Without evidence of benefit, an intervention should not be presumed to be beneficial or safe.

- Rogue Medic

Cardiac Arrest Management is an EMT-Basic Skill

The latest issue of Interventions is out – their Medical Direction Issue.

This is an important topic and I will write about it a bit.

First is an interview with Dr. Karl Sporer discussing several things about protocols. Dr. Sporer Interview.

The part that caught my attention was this (about 11 minutes in) –

The captain of that engine is running that cardiac arrest. His job is to make sure there are good chest compressions and to make sure that the medics, when they arrive, don’t get in the way of good chest compressions.

It is an EMT-Basic skill to run a cardiac arrest now. The paramedics just get in the way.

Medics should not take offense at this. We have been misled by the AHA (American Heart Association) through the ACLS (Advanced Cardiac Life Support) guidelines (not protocols, not Standards Of Care) to believe that paramedic treatment is important.

The AHA does encourage paramedic treatment, but they do point out that there is no basis for this treatment.

In addition to high-quality CPR, the only rhythm-specific therapy proven to increase survival to hospital discharge is defibrillation of VF/pulseless VT. Therefore, this intervention is included as an integral part of the CPR cycle when the rhythm check reveals VF/pulseless VT. Other ACLS interventions during cardiac arrest may be associated with an increased rate of ROSC but have not yet been proven to increase survival to hospital discharge. Therefore, they are recommended as considerations and should be performed without compromising quality of CPR or timely defibrillation. In other words, vascular access, drug delivery, and advanced airway placement should not cause significant interruptions in chest compression or delay defibrillation. There is insufficient evidence to recommend a specific timing or sequence (order) of drug administration and advanced airway placement during cardiac arrest.[1]


Epi image credit. Tube image credit. Lido image credit.

CPR and defibrillation matter.

ACLS does not, but they still want us to use these treatments, because they are hopeless optimists.

If we view leaving the hospital able to enjoy life as survival, then the ACLS treatments do not work.

When we use intubation, epinephrine, amiodarone, or lidocaine does not matter, because there is no evidence that these treatments work.

What order we use when we use intubation, epinephrine, amiodarone, or lidocaine also does not matter, because there is no evidence that these treatments work.

What do medics need to know?

 

We need to stop over-thinking CPR.

 

[youtube]sXBQru0IJcY[/youtube]

See also –

Cardiac Arrest Management is an EMT-Basic Skill – The BLS Evidence

Cardiac Arrest Management is an EMT-Basic Skill – The Hands Only Evidence

Footnotes:

[1] Part 8.2: Management of Cardiac Arrest
Part 8: Adult Advanced Cardiovascular Life Support
2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care
Free Full Text Article with links to Free Full Text PDF download

.

Comments

  1. While I agree that the BLS only portion of the cardic arrest is an important part of ROSC success, I do not think that it’s the only important part. Once CPR and AED is out of the way, then what? Antiarrythmics, therapeutic hypothermia, IV access, cardiac monitoring to find out what is actually wrong, rapid treatment of reoccurring vfib, securing an airway and monitoring it,monitoring etco2…….I could go on but I won’t. Point is that als is equally as important for a good outcome.

    • @Cody Howe Right, but his entire point is that ALS interventions can wait until later and should never get in the way of proper basic CPR and defibrillation. ALS interventions should be done when BLS interventions haven’t been successful.

      • I would like to further comment on Anonymous directed towards Cody. This is a quite simple article that goes back to the age old adage of BLS before ALS. However, Cody, even after you have began and continued your BLS treatments of CPR and AED/Defibrillation, your patient may still be apneic and pulseless. Therefore, the antiarrythmic and cardiac monitoring are not going to do much good. I will agree with you that an airway does need to be secured and maintained, however, simply just using an OP or NP airway and secured, or to go one step more invasive, you could throw in a King LT, which has less of a chance of infiltrating the esophagus and blowing air into the stomach. And theoretically, yes, monitoring CO2 is helpful, but your standard ABCs should still be the first step in the resuscitation process. ALS can be a very successful intervention, if the scenario is perfect. Like stated in the article, the ALS procedures have not been stone cold PROVEN to be successful, whereas CPR has.

    • I am pretty sure the entire point of the article was to point out exactly how wrong what you said is. “CPR and AED is out of the way then what?” Are you kidding me? You are referring to CPR and AED like they are in your way. So where should I start…. Antiarrythmics, don’t increase successful outcomes i.e. ones that actually leave the hospital!! In a great number of EMS agencies therapeutic hypothermia is a post ROSC therapy if agencies even have the equipment on their trucks to keep cold IV fluids ready to go. IV access…um not giving drugs don’t need IV access. Cardiac monitoring to find out what is actually wrong….um lets see place finger over carotid, no pulse, start CPR… you don’t need a $10,000 piece of equipment to tell you the patient doesn’t have a pulse. Rapid treatment of reoccurring ventricular fibrillation……treatment for v-fib is CPR and its pretty rapid at a rate of 100 compressions a minute so I agree with you on that one. Securing an airway and monitoring it, even ACLS has said if you are getting adequate ventilation with a BVM there is NO need to intubate, but I will give you the benefit of the doubt that you meant securing with an OPA and BVM and by monitoring it you were referring to checking for good bilateral chest rise and fall. Monitoring ETCO2….really why? so you can see the very second ROSC occurs? Unless you pause for a pulse check and find a pulse or the patient physically pushes your hands off their chest you should not stop CPR or even be concerned with how much carbon dioxide their body is expelling. So now lets talk about the issue here. The issue is that paramedics get lazy, complacent, and excited to do ALS ‘things” either because they are brand new or burnt out. All they end up doing is decreasing quality of care. I of course am over simplifying this because no resuscitation effort or situation is the same. They all have different challenges, mistakes, and successes. I will agree that if during good BLS efforts a possible reversible cause is identified, a lot of them would require ALS intervention…..but those interventions really are not going to matter if you can’t circulate blood or move air in and out adequately and consistently. I really think EMS and Emergency care need to start from the ground up and stop using unproven treatments while doing a very poor job with the proven treatments. Once that happened and we had good baseline proven data we might be able to collect enough quality well collected and documented data on the other treatments. Everyone who has used Amiodarone or Lidocaine to correct a Ventricular Tachycardia with a pulse knows the stuff works when given correctly. Amiodarone has a pretty narrow therapeutic index and it won’t make a difference if it isn’t getting circulated because of poor, interrupted, or even fatigued CPR.

      • @ Mike You are spiltting hairs for a spring board to pound your chest, I am certain the idea was not that AED and CPR are litteraly ”in the way”, I belive the writer meant “when CPR and AED had been sucessful and no longer being applied”. You may climb back up on your soapbox now.

        • No soapbox, no pounding of my chest either. The great thing about writing out what you are trying to say for all to read is that you can put time and effort into how you say things, so as to make sure you can convey what you mean to. Which makes it easier for readers to draw conclusions based on wording and overall attitude of an idea. I was only pointing out the horrendous attitude towards CPR and the use of the AED that was apparent in how they were spoken of by Cody. So its easy to continue siting examples of it when you do the exact same thing. Honestly, “when CPR and AED had been successful and no longer being applied” is not only outrageous but I am sure it is not what Cody meant. However, if that is your attitude towards them let me point out to you that again there is no evidence for anything other than CPR and the AED working. Not to mention if “CPR and AED had been successful and no longer being applied” the patient would have ROSC and we wouldn’t be talking about resuscitation anymore.

