calling a code

[GiJoe]

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asystole....easy



when do you call a code when the rhythm is v fib? i've had a couple where the rhythm is persistently v fib despite coding for for 30+ min and we called it. are there any medicolegal implications to this considering it technically is a shockable rhythm? even if you code the person for that long.... their brain is fried

same question for pea -- -what if it's organized rhythm?

 

[po' boy]

dead is dead. all of the above are terminal rhythms, shockable or not.

if you've run through the algorithms and there's no response after 30+ minutes, you're done. even if by some miracle you could bring them back at that point, would you really want to? there's ethical implications as well as medicolegal ones.

just my .02

 

[Altruist]

when do you call a code when the rhythm is v fib? i've had a couple where the rhythm is persistently v fib despite coding for for 30+ min and we called it. are there any medicolegal implications to this considering it technically is a shockable rhythm? even if you code the person for that long.... their brain is fried

same question for pea -- -what if it's organized rhythm?

In my past life as a paramedic, this came up a couple of times. Our medical director's opinion was that the treatment for refractory v-fib x 30 minutes is to turn off the monitor, for the reasons Po'boy listed. Not that you couldn't get sued, but given the survival for v-fib in the best of circumstances is so low, it would be an uphill climb to prove it's your fault the person stayed dead... but god knows what a lawyer could come up with. (FWIW, amiodarone seemed to be pretty effective at converting refractory v-fib to asystole; I can't recall a situation like you described after we started using it, but we also switched to biphasic defibs around that time, which might have been the reason. Or just luck of the draw.)

For PEA, if you have ultrasound handy, take a look to make sure there's no ventricular motion, then call it. Otherwise, pretty much the same deal.

$0.02 from an ex-medic.

 

[MSmentor018]

dead is dead. all of the above are terminal rhythms, shockable or not.

if you've run through the algorithms and there's no response after 30+ minutes, you're done. even if by some miracle you could bring them back at that point, would you really want to? there's ethical implications as well as medicolegal ones.

just my .02

yep...no need to keep flogging a dead horse

 

[SoCuteMD]

asystole....easy



when do you call a code when the rhythm is v fib? i've had a couple where the rhythm is persistently v fib despite coding for for 30+ min and we called it. are there any medicolegal implications to this considering it technically is a shockable rhythm? even if you code the person for that long.... their brain is fried

same question for pea -- -what if it's organized rhythm?

PEA - you should look with ultrasound. Can do the same for v-fib.

At the end of a prolonged code, we've been told to say "Mr. X has now been down for 45 minutes. We've given 4 rounds of epi, 4 of atropine, 2 of vasopressin. We've established central access and given a gram of calcium gluconate. We've had no return of spontaneous circulation. Does anyone have any other ideas that might help this man? Are there any objections to ceasing resuscitation efforts?"

 

[Dwindlin]

Pre-hospital in my area we can contact medical control for a order to stop after 3 rounds of shocks/drugs. I've never had a doc tell me to keep going after 3 rounds with no change.

 

[diphenyl]

When I call it after about 30 min's I usually like to use the ultrasound, document no wall motion present regardless of the whether they are in v fib or PEA. Nobody has ever come back from that.

 

[Dwindlin]

I see several mentioning confirming with ultrasound. I know there was a post a while back talking about trying to move US into the field. While generally I am against adding more and more "toys" what are thoughts on US for prehospital codes?

 

[Mighty Mouse]

I ditto what SoCute said. Talking out loud like that at the end accomplishes a few things...helps you review what you've done so far for the guy...helps everyone understand where your head is at....gives a chance for new ideas.....and gives a chance for objections. There's strength in numbers. From a medicolegal standpoint, if the whole room is in agreement, its hard to fight against that. I had a nurse object to calling it once....that was a bit more dicey. Once you open it up to somebody saying "keep going" you need to be prepared to keep going until all in the room are satisfied, even if you think its flogging.

 

[Hamhock]

if you are having internal conflict, it might help to remember that at any time, Vfib is dead...often I think even healthcare providers see Vfib on the monitor and think 'MUST KEEP GGGOOOING' and forget that the patient is dead
HH

 

[trkd]

Be careful how long you go for. Some people you don't want to get back (i.e. the one whose heart will restart and will sit on a ventilator for the next 20 years because they have a strong/healthy heart but no brain activity). Don't just think about the heart, you can't check the brain with an ultrasound for activity.

 

[jbar]

I'd argue that with a shockable rhythm in the field generally they should be moving towards transport. I'm all for sitting and working asystole for two rounds and stopping, but when I was on the rig we were usually transporting Vfib/Vtach/PEA so by the time that it was time to think about stopping we were at the hospital.

Sure it would be a use for prehospital ultrasound, but not sure that justifies putting $40,000 machines on a bunch of ALS ambulances.

 

[SoCuteMD]

I'd argue that with a shockable rhythm in the field generally they should be moving towards transport. I'm all for sitting and working asystole for two rounds and stopping, but when I was on the rig we were usually transporting Vfib/Vtach/PEA so by the time that it was time to think about stopping we were at the hospital.

Sure it would be a use for prehospital ultrasound, but not sure that justifies putting $40,000 machines on a bunch of ALS ambulances.

How did this become a discussion of presuming death in the field? The OP didn't mention it.

 

[richc]

How did this become a discussion of presuming death in the field? The OP didn't mention it.

It was in response to post #8 by atkinsje.

 

[name?]

Out of curiosity, are you guys talking cumulative efforts prehospital and in-hospital? We'll frequently get the people who have been given the full shocks, 3 rounds of drugs who are still PEA/vfib who have now been worked for 20-30 minutes in the field. I'm never quite sure what my responsibility is at that point. In our city, I've never heard a command line call for prehospital termination. Apparently there is fear of family violence if the patient isn't coded and transported. I've done as little as drag over the US and verify standstill to going for another full run-through of the ACLS protocols. Anyone else?

BR

 

[xaelia]

Be careful how long you go for. Some people you don't want to get back (i.e. the one whose heart will restart and will sit on a ventilator for the next 20 years because they have a strong/healthy heart but no brain activity).

Return to spontaneous circulation vs. survival to hospital discharge vs. functional independence.

A therapy can only be shown to be successful if you measure the correct outcomes.

 

[emtcsmith]

In our city, I've never heard a command line call for prehospital termination. Apparently there is fear of family violence if the patient isn't coded and transported. I've done as little as drag over the US and verify standstill to going for another full run-through of the ACLS protocols. Anyone else?

BR

You've never had a conversation with me.

On another note...I had a code in an assisted living facility today that I felt shouldn't have been worked or transported but I lost the battle of the "command line call"

Patient is an 88 y/o female witnessed arrest per staff on scene, no staff AED, poor CPR, presenting ekg-pea/pacemaker. Staff presents a DNR with the patient's paperwork. Now understand this is not an "PA OOH/EMS DNR" but basically makes the point she wants to remain dead when she dies clear. I called command and after the resident speaking with her attending she says she can't pronounce pea. So my answer was I have no other option but to work the code. The funny part was I said on the recorded line "but we field terminated PEA after going through all of acls a week ago?!"

 

[MSmentor018]

How did this become a discussion of presuming death in the field? The OP didn't mention it.

it's the usual SDN hijack....