Welcome again to the AmboFOAM podcast. This is part one of two episodes on cardiac arrest. These podcasts are again designed for the new paramedic or paramedic student. This time we are discussing cardiac arrest, primarily why we do what we do at an arrest. Part two will deal with the post-arrest patient and why we do what we do with them.
Please feel free to drop me a line with any comments or questions you may have.
Click to play, or right click and select “Save as” to download the MP3 version to play later.
Enjoy
AmboFOAM 
Reblogged this on PHARM and commented:
AMBOFOAM Arrest PODCAST Pt 1. TUne in and listen up to Rob!
I wholeheartedly agree Rob!
Certainly all patients who are in cardiac arrest deserve to have a resuscitation attempt considered, and if it is not not in the best interest of the patient or not otherwise inappropriate then it must be attempted. ACLS was not, as you say, designed for the 90 year old person with 300 comorbidities or the patient who is dying of end-stage disease and largely housebound or has a severely reduced HRQOL for some other reason. I did once read in one of the AHA publications that ACLS is designed to manage “the first 10 minutes of a cardiac arrest until more specialised help arrives”. Well, that may be all well and good in an American hospital where the crash team with a bunch of Doctors on it can show up and take over; but out in the real world and not in US medical fantasy land such is not the case. I know I am preaching to the converted but careful consideration must be given to whom resuscitation is attempted on as there are times when it is not in the best interest of the patient yet I have come across some people who can’t seem to get their head round the idea that 95 year old Nana who has severe end-stage COPD and cannot walk two steps or a patient who is ventilator dependent and has a GCS of 3 on a good day are not ideal candidates for resuscitation because “that was not taught to them, nor is it in my protocols and ZOMG! they doez not have teh signed DNR”. Now that brings me to advance directives and such; certainly it is not unreasonable for all advance directives (including clearly described verbal directives) to be considered and if the patient has a clear wish then it should be followed; shame that the legislative regimen in some jurisdictions does not allow such. Now obviously if Moneybags X. Inheritance Jr. III is holding a pillow over their relative to get his will to pay out but is saying “Grandad don’t want no code!” then that a bit different, but you get the idea …
ROSC is a fallacy as far as an endpoint or outcome measure is concerned; it’s not a meaningful thing to measure; yes it is true that we must have ROSC to have neurologically intact survival however it is akin to saying you put some diesel in the ambulance but were not able to respond to the cardiac arrest because there was a big hole in the tank and it all drained out. It was extremely disheartening to see the UK Ambulance Clinical Quality Indicators adopt “ROSC” over “neurological survival to discharge” mind you, I believe these UK indicators are being adopted in New Zealand however I cannot confirm this so perhaps we drank the same Kool Aid?
Oh please, oh please can we just get rid of adrenaline in primary cardiac arrest? I know again I am preaching to the converted but it needs to just be withdrawn already! It was stated that in 2009-10 that there was not enough evidence (yet) to remove it from New Zealand however, one could interpret that as saying the powers-at-be are waiting for enough evidence. Intubation, as you say I am indifferent to, I think the biggest issue is avoiding inadvertent hyperventilation and decreased venous return through raised intrathoracic pressure. We all know carbon dioxide is a cerebral vasoconstrictor so I wonder if hypocapnoea (hypocarbia) so I cannot help but wonder if in this setting it has an effect as well i.e. causing cerebral ischaemia. If we avoid secondary brain injury and impaired venous return then I do not think it matters what piece of plastic you use. Certainly an LMA is cheap, easy to insert, requires minimal skill (hell if I can learn how to do it …) and should work well unless the patient is vomiting copiously. Certainly I am all for RSI in the post-arrest patient but is the subject of a discussion in itself …
Certainly cardiac arrests are important. They are infact so important they even get their own special dispatch detriment all of their own (echo in MPDS or what NZ calls “purple”) however I will say this, if 1% of the effort that is put into cardiac arrest survival was put into the other 99% of patients seen on the street I wonder what that would look like …
I have only ever had ONE successful cardiac arrest resuscitation where the patient walked out of hospital; it was a witnessed arrest in a park; a police officer got almost immediately first and started CPR, the fireys turned up two minutes later and gave him a couple shocks with the AED and then the ambulance arrived. By the time we came to repatriate him he was up and talking and out of ICU (1.5 days later). So yeah …
Righto, thanks for the opportunity to have a spiel, look forward to part two!
Ben Hoffman
Emergency Medical & Retrieval Coordinator | Auckland, NZ
Clinical Development Analyst | CARE
Bottom line, we need more community CPR. Train everyone – schoolkids, sporting clubs, cafe owners – best outcomes will be for the witnessed arrest, immediate CPR and prompt defib – think Fabrice Muamba
Absolutely. It’s not “sexy” for us working codes, but the biggest bang for bucks comes from getting people in the community jumping up and down on chests and if possible using defibs. Research into cutting edge stuff is great, but unless the basics are done right it is a futile effort.
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