        • E,

          @ Mike You are spiltting hairs for a spring board to pound your chest, I am certain the idea was not that AED and CPR are litteraly ”in the way”, I belive the writer meant “when CPR and AED had been sucessful and no longer being applied”. You may climb back up on your soapbox now.

          When CPR and AED have been successful, the patient is no longer in cardiac arrest. That is a different topic.

          .

          • True enough, but it is an important part of resuscitation all the same. Post-arrest management has been de-emphasized to the point of absence from AHA guidelines until the latest version reintroduced it to us.

            The best management of a cardiac arrest is to prevent it from ever happening to begin with.

      • Just one point regarding your diatribe;
        EtCO2 is also a marker of effective CPR. It has absolutely nothing to do with monitoring “how much carbon dioxide their body is expelling”. It will always be low in cardiac arrest because there is no gas exchange from the blood in the lungs – therefore it has nothing to do with serum CO2, which is much higher in an arresting patient. Prolonged low EtCO2 is also a marker of poor prognosis and could be a time to cease resuscitation in the field, as the AHA now advocates. Of course, this may not be applicable to you if your agency is urban, but certainly may be applicable to rural services with long transport times who may spend more time trying to provide ACLS in the field before transporting. EtCO2 monitoring also does not require intubation – you can do it with a combitube, LMA, or King LT.

      • Mike,

        I agree with almost everything, but there are a couple of things I disagree with –

        Securing an airway and monitoring it, even ACLS has said if you are getting adequate ventilation with a BVM there is NO need to intubate, but I will give you the benefit of the doubt that you meant securing with an OPA and BVM and by monitoring it you were referring to checking for good bilateral chest rise and fall.

        There is no evidence that ventialtion has a place in resuscitation, except for respiratory arrest.

        Monitoring ETCO2….really why? so you can see the very second ROSC occurs? Unless you pause for a pulse check and find a pulse or the patient physically pushes your hands off their chest you should not stop CPR or even be concerned with how much carbon dioxide their body is expelling.

        There is no reason for EtCO2 to be ALS.

        A lot of good information can be obtained from capnography.

        Here are some reasons –

        I expect that AEDs/manual defibrillators that can read the rhythm during compressions will become common.

        Defibrillation during compressions will become common. With polyethylene gloves or with a CPR Blanket to prevent conduction to the person doing compressions.

        If we don’t need to stop compressions for a rhythm check, for charging, or for defibrillation, that only leaves a pulse check. Capnography can do a great job of notifying us of a change in cardiac output. It can also be a great way to assess the quality of compressions. And it can be used to identify cases that are futile.

        Everyone who has used Amiodarone or Lidocaine to correct a Ventricular Tachycardia with a pulse knows the stuff works when given correctly.

        No. Patients treated with miodarone and lidocaine for VT (Ventricular Tachycardia) are usually just going to be cardioverted at the hospital later on. Both drugs are likely to be removed from the treatment of VT for the same reason that ACLS will eventually remove ALS treatments from cardiac arrest. They don’t work.

        Amiodarone results in less than 30% of VT going away – and that includes the patients who get better on their own. Lidocaine is so much worse, that it makes amiodarone look good by comparison. If we compare a real antiarrhythmic with amiodarone and lidocaine, the failure of these drugs becomes clear. Procainamide converts patients out of monomorphic VT at 3 to 4 times the rate of amiodarone and lidocaine. Why do we waste our time?

        Amiodarone has a pretty narrow therapeutic index and it won’t make a difference if it isn’t getting circulated because of poor, interrupted, or even fatigued CPR.

        The next revision of the ACLS will probably be the end of amiodarone and the end of lidocaine.

        .

  2. Very good information, a point of view interesting…

  3. I have seen this coming and am not surprised. With our modern advance in AEDs and Mobile Handheld ECG monitors…

  4. I taught CPR for ARC for 5 + years in the 80’s and am pleased to see this, however, I still feel that paramedics of the 70s and 80s, still have a large roll to play in cardiac resuscitation.

  5. Coming from a Paramedic I always tell my EMT’s or trainees that ALS after BLS, you cant do ALS protocols until you have went through your BLS protocols. Makes sense, but sometimes in the mass confusion of a call sometimes our adrenaline kicks in and we jump right into ALS, just stop take a second to breathe and think and just remember BLS before ALS

    • I will respectfully disagree.

      This mantra has outlived its usefulness, and should be relegated to history. ALS and BLS measures are done in concert with each other, and frequently overlap. As the multitasking providers we should all be, one person performing a specific measure should not prevent another from being done at the same time.

  6. I agree in some way with your point. But there’s something missing, and I don’t know if you are doing it on purpouse. It is clear (I really hope it is clear) that good quality CPR is the cornerstone of resuscitation, and there’ s no reason to delay or interrupt compessions, but for defibrillation. But, as Cody says, when BLS is covered, then what? You can transport your patient to the ER with a good quality CPR and shocks every 2 minutes. Or you can use that time to try to reverse the arrest causes. As you said, ACLS doesn’t assure the patient will leave hospital to live a happy life ever after, but neither does BLS only. I strongly support good quality CPR and defibrillation before even thinking of ACLS, but I don’t think it’s a good idea to wait until ER to give a treatment tha can be started early.

    • I think Rogue’s point is the only things proven to make a difference (i.e. treatments based on evidence) are continuous uninterrupted CPR, appropriate defibrillation, and therapeutic hypothermia. Only TH is decidedly ALS, and even then, that doesn’t come into play until later in a code.

      Our ALS procedures are all null and void without BLS and there have been no studies to date showing any improvement with the addition of ALS. At best we’ve shown that the addition of ALS to quality BLS only keeps the status quo (that’s excepting the initiation of TH, which studies haven’t conclusively shown prehospital initiation being absolutely required).

      So, as I teach it: as long as you’re doing continuous, high quality, uninterrupted CPR…I could care less what you do with the patient. Dress them up, do their hair, paint their nails; just don’t stop what works!

      • I’ll amend my 2nd paragraph with: …we also don’t yet know which ALSmedications/procedures should be used once we maximize our BLS improvements! No studies show improvements with antiarrhythmics. The only promising ALS study–in a high performing system–showed that epi will get you ROSC more often, otherwise still no improvement in survival to discharge.

        • Christopher,

          Epi = more ROSC, but no improvement in survival to discharge.

          Another way of putting that is Epi = more in hospital deaths.

          Epinephrine is bad for heart attacks.

          If anyone doubts me, ask your medical director what dose of epinephrine should be given to a heart attack patient.

          The most common cause of cardiac arrest is heart attack.

          Maybe we need to identify the heart attack patients before we give epi. Maybe then we wouldn’t just be changing the location of death with epinephrine.

          Therapeutic hypothermia is not a cardiac arrest treatment. TH is only used after resuscitation.

          .

      • Christopher, I couldn’t agree more with what you said… i will add, however, that ALS can actually cause worsened survival to discharge rates if the basics we speak about, good CPR and defib, are delayed or interrupted to perform the ALS interventions. In a high performing system, ALS interventions do not improve survival to discharge. In less than high performing systems, the ALS interventions probably reduce survival.

        • David B,

          Christopher, I couldn’t agree more with what you said… i will add, however, that ALS can actually cause worsened survival to discharge rates if the basics we speak about, good CPR and defib, are delayed or interrupted to perform the ALS interventions. In a high performing system, ALS interventions do not improve survival to discharge. In less than high performing systems, the ALS interventions probably reduce survival.

          We do not know what the best system would be.

