EMS Protocol of the Week - Pulseless Electrical Activity (PEA) / Asystole (Adult)

Our specific cardiac arrest protocols are divided into two categories: VT/VF (the “shockable rhythms”) and PEA/Asystole (the “non-shockable” ones). The attached protocol for PEA/Asystole is probably the more common one our crews encounter prehospitally, and it’s worthwhile to know in order to better assist them over the OLMC phone when they call.

When paramedics arrive on the scene of a cardiac arrest and confirm the rhythm to be either PEA or asystole, their Standing Orders consist of continuing CPR, performing a needle decompression for suspected tension pneumothorax, obtaining an advanced airway (either endotracheal tube or supraglottic device) and intravascular access, administering D50 for hypoglycemia, and giving ACLS-dose epinephrine every 3-5 minutes. 

By the time medics call OLMC, they will have generally given a few doses of epinephrine, but they need physician approval to give sodium bicarbonate or calcium chloride, which are Medical Control Options (and as such are found under that section of the protocol). Why do you think this particular patient arrested? Hyperkalemia? TCA overdose? It might be worthwhile to administer one of those medications. Or do we think attempts at ROSC are futile? Maybe no medications are indicated, and we should instead consider Termination of Resuscitation (ToR). We’ll discuss ToR in a separate email, but these are the kinds of questions to consider when deciding whether to authorize a Medical Control Option.

That’s about it for PEA/asystole. What about the VF/VT arrests? Stay tuned til next week for the…shocking…conclusion!

Thank you, thank you. 

www.nycremsco.org and the protocols binder for more.

Dave

EMS Protocol of the Week - General Cardiac Arrest Care (Non-Traumatic) (Adult)

The prehospital approach to general cardiac arrest care is a good introduction to the progression of responsibilities from one level of training to the next. We get a large number of OLMC calls from our own paramedics requesting physician input in arrest cases, so it’s always good to refresh ourselves on what they can or cannot do in these instances.

Note that everything in the attached protocol is Standing Order, which, as a reminder, consist of the steps that EMS providers should be performing by default without any additional physician input.

At the CFR level, providers who encounter a patient in arrest will initiate CPR and apply an Automated External Defibrillator, following the AED’s instructions until backup arrives.

BLS providers (EMTs) will request ALS backup if not already present, but will otherwise begin to transport the patient to the hospital after 3 rounds of CPR/AED analysis.

It’s not until the ALS (paramedic) level that an actual cardiac monitor will be applied, giving a specific rhythm underlying the arrest. It’s for this reason that you might hear something from the paramedics like “our initial rhythm was asystole; patient was shocked 2 times (by AED) prior to our arrival.” From there, paramedics will branch off into separate protocols based on the specific type of arrest, each consisting of their own Standing Orders and Medical Control Options.

Can’t wait to find out more specifics? Tune in next week for more cardiac arrest talk! Or, for spoilers, there’s always www.nycremsco.org and the protocol binder!

Dave

POTD: Esmolol for Refractory Ventricular Fibrillation (Still an option)

Occasionally patients in the ER exhibit rhythms that we find slightly concerning – you know what I’m talking about - A-fib, V-tach, Asystole, V-fib.

Well today I wanted to talk about ventricular fibrillation and how sometimes people just won’t convert or they convert and decide not to maintain an acceptable rhythm - the kind of rhythm their parents would be proud of, you know? Instead they live in their parent's basement and continue rebelling against normal hemodynamic stability. Some people call it a phase but after at least 3 defibrillation attempts, 3 mg of epi, and 300mg of amiodarone, and 10 minutes of CPR, ITS REFRACTORY V-FIB.

You can throw joules upon joules at these people until you feel like…

That's a Pikachu for all of the octogenarians in the room. Its funny because it shocks things with electrici....ah oh well its too much to explain. Moving on.

After a prolonged code where it feels like Thor’s hammer of code cart driven medical justice has still had no effect upon the situation and you are out of options, you, the astute clinician, have another trick up your sleeve:

ESMOLOL. Now the idea of using a beta-blocker is to quell the CATECHOLAMINE STORM currently creating a synergistic cyclone within your patient’s body. This storm increases myocardial oxygen requirements, ischemic injury, lowers Vfib threshold, and disrupts myocardial function. Esmolol is nice because it works quickly and has a short half life in the event that you have severely miscalculated.

A study by Driver et al. from 2014 used a loading dose of 500 mcg/kg bolus followed by an infusion. 50% of patients (3 out of 6) who received esmolol survived to discharge with favorable neurologic outcome. ALL SIX OF THEM ACHIEVED SOME ROSC. This is opposed to 11% survival (2 out of 19) of the control group who received no esmolol.

Like all medical studies where your patients are extremely critical and essentially moribund with an uncommon presentation, the quantity of patients included is weak.

Another group in Korea (Lee et al.) published a study in 2016 that compared 16 refractory VF patients who received esmolol versus 25 who did not and found higher rates of temporary ROSC, sustained ROSC, and survival to the ICU. These studies are promising and hopefully more are on the way.

What's your point? These refractory VF patients likely need a cardiac catheterization more than anything else. The more you can do in the ER to stabilize them to revascularization of the vessel that precipitated their refractory VF electrical storm, the better. Esmolol should be a strong consideration in these rare situations.

Learn more: https://empharmd.blogspot.com/2017/03/revisiting-esmolol-for-refractory.html?m=1

https://www.emrap.org/episode/badbleedsinthe/3treatmentsfor

Driver BE, Debaty G, Plummer DW, Smith SW. Use of esmolol after failure of standard cardiopulmonary resuscitation to treat patients with refractory ventricular fibrillation. Resuscitation. 2014;85:1337-1341.

Lee YH, et al. Refractory ventricular fibrillation treated with esmolol. Resuscitation. 2016;107:150-155.