Well, cardiac arrest is an emergency, until we get there. By we I refer to any prehospital provider, be it a BLS fire crew, ALS ambulance, or any combination thereof.
We should, of course, treat any and all cardiac arrest with alacrity. We of course know the things that we as providers need to focus on doing: performing quality chest compressions, providing prompt defibrillation (if warranted), securing the airway, and providing ventilations. These are all things that have been shown to have any usefulness, and are all BLS interventions, at least where I work.
Once any reversible causes of cardiac arrest have been treated, and once those interventions I just mentioned have been performed, there isn’t much else to do. Sure, the AHA says we should give epinephrine to cardiac arrest every 3-5 minutes. But epinephrine doesn’t save lives in cardiac arrest.
My system frowns upon pronouncing cardiac arrest in the field. It’s been done, but pretty rarely. We have a few doctors at the hospital who are more than willing to call an arrest when requested by telephone, but the majority insist on transport to their hospital. The vast majority of providers in this area, be it firemen or ambulancemen, would never think to pronounce a patient at a scene without signs of obvious death, so the call to the doctor never gets made.
“But asystole is a sign of death!”
“No it’s not; asystole is a workable rhythm!”
Asystole is, of course, an absence of electrical activity in the heart. The heart is done. Finished. Checked out. It sucks, yeah, but it’s going to happen to each and every one of us at some point.
In my years in EMS, I have been a part of 15 cardiac arrest saves. Not a single one of those saves received a single drug prior to their conversion to a normal rhythm. Some of those did receive some drugs, be it amiodarone, lidocaine, or whatever, but not one got any medication prior to converting into a perfusing rhythm. Not one.
I have performed CPR on at a minimum, hundreds of patients in asystole. Not a single one of those has ever been resuscitated. Not one.
Asystole is a confirmation of death, and not a workable rhythm.
If we can wrap our heads around that fact, then we stand a better chance of gaining more respect in the healthcare field.
Funeral homes don’t drive as fast as they can to the hospital to have someone pronounced dead. Why do we?
My experience is pretty much the same as yours. Drugs play a role in post resuscitation stabilization, but to what extent we still don’t know.
My anecdotal experience is that any asystolic or profound bradycardia saves I’ve had have been from correcting airway problems, not from giving a drug which might well make a cardiac problem worse. As Rogue Medic might says, the plural of anecdote is war stories, not data.
Still the AHA declared as far back as 2000 that asystole was more a confirmation of death than a condition to be treated.
I think there are a number of reasons EMS systems won’t allow their medics to cease resuscitation efforts in the field. One might be distrust of their paramedics, another might be that they can’t bill for non transports and resuscitation efforts are pretty expensive. Of course some day some where, an EMS system is going to get sued for the injuries caused by a vehicle collision that occurs when an ambulance is racing to a hospital with a dead person. Then, more EMS systems will change their incredibly insane policies of transporting all cardiac arrest patients, even the ones that have zero chance of resuscitation.
I might quibble with you on the demonstrated usefulness of those last two interventions!
Which two? Quibble away!
Not much benefit shown for intra-arrest airway and ventilatory support… with perhaps a few exceptions.
Ahh. Good quibble.
Last month I had a code. Pt had a witnessed arrest, co-workers did CPR and used an AED prior to our arrival and shocked once. When I arrived it was right after the shock. I placed her on my monitor and she was in asystole. I placed an ET while my emt got the IV, before I gave any drugs, I rechecked the rhythm and she had converted to sinus tach. She was also a STEMI Alert. She is alive, at home and fine today. You can’t just write someone off due to asystole. In our system we do 3 rounds and if we do not get ROSC, we terminate the code and do not transport. Unless they are in a public place or in a hostile environment etc.
The presenting rhythm in your case was VF or VT as evidenced by the AED delivering a shock. This is not the same scenario as described by CCC.
Thanks, Christopher.