          We have the current pit crew fiasco that is seen as important, even though there is no good evidence that ventialtions improve survival, but we refuse to accept that ventilations are not helpful in cardiac arrest from cardiac causes.

          .

    • Turbosinaboy,

      I agree in some way with your point. But there’s something missing, and I don’t know if you are doing it on purpouse. It is clear (I really hope it is clear) that good quality CPR is the cornerstone of resuscitation, and there’ s no reason to delay or interrupt compessions, but for defibrillation. But, as Cody says, when BLS is covered, then what? You can transport your patient to the ER with a good quality CPR and shocks every 2 minutes.

      Why transport dead bodies?

      Transport is just changing the location of death.

      If ALS does not work on scene, what magic is going to make it work in the hospital?

      Or you can use that time to try to reverse the arrest causes.

      If you can identify a reversible cause, go ahead, but epinephrine, amiodarone, and lidocaine do not treat reversible causes.

      As you said, ACLS doesn’t assure the patient will leave hospital to live a happy life ever after,

      No.

      That is not what I wrote.

      ALS treatments interfere with treatments that work.

      but neither does BLS only.

      Actually, the only cardiac arrest treatments that improve survival to discharge with good brain function are BLS only.

      Go back and read what I wrote again. You completely misunderstood me.

      I strongly support good quality CPR and defibrillation before even thinking of ACLS, but I don’t think it’s a good idea to wait until ER to give a treatment tha can be started early.

      It is not a good idea to transport dead bodies to the ED .

      Dead and not resuscitated on scene is not going to change by putting the patient in an ambulance and taking the dead body to the doctor to be pronounced.

      Dead is dead.

      .

      • Yes. You’re right. You didn’t say that, and I misundestood you. Need to say that was the idea I was geting from you.
        Having read all your replies I get what was missing (at least for me) in the context.
        It’s not ACLS or ALS by themselves but the actions that interfere with good quality CPR and defib (BLS), even more if those actions have not been scientifically proven as benefical.
        Those interfering actions would be: Drugs (epi, amiodarone, lidocaine) and ventilation (worst if trying to intubate).

        What sounds strange to me is that part you mention about the interview, where the captain of the engine is concerned about the paramedics getting in the way of the chest compressions. I mean, whatever LS protocol or guideline or procedure you are trying to perform there’s always BLS in the front line. That may be a side problem, that ALS providers could forget the importance of continuous chest compressions. But that would not be a problem on the guideline side, but on the performer’s side. For ACLS to be performed well there’s need of a lot of staff, where the leader doesn’t do other thing that coordinate the team. This way he/she can assure chest compressions are of good quality and switch provider. If you’re out of staff you will stick to BLS only. So, even if we talk about an absurd procedure like making the patient’s nails, if you stick to a good treatment there’s no need to compromise good quality CPR and defib. But, you would be wasting your resources.

        Now , as we are talking about there’s no evidence that drugs&ventilation provide any help at the end, and they could even be of more harm…. Now what? remove drugs from guidelines just by that? or doing so through a study?

        Would you agree on keeping epi in patients whose arrest is not from a heart attack? (that would still be in the experimental therapy as you stated)

        I have this idea stuck in my head, that no matter how absurd could a procedure be, it should not interfere with good CPR and defib. I don’t know about you, but I usually see the most flaws in the ER than in the field.

        • I wanted to sat Heart Attack, not Heat Attack 😛

        • Turbosinaboy,

          Yes. You’re right. You didn’t say that, and I misundestood you. Need to say that was the idea I was geting from you.
          Having read all your replies I get what was missing (at least for me) in the context.
          It’s not ACLS or ALS by themselves but the actions that interfere with good quality CPR and defib (BLS), even more if those actions have not been scientifically proven as benefical.
          Those interfering actions would be: Drugs (epi, amiodarone, lidocaine) and ventilation (worst if trying to intubate).

          Yes. We should probably not consider intubation until after ROSC (maybe if there is a specific problem that might be better handled by an ET tube, such as continuous vomiting). If there is an extraglottic airway in place at the time of ROSC, we should leave it in place unless there is a problem with the extraglottic airway. The same is true for treatment in the ED (Emergency Department).

          What sounds strange to me is that part you mention about the interview, where the captain of the engine is concerned about the paramedics getting in the way of the chest compressions. I mean, whatever LS protocol or guideline or procedure you are trying to perform there’s always BLS in the front line. That may be a side problem, that ALS providers could forget the importance of continuous chest compressions. But that would not be a problem on the guideline side, but on the performer’s side.

          I agree with you that it is a problem on the performance side, but I see it as more of a failure of oversight.

          This is what SFFD appears to be trying to correct.

          For ACLS to be performed well there’s need of a lot of staff, where the leader doesn’t do other thing that coordinate the team. This way he/she can assure chest compressions are of good quality and switch provider. If you’re out of staff you will stick to BLS only. So, even if we talk about an absurd procedure like making the patient’s nails, if you stick to a good treatment there’s no need to compromise good quality CPR and defib. But, you would be wasting your resources.

          I disagree about ALS requiring a lot of staff.

          Part of the problem is the ridiculous pit crew procedure.

          The pit crew is only important if we think that ventilation is important. Ventilation does not appear to be as important as doing the patient’s nails.

          Without ventilations, or ALS treatments, the pit crew idea is not needed. All that is needed is for the person doing compressions to switch before tiredness interferes with the quality of compressions. I do not see why the quality deteriorates so quickly that at 2 minutes we need to change. I suspect that it is a lack of understanding of the mechanics of proper comressions. Maybe it is that EMS personnel are not healthy enough to do what 80 year old little old people do on their spouses without much training.

          I used to have people tell me that we need at least 2 paramedics on a cardiac arrest in order to do everything. I would explain that it is all a matter of appropriate prioritization of tasks. The ALS is not important, but the compressions and defibrillation are important. The personnel requirements depend on the treatments we are providing. If we limit treatments to what works, then 2 people are plenty. There is no reason to move the patient until after ROSC or for ALS until after ROSC. There is no longer a need for compressions after ROSC, just as with other live patients. 🙂

          Now , as we are talking about there’s no evidence that drugs&ventilation provide any help at the end, and they could even be of more harm…. Now what? remove drugs from guidelines just by that? or doing so through a study?

          Drugs and tubes should only be used in controlled studies until there is some good evidence that a drug, or tube, or something else improves neurologically intact survival. I do think that calcium chloride should be used in the unusual cases of arrest believed to be due to hyperkalemia (dialysis patients and very wide complex rhythms 190 milliseconds or wider), but that is based on case reports and treatment of live patients. These patients are infrequent enough that a large study probably would not be able to enroll enough patients to be statistically significant. The same for trauma arrest and needle decompression to determine if they should be pronounced, but even chest compressions are not doing anything good in trauma. Ultrasound to look for heart motion to pronounce patients.

          Would you agree on keeping epi in patients whose arrest is not from a heart attack? (that would still be in the experimental therapy as you stated)

          How do we know that they did not have a heart attack? A 12 lead for VF/VT/asystole is not going to be helpful and delaying compressions for a 12 lead is not a good idea. A 12 lead during compressions would probably be all artifact. So, how would we know which patients are having a heart attack? I still think that there should be evidence of improved survival before implementing any treatment.

          I have this idea stuck in my head, that no matter how absurd could a procedure be, it should not interfere with good CPR and defib. I don’t know about you, but I usually see the most flaws in the ER than in the field.

          I don’t see enough ED treatment of arrests to be able to have any kind of comparable sample.

