The Young Resuscitation

[joeDO2]

Had yet another "young" resuscitation the other night, 50 something, unknown etiology, no clues. These are extremely frustrating to me. What do you all use as your "protocol"? Sure, we all do the normal ACLS stuff epis, good compressions, airway. Most of the time there is no apparent reversible cause- ie glucose normal, bilat lung sounds, no pericardial effusion on u/s. Seems like there is no evidence for anything including bicarb, calcium, etc. If there was some clue as to the origin like a known PE history, known ingestion, there is some other stuff to try but usually its brought in by EMS with little to no information. Looking for some guidance from the seasoned attendings on this. Anything you routinely try in a last ditch effort for the young ones?

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[RustedFox]

tPA.

Hat tip to dChristismi for this'n.

Either they have an embolus, and you save the day... or they have an aneurysmal bleed, and they were dead anyways.

Nothing stopping you.

 

[alpinism]

First make sure you cover all the easily reversible causes of cardiac arrest (Hs/Ts and Wide/Narrow algorithm)

Further options:

- Overdose - Narcan, Bicarbonate, Glucagon, Insulin, Lipid Rescue (Polysubstance ODs can mask normal signs)
- Poisoning - Oxygen and Hydroxyocolbamin (Hard to pick up clinically once in cardiac arrest)
- Massive PE - Fluids and thrombolytics (U/S is helpful to check for signs of PE/DVT)
- Internal bleed - Blood and REBOA (U/S is helpful to check for bleeding)

If available you can also do eCPR and place the patient on ECMO until you can find a cause.

 

[carbonizedeyesockets]

Improve the EMS system including public access defibrillation, bystander CPR training, etc. If EMS routinely transports codes, the patients are probably getting to you too late to do anything meaningful and they're getting poor CPR on the way to you.

 

[InternistDO]

Improve the EMS system including public access defibrillation, bystander CPR training, etc. If EMS routinely transports codes, the patients are probably getting to you too late to do anything meaningful and they're getting poor CPR on the way to you.

My EMS service tripled or quadrupled our OOH cardiac arrest save rates when we switched to staying on scene for 30+ minutes for codes instead of transporting rapidly.

 

[canigetawhatwhat]

Tpa.

Stemi and PE are both treated

 

[BAM!]

My EMS service tripled or quadrupled our OOH cardiac arrest save rates when we switched to staying on scene for 30+ minutes for codes instead of transporting rapidly.

It didn't help Princess Diana. ;P

 

[InternistDO]

It didn't help Princess Diana. ;P

Haha well I was talking about medical arrests, though who am I to question the French healthcare system.

 

[gman33]

There are plenty of things you can try in the arrest of unknown cause.

Probably the best thing you can do is to try to get more history.
Compressions, epi, etc, that's pretty cookbook stuff.

Have the nurses keep doing that stuff and try to talk to the family if at all possible.
Either in person or on the phone.
You might get a piece of info that changes everything.

I'm not a fan of pushing TPA or doing other low yield stuff without some info that supports it.
Not that there is any real harm if the person isn't coming back anyway.


One thing I do in most younger arrests is give high dose narcan immediately on arrival.
That's mainly because where I work, that's one of the most likely reversible causes in a younger patient.

 

[Doctor Bob]

My EMS service tripled or quadrupled our OOH cardiac arrest save rates when we switched to staying on scene for 30+ minutes for codes instead of transporting rapidly.

How did it affect your discharge-with-good-neurologic-function statistics?
I find that most of these prolonged down time in the field codes turn out poorly. It would have been easier on the families had the person just been declared dead in the field (or imminently on arrival to the ED), than to get a pulse back and have to watch them linger for days before making the tough decision to withdraw life support.

Of course, you can't know which people will be which when you start a code, but if 15-20 minutes in you don't have ROSC... it's very rarely a "win" to get ROSC at 30 minutes.

 

[msgsk]

Out of curiosity, has anyone ever had ROSC after empirically administering tPA? If so, did the patient ultimately have a PE or MI? Or did they just happen to have ROSC and the tPA was no harm no benefit...

 

[InternistDO]

How did it affect your discharge-with-good-neurologic-function statistics?
I find that most of these prolonged down time in the field codes turn out poorly. It would have been easier on the families had the person just been declared dead in the field (or imminently on arrival to the ED), than to get a pulse back and have to watch them linger for days before making the tough decision to withdraw life support.

