Precordial Thump - For Asystole? - ECG Strips

Rogue Medic | 8:18 PM | , | 6 comments





Last week I posted on some of the problems with this precordial thump study.[1] This week I will look at some of the positives. While the data do not suggest that we should start using precordial thump. The data suggest that we should be doing more research. Is this harmless when it is not effective? This is an important question that the study seems not to address. I already wrote about that enough.

Here are some of the positives. The ECGs from the actual thumps are impressive:


ECG 1.



Figure 1. Restoration of cardiac activity following pre-cordial thump delivery after 52 s of asystole. Cardiac arrest was witnessed by the emergency medical service personnel during ambulance transport.

Patient 1

A 64-year-old man with a history of hypertension and syncope developed CAAS during hospital transportation. Asystole was treated solely by PT, causing prompt ROSC. The patient was discharged alive, neurologically intact, after electrical pacemaker implantation (#1 in Table 3; see Figure 1).[2]



ECG 2.



Figure 2. Patient recording of pre-cordial thump induced cardioversion during witnessed out-of-hospital cardiac arrest (OOH-CA). Subsequent to the development of asystole, a pre-cordial thump is delivered after 22 s (see arrow), restoring a palpable pulse.

Patient 2

A 51-year-old female with a history of migraine called EMS, suffering from headache, nausea and vomiting. During transportation the patient became progressively bradycardic (in the absence of further vomiting), developed 1st degree atrio-ventricular block, and suddenly lost consciousness. After 22 s of documented CAAS, PT was delivered and sinus rhythm achieved (Figure 2). The patient received an implanted pacemaker and was discharged neurologically intact (#2 in Table 3).2


ECG 3.



Figure 3. First episode of asystole successfully treated by pre-cordial thump on the scene. Two more episodes were observed during ambulance transport to the hospital, all responsive to a single pre-cordial thump.

Patient 3

A 78-year-old man experienced 160 s of EMS-witnessed CAAS. PT was followed by restoration of spontaneous circulation. P waves were recognized during post hoc analysis of the defibrillator memory card for the first 120 s of CAAS. During transportation, two additional episodes of CAAS occurred, both converted successfully into an organized viable rhythm by prompt administration of a single PT (Figure 3). The patient was conscious when admitted to the coronary care unit, and transferred to the department of internal medicine without pace-maker implantation, where he subsequently died of pneumonia complicating chronic obstructive respiratory disease (#3 in Table 3).2




Some of you may be thinking that this is all the convincing you need to start thumping patients. Especially the ones in cardiac arrest. Not so fast.

Look at these rhythms without looking at the thumps. Are they clearly asystole?

I don't think so. True, the strips are not as clear as we would like, but they are dealing with a witnessed cardiac arrest in each of these cases. Some are during transport, so there are plenty of reasons for artifact. If three beats make a rhythm, what would three beats of asystole be? Three very bradycardic beats? Three of whatever was the previous rhythm, if we already have the patient on the monitor and know what the previous rhythm was? This is really more of an answer to a documentation question. Patients are not documentation questions.

ECG 1. I have labeled the individual strips with letters, so that it is easier to specify what I am describing. What do you see?

Each is a 14 second strip. We do not know if the ECG is continuous in the same lead. Strips A and D do look alike, so they probably are the same lead. Strip B begins with a beat that looks different. Is it a different lead? Then there is asystole for 52 seconds before something is done? We are missing a lot of information.

I am more patient than most people. I am not going to wait 52 seconds after cardiac arrest to do something, except if I have given adenosine or if there is some kind of an advance directive (such as a DNR - Do Not Resuscitate order). His heart rate was already in the mid-30s. Was he symptomatic? We do not know. What was the original call for?

He has a history of syncope. He may vagal down to something that looks asystolic, but with something that could be atrial activity, somebody may shake him to see if he is OK, and his heart remembers what it was doing.

Or he could be in an ambulance, repeat that behavior, and be awoken by a medic punching him in the chest.

Or he might not need any stimulus. When he does this, it may be something that resolves spontaneously.

Does he have Cheyne-Stokes respirations? His heart rate may vary with his rspiratory pattern. 52 seconds of asystole does seem unlikely, but we do seem to be in zebra territory.

His QT segment seems to be longer after the thump (strip A vs strip D). Is this related to the thump? Is this related to the ventricular standstill? Is this at all relevant? A lot of unknowns with this patient. We don't know anything about vital signs, except ECG heart rate. Let's move on to the next one.

Should he have received atropine or transcutaneous pacing prior to arresting? Difficult to tell. Does the transcutaneous pacer work more by obtaining capture, or by painful stimulus? Maybe it is a little of both, because some of the pacer applications I have seen have not been good for anything but painful stimulus. Why should we give more credit to the precordial thump?

Is the original rhythm sinus? Is the final rhythm sinus?




