POTD: EMS Termination of Arrest

POTD: EMS Termination of Arrest (NYC)

Today’s POTD is thanks to Dr. Friedman and influenced by a cardiac arrest case last week. In very short summary, an elderly male with a history of COPD witnessed (?) cardiac arrest on the street and was ultimately brought to the ED with ongoing CPR after 40 minutes of ACLS in the field. Asystole/PEA. They were already intubated on arrival, and ROSC was achieved ~10min after arriving to the ED. 

We were debriefing the case afterwards when the comment came up that EMS didn’t terminate in the field because it was in the street, and if the arrest had happened in the home they would have called for termination. Which prompted the question: When do pre-hospital providers consider termination of resuscitation vs. transport to the hospital?

Termination of Resuscitation shall be considered for cardiac arrests with all of the following criteria:

Patient Characteristics

• Age ≥ 18 years old

• Arrest etiology is non-traumatic or is not due to any of the following:

• Drowning

• Hypothermia

• Suspected pregnancy

• Lightning injury/electrocution

• Suspected overdose

• Hanging/asphyxia

Resuscitation Components:

• Unwitnessed arrest without bystander CPR

• At least 30 minutes of EMS resuscitation time, including at least ALS resuscitative care for 20 minutes

• No return of spontaneous circulation (ROSC) during resuscitation at any time

• No defibrillation is performed during resuscitation at any time

• Rhythm remains in asystole or PEA (rate < 40) throughout resuscitation

• Arrest does not take place in a public area

Important Exceptions to TOR Guidelines

1.     Resuscitation attempts should be immediately terminated upon presentation of a valid DNR (Do Not Resuscitate) order. TOR criteria do not need to be met to halt resuscitation when a patient’s DNR status is identified.

The following DNR orders may be accepted by prehospital providers (other DNR orders cannot be honored in the prehospital setting):

a. New York State Department of Health (DOH) Out-of-Hospital DNR form or DNR bracelet.

b. MOLST (Medical Orders for Life-Sustaining Treatment) form indicating DNR status. c. Physician’s DNR order in the medical chart when the patient is in the medical care facility under the physician’s care.

We all know that out-of-hospital cardiac arrests (OHCA) have very poor outcomes at baseline, whether for neurologically intact survival or even just survival until discharge. These numbers are even worse for PEA/Asystole. UpToDate estimates that, for asystole, 10% of OHCA survive until discharge, with 5% surviving with good neurological function. For PEA, the numbers were ~20% survival and ~10% with good neurological function.

Two important factors that are known to improve outcomes are (1) immediate, well performed compressions (most of the time initiated by a bystander) and (2) early defibrillation for shockable rhythms. These factors appear to be heavily involved in the decision making to terminate arrest in the above EMS protocol.

As Q likes to say (and others, I’m sure, but I live with Q), there’s good medicine in these EMS protocols. Personally, I haven’t read many of them, but I’ll be paying more attention from now on.

Lastly, some guidelines on when EMS will initiate CPR.

CPR shall be initiated on all patients who are not breathing (apneic) and pulseless unless the patient has any of the following conditions:

• Extreme dependent lividity

• Rigor mortis 

• Tissue decomposition

• Obvious mortal injury

• Valid do not resuscitate (DNR) order or medical orders for life-sustaining treatment (MOLST) form or eMOLST (Appendix C: Do Not Resuscitate (DNR) / Medical Orders for Life Sustaining Treatment (MOLST)

• Terminal illness is not a contraindication to CPR

• Cardiac arrests secondary to drowning, hanging, or electrocution shall be treated as non-traumatic cardiac arrests

 Pediatric:

• CPR is required for pediatric patients with severe bradycardia (heart rate < 60 beats/min AND signs of shock or altered mental status) 

• If available, pediatric AED/monitor pads and cables shall be used for all pediatric patients age < 9 years 

• If pediatric AED/monitor pads and cables are not available, the adult AED/monitor pads and cables shall be used

• CPR shall be continued until any of the following conditions are present 

• Return of spontaneous circulation (ROSC) 

• Resuscitative efforts have been transferred to providers of equal or higher level of training 

• Qualified, licensed physician assumes responsibility for the outcome of the patient

Thanks,

David

https://www.uptodate.com/contents/prognosis-and-outcomes-following-sudden-cardiac-arrest-in-adults

https://www.nycremsco.org/wp-content/uploads/2020/02/2020-13-REMAC-Advisory-Termination-of-Resuscitation-Physician-Guidelines-REVISED.pdf

Trauma Tuesday: Electrocution Injuries

 Epidemiology

-       3 primary age groups

o   Toddlers – household sockets, appliances, etc.

o   Adolescents – risk-taking behavior

o   Adults – occupational hazard

-       Lightning strikes – account for 50-300 deaths per year in US (mostly Florida)

-       ~6,500 injuries and 1,000 deaths annually from all electrocution injuries

Classification

-       Low voltage: ≤1000 volts (V)

o   Household outlets in US typically 120 V

-       High Voltage: >1000 V

o   Power lines > 7000 V

-       Alternating current (AC) = electrical source with changing direction of flow  household outlets

o   Induces rhythmic muscle contraction  tetany  prolonged electrocution as individual is locked in place

o   Although generally lower voltages, can be more dangerous than DC as the time of electrocution is much higher

-       Direct Current (DC) = electrical source with unchanging direction of current of flow  lightning strikes, cars, railroad tracks, batteries

o   Usually induces a single, forceful muscle contraction  can throw an individual with significant force  higher risk of severe blunt trauma 

Mechanisms of Injury

-       Induced muscle contraction  rhabdomyolysis

-       Blunt trauma

-       Burns

o   Internal thermal heating – most of damage caused by direct electrocution

o   Flash/Arc burns – electricity passes over skin causing external burns

o   Flame – electricity can ignite clothing

o   Lightning strikes can briefly raise the ambient temperature to temperatures greater than 54,000F

Severity of Injury – is determined by…

-       Type of current – AC vs. DC

-       Duration of contact

-       Voltage

-       Environmental circumstances (rain, etc.)