Of course, you can't know which people will be which when you start a code, but if 15-20 minutes in you don't have ROSC... it's very rarely a "win" to get ROSC at 30 minutes.

It improved them. The previous method used at work was to do about ten minutes of CPR, which was enough time for 2/3 rounds of epi, plus an advanced airway and a fluid bolus followed by zipping off lights and sirens to the ED. I think our total survival was like 2%. We would also transport patients who had no chance, unwitnessed older patients found in asystole and the like.

Now we spend more time on scene doing basic CPR, and in addition we were pronouncing a significant amount of patients who didn't respond to ACLS on scene. I'm sure among the significantly increased neurologically intact save rate are a decent amount of patients who will either die in the ICU or linger in acute care homes but I'm not sure if there's a way to separate the two on scene or even in the ED.

I'm in school now so I don't have access to the actual data until I go home for breaks.

 

[engineeredout]

US to help eval for reversible problems.

Consider hail-Mary's such as tPa, esmolol, dual sequential defibrillation in the right patient.

20 years from now? Get them cannulated for ECMO

 

[carbonizedeyesockets]

How did it affect your discharge-with-good-neurologic-function statistics?
I find that most of these prolonged down time in the field codes turn out poorly. It would have been easier on the families had the person just been declared dead in the field (or imminently on arrival to the ED), than to get a pulse back and have to watch them linger for days before making the tough decision to withdraw life support.

Of course, you can't know which people will be which when you start a code, but if 15-20 minutes in you don't have ROSC... it's very rarely a "win" to get ROSC at 30 minutes.

Any EMS system worth its salt measures outcomes in terms of survival to hospital discharge and similarly measures survival with CPC 1 or 2 (CARES makes this easy for many services). It's expected that most codes with long down time will have bad outcomes, but there is research showing that there are people who survive with reasonably good neuro function despite down times much longer than 20 minutes and they survive frequently enough to make the effort (15% even with down time of 50-60 minutes in one study). As of now, good CPR on-scene by EMS will save more lives than ECMO, esmolol, TPA, and dual-sequence defibrillation combined. And I would say that most EM physicians (and even EMS physicians) overlook just how important good CPR is, which is why so many seem to look to silly gadgets like the ITD, LUCAS, and putting paramedics on any big truck even though many EMS systems achieve phenomenal results without relying on such gadgets or over-staffing with paramedics (Seattle/King Co, Wake Co, Boston, etc.).

 

[BoardingDoc]

Out of curiosity, has anyone ever had ROSC after empirically administering tPA? If so, did the patient ultimately have a PE or MI? Or did they just happen to have ROSC and the tPA was no harm no benefit...

Yeah. I did a couple of months ago. Guy came in s/p arrest. Had a hx of pancreatic ca. Nothing else I could think of on Hs/Ts except PE given his hypercoagulable state. Pushed it and got rosc maybe 5 min later.

 

[carbonizedeyesockets]

Yeah. I did a couple of months ago. Guy came in s/p arrest. Had a hx of pancreatic ca. Nothing else I could think of on Hs/Ts except PE given his hypercoagulable state. Pushed it and got rosc maybe 5 min later.

You sure it wasn't the epi?

 

[BoardingDoc]

You sure it wasn't the epi?

Nope, not sure. He had gotten 4 rounds already with no response. Maybe it just finally kicked in. Maybe it was the tPA. IDK. Just answering the question.

 

[dchristismi]

I'm glad someone else mentioned esmolol and dual defibrillation - only works for refractory VF, but worked for me once. I was honestly pretty surprised - I'd tried the dual defib on 2 other patients, but it wasn't until I threw in the esmolol that the electrical storm aborted. If I had time, I'd find the article where I first read about it.

TPA is sort of a pipe dream, but if you're really going to try everything...

 

[Doctor Bob]

It improved them. The previous method used at work was to do about ten minutes of CPR, which was enough time for 2/3 rounds of epi, plus an advanced airway and a fluid bolus followed by zipping off lights and sirens to the ED. I think our total survival was like 2%. We would also transport patients who had no chance, unwitnessed older patients found in asystole and the like.
Now we spend more time on scene doing basic CPR, and in addition we were pronouncing a significant amount of patients who didn't respond to ACLS on scene. I'm sure among the significantly increased neurologically intact save rate are a decent amount of patients who will either die in the ICU or linger in acute care homes but I'm not sure if there's a way to separate the two on scene or even in the ED.
I'm in school now so I don't have access to the actual data until I go home for breaks.

