Dr Singer returns for a discussion of cardiac arrest and post ROSC best practices

Stay and play vs. load and go - load ang go is for trauma patients

Old ideals get moving to the hospital, care enroute

Good evidence that staying for cardiac arrest cases for optimal outcomes

EMS can do what the hospital does in the ACLS realm, with only a few exceptions

• PE's

• Hyperkalemia

• Maternal Arrest

• Refractory VF/VT

• Hypothermia

Care during extrication and transport is inferior to stationary care 

Care on scene - defined "where that patient fell" 

Assuming safe scene,  bring equipment to the patient

Moving patient to ambulance can be detrimental 

• May miss opportunities to deliver meds or defibrillation

• Likely providing suboptimal ventilations during move

• CPR without machine is going to be poor during move

eCPR cases may need to transport sooner to make the window for ECMO

The stay and play mindset not applicable in these cases

This is for select departments near to ECMO centers

Once in ambulance, patient must go to hospital 

Can still terminate efforts if in ambulance, but cannot put them back on the scene after

If resuscitation terminated in ambulance, it is not necessary to run hot to hospital

We are not in the business of getting ROSC, we are in the business of neuro intact recovery

Code Stat data is used to detail quality after the event

Used for quality improvement 

Tools

Proper kit setup to take the right gear to the patient 

Review your equipment and design your kit accordingly

The bag is not supposed to be a portable ambulance

What's needed to resuscitate without going back to the truck

Rehearse the process

When calling for DOA / Field Termination be succinct

State what you need.... Ex. We are calling for consideration of field termination

Time sensitive interventions

CPR

Defibrillation - if shockable must be done quickly before the window is missed (monitor/defib)

Epinephrine - early administration yields the most optimal outcomes (vascular access)

Delaying these reduces neurological outcomes

Refractory VFIB / TACH - already in a bad spot

Review interventions to this point

Review H&T's

Electrical vector change

Double sequential defibrillation

Consider other unused anti-arrhythmics

Points for improvement

• Minimize CPR pauses - CPR during defib charging - shock through CPR devices, only stop if manual CPR and immediately resume

• Never hold compressions for airway - use supraglottic if unable to intubate during CPR - Practice VL during CPR

Field Termination

The Co2 target is not an absolute for termination

Likely higher with mechanical CPR

If Co2 <10 regardless of optimal CPR, likely non-salvageable patient

Low Co2 is still telling of probability of outcome 

Post ROSC Care

Work is not "done" once ROSC is obtained

Biggest threat to patient is re-arrest

You just got pulses back, didn't likely "fix" the underlying problem

Optimize EVERYTHING before moving the patient

Optimize oxygenation - consider PEEP if patient refuses to oxygenate despite high FiO2

Optimize ventilation - Follow Co2

Optimize BP - fluids and / or vasopressors

Multiple IV's or IO's

Have fluids spiked and ready to go if not needed right now

Prepare push dose epi

Take the airway now if not already done

Leave CPR device in place in case of re-arrest

Place C-collar (maybe trauma caused arrest, if for nothing else to help keep airway in place)

Sedate if patient wakes up combative after arrest or preventing ongoing resuscitation

Don't exchange supraglottics unless is not working - If its not broken....

Consider PCI destination based on post-arrest EKG 

Leave 12 lead on - machine will auto-analyze if changes occur