          I see a lot of horrible prehospital codes.

          No compressions.

          Interrupting compressions for all sorts of unhelpful procedures.

          Moving the patient quickly, rather than treating on scene.

          There is not much good cardiac arrest treatment that I see.

          .

  7. Its this line of logic that has led it to be ok to dispatch a bls unit with bls fire unit to a code in my city. We must save our ALS for the ALS abdominal pain calls, cause BLS can handle a code. I respectfully disagree with promoting BLS as a lead role in codes.

    • The OPALS study showed that in a high performing BLS system, the addition of ALS care for cardiac arrest did not improve survival to discharge.

      CONCLUSIONS
      The addition of advanced-life-support interventions did not improve the rate of survival after out-of-hospital cardiac arrest in a previously optimized emergency-medical-services system of rapid defibrillation. In order to save lives, health care planners should make cardiopulmonary resuscitation by citizens and rapid-defibrillation responses a priority for the resources of emergency-medical-services systems.

      1. Stiell IG, et al. Advanced Cardiac Life Support in Out-of-Hospital Cardiac Arrest. N Engl J Med 2004; 351:647-656. [Overview]

    • CS,

      Its this line of logic that has led it to be ok to dispatch a bls unit with bls fire unit to a code in my city. We must save our ALS for the ALS abdominal pain calls, cause BLS can handle a code. I respectfully disagree with promoting BLS as a lead role in codes.

      You can dislike reality, but ALS does not improve survival to discharge.

      If BLS cannot resuscitate them, pronounce them dead on scene.

      .

  8. While I agree with you – mostly – and I’m an outspoken advocate of perfect BLS care in the BLS & ACLS classes I teach, “Early Advanced Care” is still a link in the chain of survival and always will be. ALS in the field is hotly debated, depends on the resources of the system and the individual logistical situation, but BLS in cardiac arrest (other than defibrillation) simply buys time until advanced interventions can be performed.

    Some things are known to improve survivability, but haven’t been proven in a formal study… like epinephrine… are you going to sign informed consent to enroll your mom in a study where she might get a placebo of NS instead of epi? While we don’t know what the exact dose, we certainly know that coronary perfusion is a function of diastolic blood pressure, and we know that epinephrine therefore raises CPP.

    Here’s the list of my “5 things” that have emerged over the years to be proven efficacious. This is right out of the powerpoint I teach with, and extrapolated from the book and the October 2010 ‘Circulation’:
    • Excellent BLS skills are favored over knowledge of esoteric pharmaceuticals and doses
    • Intraosseous (IO) route replaces inhalational (ET) route
    • Focus on teamwork, better communication, and clearer leadership
    • Search for reversible causes (The H’s & T’s)
    • Emphasis on post-arrest care to improve neurologic survivability

    #2, #4, and #5 are all ALS skills. The patient with ROSC’s ultimate survivability hinges upon the optimization of their hemodynamics and ventilation – that’s right out of the research. These are all ALS skills, and ideally judicious ALS interventions, which can be preformed without interrupting BLS care, should be initiated as soon as possible. Combitubes, LMA’s, and IO’s can be placed, fluids and meds administered, without interrupting CPR by ALS while BLS crews continue to provide perfect care.

    Again, while I agree with the point – and I harp on it constantly to my students – you have to be careful when you say cardiac arrest management is a BLS skill only. “BLS is the fundamental of ALS” “All Paramedics are also EMT’s” While this is all true, BLS care to the victim of cardiac arrest primarily keeps the patient alive until the cause of the arrest be determined and reversed – be that a basketball ref collapsing from an LAD occlusion with a resultant dysrhythmia requiring defibrillation, or be it a complex renal patient collapsing before dialysis with likely hyperkalemia who will only be saved with calcium, dextrose and insulin. Taking care of an arrest patient is complex, and unfortunately the sophistication of this artform is being de-emphasized due to advanced clinicians’ tendency to trump basic skills in favor of more advanced skills that detract from those basic skills – but the fact remains that advanced care is what *really* saves lives. Regardless of the simplified guidelines and algorithms, the complexity of the arresting patient will never be cured with BLS alone, and ALS will always have a critical role in resuscitation, including out of hospital, and need to be started as soon as possible.

    • Excellent points! Perhaps the #1 improvement ALS can have on BLS is searching for and correcting the H’s and T’s. My only nit is your assertion that IO access must be an ALS skill.

      [Emergency medical technician-basic providers] successfully placed the EZ-IO in 17 of 18 scenarios (94%; 95% confidence interval, 73% to 100%), all on the first attempt.

      1. Guyette FX, et al. Feasibility of Basic Emergency Medical Technicians to Perform Selected Advanced Life Support Intervensions. Prehospital Emerg Care 2006; 10(4):518-521. [Abstract]

      • I agree with you, and with the comment below about BLS airway management – particularly the use of blindly inserted supraglottic airways, not ETT’s. Most EMT-B’s are not trained in this, and it is outside their scope of practice in most areas.

        Also, if an EMT-B places an IO, is it within their scope of practice to use the device with meds and fluids? If that’s the case, there’s a really fine line between basic and paramedic… where do you draw the line? Of course, anyone could do it… I could teach a 2nd grader to do it… it’s just a skill.

        • My honest answer is current ACLS protocols could be added into an AED’s instructions, with a screen on the front that gives what to administer:

          1. Apply pads to patient’s bare chest, plug in pads connector next to flashing light
          2. Do not touch patient, analyzing heart rhythm
          3. No Shock Advised/Shock advised, charging
          3.1 [Optional] Press shock now
          5. Resume CPR, beginning with compressions
          6. Obtain IO access and attach IV fluids
          7. Do not touch patient, analyzing heart rhythm
          8. No Shock Advised/Shock advised, charging
          8.1 [Optional] Press shock now
          9. Resume CPR, beginning with compressions
          10. Administer 1.0 milligrams epinephrine via IO if in place
          11. Place Blind Insertion Airway Device
          …so on and so forth.

          I think EMT-B’s being able to perform certain simple skills could free up paramedics to do other things in certain service areas (like my FD where we run P/B medic units and BLS engines).

        • I found this article disturbing. I agree that without BLS patients would die. However the short sighted theme of this article proves the bias of the writer. I am an advocate for up-skilling paramedics where appropriate. Where I’m from (Australia) P1 paramedics can insert LMAs, give IV adrenaline, manually defibrillate a patient and perform direct laryngoscopy to visualize the cords and then use Magil’s forceps to remove forigen bodies etc. these do not detract from the importance of ACLS provided by intensive care paramedics, rsther they start the advanced care early! This gives the patient the BEST CHANCE. Sure the emphasis is off intubation, and rightly so. But amiodarone and adrenaline are important, life saving measures. Also the ability to manually shock pulseless VT at a rate less than 180bpm (your AED won’t shock if it’s below 180 potentially resulting in prolonged delay of ROSC)is an important ACLS skill. ACLS will always have a strong role in pre-hospital care. Don’t forget the post ROSC care that can be provided by ACLS providers can prevent refractory arrests (IV adrenaline infusions, amiodarone infusions, pacing, continuing correction of reversible causes (of which only one can be reversed by BLS!)).
          The statements about “ALS is not important” is uneducated and ignorant. Besides, you all seem to have forgotten that this is the 21st century where we can provide high standards of care prehospital and to remove these would be negligent. And a blind monkey could see that this is really about feuding between BLS and ALS providers in the US. A ridiculous system where you send fire trucks to medical emergencies. Anyway.. That’s another topic!

