospital cardiac arrest care for patients without prehospital return of spontaneous circulation Resuscitation. 2012 Nov;83(11):1338-42 STUDY OBJECTIVES: The aim of this study was to evaluate the risk of prolonged transportation against the benefit of treatment in high-volume centres for out-of-hospital cardiac arrest (OHCA) patients without prehospital return of spontaneous circulation (ROSC). METHODS: This study used a nationwide EMS-assessed OHCA database (2006-2008). Patients with cardiac aetiology were selected from the registry. A high-volume centre was defined as a hospital that received an average of more than 33 cases… Read more »
Interesting comment Cliff (!) – and without access to PubMed I don’t have the original article. Clearly the large numbers of patients studied is impressive – but looks like it is a data registry (ie, retrospective) – and lots has changed in just the past couple of years in this country – so unknown how the 2006-08 experience in Korea compares to what is currently being done. Potentially problematic with this study is the “unknown” of why patients went to a “high-volume” vs “low-volume” center (some self-selection?) – and I’m curious as to why an average of “33” (rather than… Read more »
not really much of a difference in transport times. previous studies agree with this, post-arrest patients do better at centers that are experienced with post-arrest care. another one to add to the database.