Any EMS system worth its salt measures outcomes in terms of survival to hospital discharge and similarly measures survival with CPC 1 or 2 (CARES makes this easy for many services). It's expected that most codes with long down time will have bad outcomes, but there is research showing that there are people who survive with reasonably good neuro function despite down times much longer than 20 minutes and they survive frequently enough to make the effort (15% even with down time of 50-60 minutes in one study). As of now, good CPR on-scene by EMS will save more lives than ECMO, esmolol, TPA, and dual-sequence defibrillation combined. And I would say that most EM physicians (and even EMS physicians) overlook just how important good CPR is, which is why so many seem to look to silly gadgets like the ITD, LUCAS, and putting paramedics on any big truck even though many EMS systems achieve phenomenal results without relying on such gadgets or over-staffing with paramedics (Seattle/King Co, Wake Co, Boston, etc.).

I'm going to take these two together.
So, I'll start by saying I'm primarily an ICU doc these days so my denominator is only the people who get a pulse back because otherwise they don't come to me. And that's one way to adjust the numbers and show improvement in research; exclude a group. If you don't transport someone who doesn't have ROSC after 30 min of on scene CPR, and then look at the percent of people who make it to the hospital who ultimately have good neuro outcomes, then yes your numbers improve. Admittedly I haven't done an exhaustive lit-review, but that's been my problem with pre-hospital EMS studies. They would compare new data of hospital outcomes with old data which included all of the pre-hospital dead.

I've currently got 2 people on the service with >10 minutes of CPR time, and both are neuro wrecks. In the past month that number rises to 11, all of whom are neuro wrecks. I have to go back about 3 months to get one with a decent neuro outcome with greater than 10 minutes of CPR. That's purely anecdotal however, and the plural of anecdotes isn't data.

And good quality CPR is vitally important. Which is why it's such a problem pre-hospital. In a big well trained EMS system that (sadly) sees a lot of fresh full arrests, you can have well trained medics. But most EMS systems country wide aren't that way. Heck, we can't even get a lot of ED techs and hospital techs to give good quality CPR. What works in Seattle/King Co, etc, isn't really feasible in smaller agencies.

I don't know what the right answer is. It's probably not grab and run (lots of dead bodies will get transported that way). I'm not sure staying on scene for a half hour is the best plan either. But I'll leave it up to the EMS directors to figure out what makes the most sense for their system, and I'll just take care of the fallout.

 

[msgsk]

Nope, not sure. He had gotten 4 rounds already with no response. Maybe it just finally kicked in. Maybe it was the tPA. IDK. Just answering the question.

Do you know if he had radiographic evidence of PE after ROSC? Any idea if he walked out of the hospital?

 

[evilbooyaa]

It improved them. The previous method used at work was to do about ten minutes of CPR, which was enough time for 2/3 rounds of epi, plus an advanced airway and a fluid bolus followed by zipping off lights and sirens to the ED. I think our total survival was like 2%. We would also transport patients who had no chance, unwitnessed older patients found in asystole and the like.

Now we spend more time on scene doing basic CPR, and in addition we were pronouncing a significant amount of patients who didn't respond to ACLS on scene. I'm sure among the significantly increased neurologically intact save rate are a decent amount of patients who will either die in the ICU or linger in acute care homes but I'm not sure if there's a way to separate the two on scene or even in the ED.

I'm in school now so I don't have access to the actual data until I go home for breaks.

DoctorBob already addressed this in his post, but to re-iterate - If you are comparing quick transport (let's say 10 mins pre-hospital) to staying out in the field (let's say 30 mins pre-hospital), all of the extra people that you declare dead in the field between minutes 11-30 need to be included in your survival comparison numbers.

Focusing on the bolded - If you bring dead bodies (that are likely to stay dead) to the ED in arm #1 but not in arm #2 (30 minute CPR), and your metric is "What percentage of arrests survive through their ED course", then of course arm #2 will look better. That's not of any significant clinical significance.

It's a very admirable goal to improve arrest-survival percentage, but I'd take a step back and wonder HOW you're getting that improvement.

 

[InternistDO]

DoctorBob already addressed this in his post, but to re-iterate - If you are comparing quick transport (let's say 10 mins pre-hospital) to staying out in the field (let's say 30 mins pre-hospital), all of the extra people that you declare dead in the field between minutes 11-30 need to be included in your survival comparison numbers.