          • I’m a practicing paramedic in the US for a private 3rd service, an ALS transporting fire department, and an ALS hospital service (pretty much every way EMS is delivered stateside). My comments have nothing to do with “feuding between BLS and ALS providers”. Not quite sure where you got that from 🙂

            Amiodarone has not been proven to improve survival to discharge.
            Adrenaline (epinephrine) has not been proven to improve survival to discharge.
            Intubation has been proven to worsen survival to discharge.
            Manual defibrillation has not been shown to be superior over AED’s.
            Delaying appropriate defibrillation has been shown to worsen survival to discharge.

            My comments are simply ALS and BLS providers need to focus on what works before focusing on what doesn’t.

          • Anon,

            I found this article disturbing. I agree that without BLS patients would die. However the short sighted theme of this article proves the bias of the writer.

            Which is?

            I am an advocate for up-skilling paramedics where appropriate. Where I’m from (Australia) P1 paramedics can insert LMAs, give IV adrenaline, manually defibrillate a patient and perform direct laryngoscopy to visualize the cords and then use Magil’s forceps to remove forigen bodies etc. these do not detract from the importance of ACLS provided by intensive care paramedics, rsther they start the advanced care early! This gives the patient the BEST CHANCE.

            OK. Show me the research to support your opinion.

            Sure the emphasis is off intubation, and rightly so.

            Again, where is the research to show improved survival with intubation?

            But amiodarone and adrenaline are important, life saving measures.

            Not to be predictable, but where is the research to support your opinion?

            Also the ability to manually shock pulseless VT at a rate less than 180bpm (your AED won’t shock if it’s below 180 potentially resulting in prolonged delay of ROSC)is an important ACLS skill.

            Please provide a source for your information on non-shockable heart rates and some idea of the frequency of pulseless VT.

            ACLS will always have a strong role in pre-hospital care. Don’t forget the post ROSC care that can be provided by ACLS providers can prevent refractory arrests (IV adrenaline infusions, amiodarone infusions, pacing, continuing correction of reversible causes (of which only one can be reversed by BLS!)).

            This is just about cardiac arrest treatment, not post-cardiac arrest care. Even then epinephrine and amiodarone are not at the top of the list of treatments.

            The statements about “ALS is not important” is uneducated and ignorant.

            Then show me even one good study that demonstrates improved survival with good neurological function due to ALS during cardiac arrest.

            Besides, you all seem to have forgotten that this is the 21st century where we can provide high standards of care prehospital and to remove these would be negligent.

            Was that in English?

            Does it have anything to do with ALS during cardiac arrest?

            And a blind monkey could see that this is really about feuding between BLS and ALS providers in the US.

            Please provide some evidence to support your opinion, Blind Monkey.

            A ridiculous system where you send fire trucks to medical emergencies. Anyway.. That’s another topic!

            We do have more firefighters, so sending them to cardiac arrests is a good idea. Sending them on fire trucks seems to be because they feel insecure in a more appropriate truck. What if there is a fire? This is not any better of ab excuse than the medics worrying, What if there is a cardiac arrest? That’s why there is mutual aid.

            .

    • Why do you feel airway management is an ALS skill? Airway management certainly begins as a BLS skill. OPAs, NPAs, BVM… all are BLS. Historically, esophageal airways, used to be in the EMT arsenal. King, Combitube, and even ETs CAN and HAVE been done by EMTs, depending on geography. Even here in California, there are areas that EMTs have “expanded scope of practice”. And they are successful at it. More aggressive management, such as more advanced airways (crichothyrotomy, retrograde airways, etc) usually are not performed on SCA patients.

      I do appreciate the article in showing, very succinctly, that GOOD CPR and defibrillation are of the most benefit to the patient.

      • Renee Roberts,

        Why do you feel airway management is an ALS skill?

        What is ALS, airway-wise, is going to depend on regional rules.

        On the other hand, I do not see any research showing a benefit from ventilation during cardiac arrest.

        I do appreciate the article in showing, very succinctly, that GOOD CPR and defibrillation are of the most benefit to the patient.

        Thank you.

        ACLS has been stating this for as long as I can remember.

        The problem has been instructors only reading the algorithm flow chart, rather than reading the text. I would start my classes by explaining that high quality CPR and defibrillation were the only things that mattered. I would point to the places this was written in the text (this is not new to 2010, was not new in 2005, was not new in 2000, was not new in 1992, was not new in 1988).

        The text clearly states that none of these ALS treatments have been shown to improve survival to discharge. That has not changed since before books were written or since before people could speak. We just act surprised because our instructors have not understood this or they have been reluctant to mention this.

        .

    • Jeff, what saves lives are early good quality CPR and early defibrillation. That’s it. I won’t quarrel with you about H’s and T’s being important in a non-shockable arrest, but these are rare events when calcium saves a patient in cardiac arrest.
      Since you mention EPI: why do you think it improves ROSC but not survival to discharge? It is an extremely cardiotoxic drug, and the leading theory put forth by many who lead the ROC consortium is that any short term benefit of EPI is negated by the cardiotoxic properties that damage the heart.
      I mean, if you wanted to kill a live person, give them 1 mg of EPI. So we are supposed to believe that the same 1mg of EPI will bring back the dead? seriously. Not gonna happen right now.
      The reason we still hang on hope of a future of ACLS is that as we learn more about improving CPR quality, and learn more about the proper dosage and timing of giving ACLS drugs, “perhaps” they will do some good in the future.
      But for now, basic skills are all that change outcomes in the large majority of arrests.

      • The evidence speaks to that because it has become such commonplace to abandon perfect CPR in favor of advanced interventions, because so many of these advanced interventions interfere with the CPR. My point is that it all needs to happen together, and nothing should get in the way of the CPR. In an ideal scenario, you can start ALS early but maintain a no-tolerance rule for interruptions in BLS. I think it’s overboard to blindly advocate the removal of ALS care in cardiac arrest. BLS is a temporizing measure to keep a patient alive until definitive reversal of the underlying cause of their arrest is reversed – be that a defibrillation at a basic level, or treatment of their severe underlying derangement.

        • Jeff,

          I think it’s overboard to blindly advocate the removal of ALS care in cardiac arrest.

          How many decades have we had to study the ALS treatments, but have not uet come up with a large enough trial to show a difference in outcomes – or maybe we have had large enough trials, but the reports were never published, because the results did not favor the study drug?

          What happened to the amiodarone survival study that Wyeth reported was taking place a decade ago? Those results were never published.

          There is nothing blind about getting rid of old opinion-based treatments that have never demonstrated efficacy.

          The continued use of experimental treatments outside of controlled studies is a severe underlying derangement.

          .

      • Also – I work quite closely with a physician who was on the committee that wrote the latest guidelines – as he says, and as I alluded to, no one knows the proper dosage, but we do know that you need to maintain physiologically normal pressures within the heart itself to maintain adequate coronary blood flow, and many studies have shown maintaining a CPP>15 to be the one thing that differentiates between those who survive and those who die (when measured). Epi is used for that reason. If you have the luxury of an arterial line and can dose your epi more closely, you’re likely to have success. I’d encourage you to listen to the October 2010 podcast by Scott Weingart on his EMCrit.org page for further explanation.

        • If EPI has been proven to NOT IMPROVE survival to discharge, then it makes no sense to me that its use in cardiac arrest is one thing that differentiates between those who survive and those who don’t. If i am wrong, show me the study.