Clinical Manifestations

-       Cardiac – 15%, mostly benign and occur within few hours of hospital stay

o   Arrhythmias - Most occur shortly after the event, though non-life-threatening arrhythmias can occur a few hours after the event and are usually self-resolving. Generally, …

§  DC = asystole

§  AC = ventricular fibrillation

o   Other EKG findings – QT prolongation, ST elevations, bundle branch blocks, AV blocks, atrial fibrillation

-       Pulmonary

o   Respiratory paralysis – diaphragmatic muscle

o   Blunt trauma – pneumothorax, hemothorax, pulmonary contusions, etc.

-       Neurologic – generally, patient can APPEAR DEAD but is the cause of neurologic electrocution and may be temporary. IE.

o   Coma

o   Fixed, dilated pupils

o   Dysautonomia

o   Paralysis or anesthesia

-       Renal – Rhabdomyolysis

-       Skin – All kinds of burns

-       MSK – from severe muscle contractions

o   Always assume C-spine injury

o   Compartment syndrome

o   Fractures/Dislocations

Management – we’ll divide them into categories of severity. Basically, always do an EKG!!

1)    Mild (<1000V) – examples include brief house outlet shock, stun gun

a.     EKG – other work-up such as troponin and CPK usually unnecessary

b.     If history/physical unremarkable (patient endorses brief contact with house outlet) patient can be discharged without further work-up

c.     If PMH puts patient at higher risk of arrhythmia (cardiac disease, sympathomimetics) can do a brief period of telemetry observation

d.    Can always observe 4-8 hours to be on the safe side

e.     High Risk Features

                                               i.     Chest pain

                                             ii.     Syncope

                                            iii.     Prolonged exposure

                                            iv.     Wet skin

2)    Severe Electrocution (>1000V) – industrial accidents, lightning strikes

a.     Coding – pursue usual ACLS

                                               i.     Keep in mind traumatic causes of arrest (tension pneumothorax, etc.)

                                             ii.     KEY FACT: remember that patients with fixed, dilated pupils, no respiratory effort, and no spontaneous movement may only have TEMPORARY neurologic stunning

                                            iii.     Pursue resuscitation longer than usual as patient with ROSC can still have good outcomes  does not appear to be any definitive guidelines on when to terminate, at physician discretion

b.     Otherwise, broad medical and traumatic work-up and likely admission for telemetry monitoring (basically just send all the labs and images)

                                               i.     Start with primary/secondary trauma survey and further imaging as required

                                             ii.     Don’t forget CPK to assess for rhabdomyolysis

c.     Consider transfer to burn center

TL;DR

-       Treat as you would a trauma/burn patient

-       Most household outlet shocks – history/physical, EKG, and likely quick discharge unless high risk features

-       Industrial shocks – at best admit for telemetry. At worst prolonged ACLS as good outcomes are possible. Don’t forget traumatic causes such as tension pneumothorax

http://brownemblog.com/blog-1/2020/4/14/acute-care-of-the-electrocuted-patient

http://www.emdocs.net/electrical-injury/

http://www.emdocs.net/em3am-electrical-injuries/

http://www.emdocs.net/em-cases-electrical-injuries-the-tip-of-the-iceberg-view-larger-image/

https://www.tamingthesru.com/blog/air-care-series/electrocution

EMS Protocol of the Week - General Pain Management (Adult and Pediatric)

New year, new protocols! The newest version of the REMAC protocols will be live on the streets in February, and there are plenty of new changes and additions to keep us all on our toes. One of the biggest new features is something that’s been long overdue and in the works for years – let’s kick things off with our new General Pain Management protocol!

A couple years ago, you found orders for the available prehospital pain meds (namely, morphine and fentanyl) scattered across different protocols – they were listed for burns or extremity injuries, and sometimes crews requested them as Discretionary Orders for abdominal pain, or eye pain, et cetera. Boiling everything down to one general pain management protocol brings a lot of simplicity to the process and decreases opportunities for error.

Even more exciting, however, is the fact that this protocol finally introduces some non-opiate analgesic alternatives to the ALS toolbelt! Ketorolac and acetaminophen have entered the arena as Standing Order options for paramedics, with ketamine becoming a Medical Control Option for you all answering the OLMC phone. When discussing these meds over the phone, be sure to review any possible contraindications for these new medications with the crews (as written out in the protocol), and, as always, remember to practice good closed-loop communication to confirm dosage and route for all medications.

And for those of us on the receiving end of these patients, here’s an extra reminder of the importance of verifying prehospital medications to avoid excessively dosing any of these meds.

This is an amazing step forward for the quality of care our crews can provide out in the field, and I’m excited to keep showing you what more to expect this year! Check the protocol binder for more, as well as www.nycremsco.org for the entirety of the 2022 version.

Dave