Focusing on the bolded - If you bring dead bodies (that are likely to stay dead) to the ED in arm #1 but not in arm #2 (30 minute CPR), and your metric is "What percentage of arrests survive through their ED course", then of course arm #2 will look better. That's not of any significant clinical significance.

It's a very admirable goal to improve arrest-survival percentage, but I'd take a step back and wonder HOW you're getting that improvement.

To answer both of your questions, our survival rate is based on worked cardiac arrests, so any non traumatic arrest that has any form of CPR performed, whether or not they are transported. Patients pronounced after 20-30 minutes of CPR would count as part of the rate, patients who were determined not to be viable (rigor, lividity, etc) would not. So for us the overall number of intact saves increased, as well as the rate, even including those who were left on scene dead.

I think the data is pretty clear on effective and early CPR and defibrillation being the primary determination of outcome in OOH arrests. It's also fairly clear that patients who do not achieve ROSC after an aggressive EMS resuscitation in the field are extremely unlikely to have neurological recovery, and coupled with the fact that CPR in a moving ambulance is of very poor quality, I think that makes rapid transport a bad choice, unless in certain cases like refractory v-fib with mechanical CPR in place so the patient can go directly to the cath lab (even then I would say wait for at least ten minutes so you can shock multiple times).

As for length of time on scene I'm not really sure. I do know that longer scene times in pediatric arrests are associated with improved outcomes, right in the time range we're talking about (http://www.resuscitationjournal.com/article/S0300-9572(15)00258-0/abstract?cc=y=), I think I remember a study that found that witnessed vfib/vtach arrests did best with less than 30 minutes of CPR which also falls into this same time frame, but I can't find it right now.

 

[gman33]

I can't find the study, but i know there is a European study that showed patients who didn't get cpr had a higher survival rate.

I'll see if I can get that one through my irb.

 

[InternistDO]

http://jamanetwork.com/journals/jama/fullarticle/181606

This is not the study I was looking for, and I can't find anything in here about scene times, but approach is similar to what we implemented.

 

[Vandalia]

One thing I do in most younger arrests is give high dose narcan immediately on arrival.
That's mainly because where I work, that's one of the most likely reversible causes in a younger patient.

And the not so young patient. I am willing to rule out drugs of abuse as a cause in non-ambulatory nursing home patients. But, other than that, it has to be a consideration for everyone else in these types of cases.

When I first started you could pretty much rule out illicit drugs if the patient was older than 30. Perhaps a bit over if there was a positive "hippie sign." Now, one of our pain management physician tells me he sees abnormal urine drug screens in 60+ year olds. A tiny fraction of the rate for those under 40, but present nonetheless. When you add in a possible (un)intentional overdose of prescribed meds, I don't think you can rule this out when you are faced with a resuscitation and you have no clues why it is happening.

Sure, the 95 year old who "dropped dead" while eating a donut with the grandkids watching and they bring in to play out the string probably just "dropped dead." But if drugs are a possible cause, then drugs are a possible cause.

 

[e30ftw]

I have never given narcan for a patient in cardiac arrest.

If the patient overdosed on opiates, became apneic, then suffered a profound hypoxia sufficient to cause myocardial death/dysfunction resulting in cardiac arrest (ie, not perfusing), the patient's primary pathology is no longer opiate overdose. Narcan will not affect the irreversible neuronal death which occurs within 5 minutes of hypoxia and supporting the patient's ventilatory and cardiac systems as is done in every ACLS protocol ED arrest treats opiate overdose anyway, regardless of narcan administration.

Opiate overdose does not require an "antidote". Narcan prevents living patients from dying but does nothing for the dead.

Am open to evidence-supported views to the contrary, just curious why it's being mentioned outside of "It couldn't hurt.."

 

[gman33]

I have never given narcan for a patient in cardiac arrest.

If the patient overdosed on opiates, became apneic, then suffered a profound hypoxia sufficient to cause myocardial death/dysfunction resulting in cardiac arrest (ie, not perfusing), the patient's primary pathology is no longer opiate overdose. Narcan will not affect the irreversible neuronal death which occurs within 5 minutes of hypoxia and supporting the patient's ventilatory and cardiac systems as is done in every ACLS protocol ED arrest treats opiate overdose anyway, regardless of narcan administration.

Opiate overdose does not require an "antidote". Narcan prevents living patients from dying but does nothing for the dead.