          • There will never be such a study – because you’d need a control group that doesn’t get epi, which will never happen – because how could you obtain consent?
            Again, not everything we do will be PROVEN – a lot must be based on a higher level of understanding about the physiology of arrest. Also, a lot of the advanced interventions are skewed to appear as if they cause harm — because over the years the advanced interventions have caused providers to de-emphasize basic CPR, which we know to be harmful. If we refocus on keeping blood pumping with CPR, the advanced interventions are more likely to work.

            • Jeff,

              There will never be such a study – because you’d need a control group that doesn’t get epi, which will never happen – because how could you obtain consent?

              Plenty of research is done according to the FDA’s Exception from Informed Consent Requirements for Emergency Research. You can read the rules at the link below. It is a PDF Download from the FDA.

              Exception from Informed Consent Requirements for Emergency Research

              Again, not everything we do will be PROVEN – a lot must be based on a higher level of understanding about the physiology of arrest.

              That is true, but it is not a good reason to avoid studying the things that we can study.

              There are between 300,000 and 400,000 cardiac arrests worked by EMS each year. We have plenty of opportunity to find out if we are making things worse. We owe that to our patients.

              Also, a lot of the advanced interventions are skewed to appear as if they cause harm — because over the years the advanced interventions have caused providers to de-emphasize basic CPR, which we know to be harmful. If we refocus on keeping blood pumping with CPR, the advanced interventions are more likely to work.

              That may be true, or it may be that therapeutic hypothermia decreases the harm from ALS to acceptable levels, or ALS may be dangerous to patients.

              We need research to show what is the truth.

              What we do not study MUST be discarded.

              .

              • Paiva et. al, Resuscitation 2002 shows increase in CPP with epinephrine. It also shows increase in CPP with epinephrine and amiodarone combined, when clinically appropriate.

                Paradis NA, et. al. JAMA. 1990;263:1106–1113 Demonstrates that patients who do not attain a CPP>15 will not survive cardiac arrest.

                Multiple studies show aggressive ventilation and pauses in CPR to lower CPP.

                If CPR is optimized, ACLS interventions will improve outcomes. Again, the trouble lies when advanced interventions detract from basic interventions. I’m very interested to see how outcomes improve with a re-emphasis on BLS care – and then hopefully we can transcend this over-compensation and attain synergy between ALS & BLS care for the arresting patient.

                So train the lay rescuer in hands only CPR, send your CPR trained police, send your BLS engine crews, send your BLS ambulances, and send your ALS paramedics. Let the BLS crews run the code if you want – but let the ALS providers do their thing too – just don’t get in the way of the BLS.

                • Jeff,

                  Paiva et. al, Resuscitation 2002 shows increase in CPP with epinephrine. It also shows increase in CPP with epinephrine and amiodarone combined, when clinically appropriate.

                  That is just a surrogate endpoint. Surrogate endpoints are good for creating hypotheses for research on survival, but they are not a substitute for research on survival.

                  There are no studies that demonstrate improved survival past discharge with good brain function.

                  Until these studies exist, epinephrine in cardiac arrest is just an unproven experimental treatment.

                  Paradis NA, et. al. JAMA. 1990;263:1106–1113 Demonstrates that patients who do not attain a CPP>15 will not survive cardiac arrest.

                  We knew that post-MI patients with ectopy died at a higher rate than those without ectopy. CAST demonstrated that getting rid of that ectopy, which would be as logical as giving epinephrine to improve CPP, more than tripled the death rate.

                  Things that look great on paper can be very bad medicine.

                  Multiple studies show aggressive ventilation and pauses in CPR to lower CPP.

                  I have provided some research that ventilation and interruptions in compressions lead to worse outcomes.

                  The CPP doesn’t matter if the treatment does not improve survival.

                  If CPR is optimized, ACLS interventions will improve outcomes.

                  All you have to do is prove it.

                  If you can’t prove it, you are just killing patients with voodoo treatments.

                  Again, the trouble lies when advanced interventions detract from basic interventions.

                  That is one possible explanation for the continual failure of ALS to improve survival.

                  Another explanation is that ALS just does not improve survival.

                  Until there is evidence of improved survival with any ALS, it is just an opinion and everybody has opinions.

                  I’m very interested to see how outcomes improve with a re-emphasis on BLS care – and then hopefully we can transcend this over-compensation and attain synergy between ALS & BLS care for the arresting patient.

                  If the result is that ALS still does not improve survival, will you come up with some other excuse to justify ALS treatment without evidence of improved survival?

                  So train the lay rescuer in hands only CPR, send your CPR trained police, send your BLS engine crews, send your BLS ambulances, and send your ALS paramedics. Let the BLS crews run the code if you want – but let the ALS providers do their thing too – just don’t get in the way of the BLS.

                  If any paramedic gets in the way of BLS treatment on a code, that is bad treatment.

                  If protocols prioritize ALS over BLS, that is bad treatment.

                  Continuing unproven treatment – ALS for cardiac arrest – outside of a controlled study is bad treatment.

                  .

        • Jeff,

          It is a good podcast.

          EMCrit Podcast 34 – 2010 ACLS Guidelines

          Certainly, giving epinephrine for a specific indication (not just too dead to run away) is something that makes it a bit medical, rather than blindly following the algorithm – Everybody Dead Gets Epi.

          Dr. Weingart strongly discourages the blind administration of epi that ACLS encourages.

          .

      • David B,

        Epi is a toggle switch drug. If the light was on, it turns the light off, the next dose turns it back on – or something like that. 🙂

        .

    • Jeff,

      “Early Advanced Care” is still a link in the chain of survival and always will be.

      Eventually, the AHA will have to find some ALS that works, or remove the early ALS promotion.

      Some things are known to improve survivability, but haven’t been proven in a formal study

      The quacks who push homeopathy say the same thing. We know it works, but that darned reality keeps preventing us from proving it

      .… like epinephrine… are you going to sign informed consent to enroll your mom in a study where she might get a placebo of NS instead of epi?

      I would refuse epinephrine for my mother. I would also refuse other magic treatments.

      What are we – superstitious illiterates?

      Epi needs to be studied or thrown out.

      While we don’t know what the exact dose, we certainly know that coronary perfusion is a function of diastolic blood pressure, and we know that epinephrine therefore raises CPP.

      So what?

      Where is the improved survival?

      Here’s the list of my “5 things” that have emerged over the years to be proven efficacious. This is right out of the powerpoint I teach with, and extrapolated from the book and the October 2010 ‘Circulation’:
      • Excellent BLS skills are favored over knowledge of esoteric pharmaceuticals and doses
      • Intraosseous (IO) route replaces inhalational (ET) route
      • Focus on teamwork, better communication, and clearer leadership
      • Search for reversible causes (The H’s & T’s)
      • Emphasis on post-arrest care to improve neurologic survivability

      The endotracheal route of drug administration would not be a good idea, even if there were a good reason to believe that any of the drugs work. What kind of pulmonary circulation is there in cardiac arrest? It is just another excuse to interrupt compressions at least twice – first for the tube, then for the drug.

      #2, #4, and #5 are all ALS skills. The patient with ROSC’s ultimate survivability hinges upon the optimization of their hemodynamics and ventilation – that’s right out of the research. These are all ALS skills, and ideally judicious ALS interventions, which can be preformed without interrupting BLS care, should be initiated as soon as possible. Combitubes, LMA’s, and IO’s can be placed, fluids and meds administered, without interrupting CPR by ALS while BLS crews continue to provide perfect care.

      Show me the research that demonstrates improved survival with good brain function with these treatments. Without that, these are just opinions.

      Again, while I agree with the point – and I harp on it constantly to my students – you have to be careful when you say cardiac arrest management is a BLS skill only. “BLS is the fundamental of ALS” “All Paramedics are also EMT’s” While this is all true, BLS care to the victim of cardiac arrest primarily keeps the patient alive until the cause of the arrest be determined and reversed – be that a basketball ref collapsing from an LAD occlusion with a resultant dysrhythmia requiring defibrillation, or be it a complex renal patient collapsing before dialysis with likely hyperkalemia who will only be saved with calcium, dextrose and insulin. Taking care of an arrest patient is complex, and unfortunately the sophistication of this artform is being de-emphasized due to advanced clinicians’ tendency to trump basic skills in favor of more advanced skills that detract from those basic skills – but the fact remains that advanced care is what *really* saves lives. Regardless of the simplified guidelines and algorithms, the complexity of the arresting patient will never be cured with BLS alone, and ALS will always have a critical role in resuscitation, including out of hospital, and need to be started as soon as possible.

      I was agreeing with you, right up until you wrote advanced care is what *really* saves lives.

      Prove it.

      .

  9. High quality CPR and early defibrillation should certainly be the number one goals of cardiac arrest management, and no other intervention should interfere with them even if those interventions must be forgone entirely. However, I will say with regards to cardiac arrest management that while any successful return of spontaneous circulation is meaningless without survival to discharge with intact neurological function, the first step in advancing to that goal is the successful return of spontaneous circulation. It may be that the current medications used in cardiac resuscitation are simply not the right ones, and that other, newer drugs may emerge that ARE effective at improving survival to discharge (I for one am interested in seeing what additional studies of sodium nitroprusside will bring) or it may be that there is no ideal drug for cardiac resuscitation. I also believe that it is difficult to say whether this is a problem of bad drugs versus a fault of proper post-resuscitative care, which is far from becoming the universal standard in this country–at least in practice.

    The drugs currently administered during cardiac arrest may be helpful in bringing about ROSC, however what we know about these drugs is that their effectiveness stops there; which to me means that our care should not stop at the current treatment, but extend to bridge the gap that they fail to provide for which is going from ROSC to survival to discharge neurologically intact. This gap is (to our current knowledge) best bridged with therapeutic hypothermia, and studies have shown a tremendous increase in survival to discharge neurologically intact with therapeutic hypothermia following successful ROSC utilizing the currently recommended resuscitative methods including high quality CPR, early defibrillation and drug therapy.

    What I would like to see (and if there is a study that has touched on this, please refer me to it) is a study that compares high quality CPR, early defibrillation, therapeutic hypothermia AND the currently recommended ACLS drugs versus all of the above MINUS ACLS drugs. I believe that such a study will help give us an idea of whether or not there is any place for current pharmacological treatment of cardiac arrest in conjunction with high quality CPR, defibrillation, and therapeutic hypothermia or whether those drugs have nothing to offer in the way of benefit even WITH appropriate post-resuscitation care.

    Note: When I refer to “ACLS drugs”, I mean specifically those which HAVE been proven to increase ROSC. Any medication that has not been proven to have ANY benefit (even if it doesn’t change the ultimate outcome) in cardiac resuscitation simply has no place in our arsenal of cardiac resuscitation tools.

    • Justin Sleffel,

      It may be that the current medications used in cardiac resuscitation are simply not the right ones, and that other, newer drugs may emerge that ARE effective at improving survival to discharge (I for one am interested in seeing what additional studies of sodium nitroprusside will bring) or it may be that there is no ideal drug for cardiac resuscitation.

      I agree.

      I am interested in seeing nitroglycerine studied.

      High dose nitroglycerin treatment in a patient with cardiac arrest: a case report.
      Guglin M, Postler G.
      J Med Case Reports. 2009 Aug 10;3:8782.
      PMID: 19830240 [PubMed]

      Free Full Text from PubMed Central with link to PDF Download

      The one study which comes close to what you are looking for drugs and hypothermia vs. BLS and hypothermia is –

      Intravenous drug administration during out-of-hospital cardiac arrest: a randomized trial.
      Olasveengen TM, Sunde K, Brunborg C, Thowsen J, Steen PA, Wik L.
      JAMA. 2009 Nov 25;302(20):2222-9.
      PMID: 19934423 [PubMed – indexed for MEDLINE]

      Free Full Text PDF from EMS Garage

      .

  10. I have to disagree that cardiac arrest management is an EMT-Basic skill for two major reasons.

    1. Most systems will not allow EMTs to stop resuscitation efforts. Thus, with just EMTs running cardiac arrest, most patients will be transported even if they are well past any sort of time of being viable.

    2. Post cardiac arrest management in order to increase survivability (things like therapeutic hypothermia) or catching and treating patients trending towards, or reentering cardiac arrest. While this could be considered distinct from cardiac arrest management itself, I wouldn’t want EMTs waiting until ROSC to call for paramedics.

    • Joe Paczkowski,

      I have to disagree that cardiac arrest management is an EMT-Basic skill for two major reasons.

      1. Most systems will not allow EMTs to stop resuscitation efforts. Thus, with just EMTs running cardiac arrest, most patients will be transported even if they are well past any sort of time of being viable.

      That is an administrative issue.

      It has nothing to do with whether ALS treatments affect survival.

      2. Post cardiac arrest management in order to increase survivability (things like therapeutic hypothermia) or catching and treating patients trending towards, or reentering cardiac arrest. While this could be considered distinct from cardiac arrest management itself, I wouldn’t want EMTs waiting until ROSC to call for paramedics.

      Post-cardiac arrest is not cardiac arrest. If I want to write about post–cardiac arrest I will. And I will.

      It doesn’t have to do with BLS calling for ALS. It has to do with what treatments improve the survival of cardiac arrest patients, not post-cardiac arrest patients.

      .

  11. I’m on the fence with this. I agree with BLS before ACLS However I have seen patients come out of the hospital and live functional lives if CPR is initiated with a witness arrest. But DEAD is Dead…even with all the tools and drugs we have we can’t save everybody. Proven fact..witnessed arrest has a higher chance of survival than unwitnessed arrest provided Good Quality CPR is initiated right then. Yes I’m a Paramedic of 10 years and have been in Fire and EMS for 23 years. Without basic procedures you can’t do Advanced very well.

  12. One of the First things I was taught as an EMT and enforced thru Intermediate and Paramedic is DO NOT HARM. If what I’m doing as Paramedic is not helping but harming the patient I should not be doing it. There is no place for Ego in EMS. I believe in Evidence Based Medicine. I take no offense at this. Being in the back alone one cannot do good CPR while trying to perform intubation, IV and and drug therapy. Its hard enough for 2 people (I work Rural EMS and we dont always have access to back up assist) to get an arrest patient out of the house while trying to do CPR let alone perform ALS and stay within the Protocol limits of Load and GO! and ten minute scene times. Not mention having to hold on with one hand because of the misguided EMS culture of Lights and Siren and speed saves lifes.