Am open to evidence-supported views to the contrary, just curious why it's being mentioned outside of "It couldn't hurt.."

I have at least 5 patients this year who presented in cardiac arrest, got narcan, and left the hospital with no deficits.

 

[namethatsmell]

Do you know if he had radiographic evidence of PE after ROSC? Any idea if he walked out of the hospital?

I had a pt recently who came in pea after flagging down an ambulance complaining of SOB. Pt arrents en route and after compressions+4 doses of epi in the ED got a pulse back long enough for a bedside echo (which I was honestly standing by with to document standstill) that showed clear RV dilation. Pushed tpa and after another 15 mins of working pt had sustained pulses. CT showed multiple bilateral PEs, probably remnants of a saddle. Pt walked out of hospital neuro-intact.

I've otherwise not had success in the maybe 3 other codes I've tried to lyse. There's some more anecdote for ya.

 

[carbonizedeyesockets]

I'm going to take these two together.
So, I'll start by saying I'm primarily an ICU doc these days so my denominator is only the people who get a pulse back because otherwise they don't come to me. And that's one way to adjust the numbers and show improvement in research; exclude a group. If you don't transport someone who doesn't have ROSC after 30 min of on scene CPR, and then look at the percent of people who make it to the hospital who ultimately have good neuro outcomes, then yes your numbers improve. Admittedly I haven't done an exhaustive lit-review, but that's been my problem with pre-hospital EMS studies. They would compare new data of hospital outcomes with old data which included all of the pre-hospital dead.

I've currently got 2 people on the service with >10 minutes of CPR time, and both are neuro wrecks. In the past month that number rises to 11, all of whom are neuro wrecks. I have to go back about 3 months to get one with a decent neuro outcome with greater than 10 minutes of CPR. That's purely anecdotal however, and the plural of anecdotes isn't data.

And good quality CPR is vitally important. Which is why it's such a problem pre-hospital. In a big well trained EMS system that (sadly) sees a lot of fresh full arrests, you can have well trained medics. But most EMS systems country wide aren't that way. Heck, we can't even get a lot of ED techs and hospital techs to give good quality CPR. What works in Seattle/King Co, etc, isn't really feasible in smaller agencies.

I don't know what the right answer is. It's probably not grab and run (lots of dead bodies will get transported that way). I'm not sure staying on scene for a half hour is the best plan either. But I'll leave it up to the EMS directors to figure out what makes the most sense for their system, and I'll just take care of the fallout.

When EMS systems look at cardiac arrest survival, they calculate it as (survivors/total resuscitations attempted). There has been an attempt to standardize definitions and data collection via the Utstein Template (http://circ.ahajournals.org/content/110/21/3385.long). Many systems will report "survival" according to the "Utstein definition", which is generally accepted as the % survival of patient who presented to EMS with a bystander-witnessed arrest (EMS-witnessed arrests are excluded from this) for whom the initial rhythm was shockable. There is NO EXCLUSION from these calculations if the patient is not transported, only if a resuscitation isn't attempted (e.g. obvious death or DNR).

To be sure, places like Seattle/King Co., Boston, and Wake Co benefit from a population that is healthier at baseline than places like Baltimore or Philadelphia. However, Baltimore and Philadelphia are not known for quality EMS. While some cities may never be able to achieve the same survival rates as others (if all EMS factors were the same), there is no question in my mind that most cities could improve survival if they modeled themselves on "high performing" systems.

As far as poor CPR, you get what you expect/demand. If you do not expect good CPR and thus do not demand good CPR, you will not get it. But, to get techs, EMTs, and paramedics to consistently give high-quality CPR, you need to train, measure, and actively work to improve. Most physicians don't want to make that effort. Too many think of cardiac arrest resuscitation as futile and and an act of "going through the motions" whether prehospital or in-hospital.

As far as early or late transport - there's never been an RCT as far as I know of rapid or late transport. Almost all (if not all) of the systems with the best outcomes do not routinely transport with CPR in progress. I know of many services that had large improvements in survival when they stopped rapidly transporting cardiac arrests. I think the future of cardiac arrest resuscitation will be identifying which small subset of patients would benefit from rapid transport for an intervention such as ECMO (though if you're in Paris, a doc will come to the scene and implement ECMO, even if you're in the middle of a gallery in the Louve). As of right now, the standard of care should be to work it on scene unless it's trauma. But, we should realize that even in the best systems, the majority will die - death will be very common, but survival is possible