    Anyway the problem will be convincing the Nurses and Docs at the recieving ED will be the problem. They expect an IV, ETT and first round drugs even if the transport time is under 2 minutes. We have all had the same ACLS classes that stress high quality CPR above anything else. There is a big difference in ACLS guidelines and State EMS protocol that puts ALS measures for Arrest as the defintiive treatment. If you dont follow protocol to the letter you get called out on the carpet. My last arrest patient had a difficult airway short obese neck limited TMJ movement Mallampati score IV. I was unable to view vocal cords after 2 attempts, I deferred further attempts and deferred a BIAD to avoid further trauma to the airway. I did have an IV and first round drugs, and continued CPR enroute, no shockable rythym . I was tagged by QI for not attempting the BIAD and this the same person that teaches our ACLS and CPR. Nothing was mentioned about whether or not if there was good CPR. All emphasis was on invasive ALS. If laypersons are held to the standard of high quality CPR, we in EMS should be as well above ALS. And if there is enough hands then perform ACLS, if not CPR and defib till there is enough so CPR is not comprimized. But getting everyone onboard with that and the decreased use speed and Lights and Siren. CPR has been shown to be able to keep an patient viable for ALS measure up to 96 minutes if it is high quailty and uninterupted, more than enough time to transport to an ED in non emergency mode.

    • Jeff Barnes,

      to get an arrest patient out of the house while trying to do CPR let alone perform ALS and stay within the Protocol limits of Load and GO! and ten minute scene times. Not mention having to hold on with one hand because of the misguided EMS culture of Lights and Siren and speed saves lifes.

      You have my condolences. The medical director needs to be replaced.

      There is rarely a good reason to transport a dead body, except in a hearse.

      If we can’t resuscitate them on scene, there is no reason to transport.

      Your doctors quality control people need to learn ACLS.

      It doesn’t matter if they teach it. They certainly do not understand what they are teaching.

      .

  13. This is not an either/or issue. Few people will return to a perfusing rhythm, stay there, and return to a FULLY MENTATED state without some things besides CPR and defibrillation. Our system is seeing survivors walk out of the hospital after being found in asystole – compressions and NOT defibrillation, but other peri-arrest therapies, seem to help.

    Like other things in medicine, the decision is rarely binary…..

    • Skip, i would be interested in knowing which peri-arrest therapies you are finding beneficial, and what occurs in your system that perhaps is not happening in others with poorer survival rates.

    • I think though, the big difference is your system has certainly optimized the fundamentals of CPR! With that foundation in place you’ve been able to work towards effective, aggressive ALS care. I too am wondering what your system is finding that works.

    • Skip,

      This is not an either/or issue. Few people will return to a perfusing rhythm, stay there, and return to a FULLY MENTATED state without some things besides CPR and defibrillation. Our system is seeing survivors walk out of the hospital after being found in asystole – compressions and NOT defibrillation, but other peri-arrest therapies, seem to help.

      There may be ALS treatments that work, or it may be coincidence that the patient improved after an ALS treatment. Without studying this, we do not know what works consistently.

      If we want something that works inconsistently (just a coincidence, but no causation), then we can abandon research.

      Like other things in medicine, the decision is rarely binary…..

      Very true.

      .

  14. My system doesn’t have a high functioning BLS system. We also know CPR is ineffective during movement, and dangerous during transport why leave these calls in the hands of providers that still believe in “scoop and swoop” and can’t even immobilize a patient correctly.

    • CS,

      My system doesn’t have a high functioning BLS system. We also know CPR is ineffective during movement, and dangerous during transport why leave these calls in the hands of providers that still believe in “scoop and swoop” and can’t even immobilize a patient correctly.

      You have a system problem that will not get better by making small changes in protocols.

      All of the people in charge need to go. Then the system can be created from scratch. Until then, it is just a matter of applying more makeup, not anything substantial.

      .

  15. Wow! There has been alot of comments on this subject while I was gone. However, being a firm believer in basic cardiopulmonary resuscitation and having taught it for ARC in the 80, I am distressed by the way CPR has turned currently where only cardiac compression is only taught. In my opinion, a person breathing into another person is vital for oxygen flow to resume.

    In addition, what happened to demand valve resuscitators in ambulances? When I was working on an ambulance in California, I remember using a demand valve resuscitator on a code in the back of an ambulance. In my experience, I found it to be very effective.

    • Barotrauma… That’s what happened.

    • Jeff McSherry,

      Wow! There has been alot of comments on this subject while I was gone. However, being a firm believer in basic cardiopulmonary resuscitation and having taught it for ARC in the 80, I am distressed by the way CPR has turned currently where only cardiac compression is only taught. In my opinion, a person breathing into another person is vital for oxygen flow to resume.

      Oxygen flow does not appear to suffer from a lack of ventilation. My post tomorrow addresses this.

      In addition, what happened to demand valve resuscitators in ambulances? When I was working on an ambulance in California, I remember using a demand valve resuscitator on a code in the back of an ambulance. In my experience, I found it to be very effective.

      Others found demand valves to cause more harm than benefit. I think California banned them in the early 90s.

      .

  16. Great debate!

  17. Find patient with no pulse >
    Insert OP tube>
    Compress chest>
    Deffibrilate if VF>
    Continue compressions>
    Nothing else has been proven as effective as this
    In the 10 seconds you spend deciding what ALS procedures to do and not compressing the chest you decrease survival rate drastically
    The point is to keep the brain and other vital organs alive by circulating oxygen until you have a rythym that can be defribrilated.
    The issue of compression only CPR is new and can be debated but for the layman on the street it is more important to give effect compressions than giving them breaths, and by compressing the chest you not only compress the heart but the lungs as well

    • Graham,

      I agree, except about continuous compression CPR for healthcare professionals. Currently, you would get better CPR from a lay person, because they won’t pause for ventilations. We need to eliminate ventilations.

      Is an OP tube the same as an OroPharyngeal Airway?

      The issue of compression only CPR is new and can be debated

      Actually, that is looking at it backwards.

      There is evidence that compressions improve survival.

      There is no evidence that ventilations improve survival.

      Cardiac Arrest Management is an EMT-Basic Skill – The Hands Only Evidence

      .

      • Yes an OP tube the same as an OroPharyngeal Airway.

        The issue of eliminating ventilation is new as this has been protocol for layman and healthcare provider alike. We have always been told taught ABC, with ventilation before compression. I believe compression only CPR is the most effective as this makes sense but it is not as easily accepted by the majority as they have been taught ABC, not CAB. Very few people question the mainstream and trying to change the way people see CPR needs huge awareness campaigns.

  18. May I ask a question on a side issue:

    Does anyone have an opinion on the layman Handheld ECG Heart Machines, like the PC-80B black and white and colored version?

    Will they have a future in ALS care?

    • Jeffrey B McSherry SR,

      May I ask a question on a side issue:

      Does anyone have an opinion on the layman Handheld ECG Heart Machines, like the PC-80B black and white and colored version?

      I had not seen it. Tom Bouthillet at EMS 12 Lead would be a better person to ask. He may know of something, but I have not seen the device.

      Will they have a future in ALS care?

      My initial impression is that it will not add much, if anything to patient care. I have not had a chance to use one, so that is just a guess. I think that to have a future in ALS care, the device would need to do something important that cannot be currently done. It seems to be a cheaper personal Holter.

      It may be able to demonstrate that arrhythmias are more common than we realize because this will be used by people who would not have used a Holter.

      Cardiology will recognize that these arrhythmias are more common than they had known and that they often terminate spontaneously without recurrence in the hospital (if a patient does go to the hospital).

      Papers will be written about the surprising number of arrhythmias that resolve spontaneously and do not result in a trip to the emergency department.

      EMS will probably continue to rush to push antiarrhythmics to get these arrhythmias to go away. We will assume that the drug caused the arrhythmia to go away and feel that we saved a life.

      Do cause more arrhythmias with the antiarrhythmic drugs?

      Do cause more serious arrhythmias with the antiarrhythmic drugs?

      .

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