Figure 1. Restoration of cardiac activity following pre-cordial thump delivery after 52 s of asystole. Cardiac arrest was witnessed by the emergency medical service personnel during ambulance transport.

Patient 1

A 64-year-old man with a history of hypertension and syncope developed CAAS (Cardiac Arrest - ASystole) during hospital transportation. Asystole was treated solely by PT, causing prompt ROSC. The patient was discharged alive, neurologically intact, after electrical pacemaker implantation (#1 in Table 3; see Figure 1).2



ECG 2. Each is a 6 second strip. As with ECG 1., there appears to be some atrial activity. Sinus rhythm with a first degree block. This seems to progress to a more serious form of first degree block - one without ventricular activity. The rate is about 80 before the arrest, so it does not appear that this would have been prevented by treating the presenting rhythm. The resuscitated rate is only about 60 (strip Cand it seems to take its time getting there if strip B is any indication.




Figure 2. Patient recording of pre-cordial thump induced cardioversion during witnessed out-of-hospital cardiac arrest (OOH-CA). Subsequent to the development of asystole, a pre-cordial thump is delivered after 22 s (see arrow), restoring a palpable pulse.

Patient 2

A 51-year-old female with a history of migraine called EMS, suffering from headache, nausea and vomiting. During transportation the patient became progressively bradycardic (in the absence of further vomiting), developed 1st degree atrio-ventricular block, and suddenly lost consciousness. After 22 s of documented CAAS, PT was delivered and sinus rhythm achieved (Figure 2). The patient received an implanted pacemaker and was discharged neurologically intact (#2 in Table 3).2



ECG 3. Again, each is a 6 second strip. This patient arrests 3 times. What are the rhythms before the asystoles? I thought 52 seconds of asystole was demonstrating extreme patience. This patient was in asystole for 160 seconds before being thumped. 2 minutes 40 seconds. Top marathoners will run over half a mile in that time - at a pace that they will maintain for over 26 miles. Try holding your breath for that amount of time. This is a small amount of time for many things, but for going without a heartbeat during a witnessed cardiac arrest, this can be a lifetime - at least for the patient. I've had to explain to some patients that they were dead for a few minutes, but at least I was treating them during that time. In this study, the patients received a precordial thump as the first treatment. If not they were not included in the precordial thump treatment group. This patient was included in the precordial thump treatment group. This is described as an EMS witnessed cardiac arrest. Were they waiting for the P waves to go away? Were they trying to see what interesting colors the patient could demonstrate? Was someone preventing them from treating the patient? Again, there are a lot questions, but not enough answers. Since no CPR was described for this patient, what were they doing for almost 3 minutes? After 3 minutes it is more likely to be time to repeat a treatment, rather than to decide to finally initiate treatment.

We have three different looking post-arrest rhythms. Do they begin to look more alike after a few beats? In describing him, there is almost as much space used as for both Patient 1 and Patient 2 combined. It is almost as if they view the death in the hospital after resuscitation with return of consciousness as a failure of the precordial thump, that needs to be explained.

What was the original call for?




Figure 3. First episode of asystole successfully treated by pre-cordial thump on the scene. Two more episodes were observed during ambulance transport to the hospital, all responsive to a single pre-cordial thump.

Patient 3

A 78-year-old man experienced 160 s of EMS-witnessed CAAS. PT was followed by restoration of spontaneous circulation. P waves were recognized during post hoc analysis of the defibrillator memory card for the first 120 s of CAAS. During transportation, two additional episodes of CAAS occurred, both converted successfully into an organized viable rhythm by prompt administration of a single PT (Figure 3). The patient was conscious when admitted to the coronary care unit, and transferred to the department of internal medicine without pace-maker implantation, where he subsequently died of pneumonia complicating chronic obstructive respiratory disease (#3 in Table 3).2



These problems with the research did not go completely unnoticed outside of this blog. In the same issue there is an article pointing out some of these problems. Here is a quote:

In this study therefore, the precordial thump may have played only a marginal role. Pellis et al, nevertheless, do recommend the continued use of the precordial thump in out-of-hospital cardiac arrest and cite an “interesting cost-to-benefit potential” for patients in EMS-witnessed asystole. Let us, for the sake of argument, accept that the cost of the precordial thump is low, maybe even zero. But is there any benefit? I am not convinced. As discussed by the authors, the ambulance-witnessed asystole cannot be the late asystole from end-stage VF as this, almost by definition, is associated with late arrival of the ambulance and no bystander CPR. In the tracings, at least in two out of the three cases, p waves are visible, suggesting complete AV block with lack of an escape activity as the cause of the asystole. But why was the ambulance called in the first place? The authors do not answer this question, but it is not unlikely that an earlier symptomatic episode of asystole was the reason to call for ambulance help, confirming the transient and repetitive nature of the conduction disturbance. In any case, no alternative diagnosis was apparent and the uncontrolled nature of this cohort makes it impossible to establish a causal relation between the precordial thump and the positive outcome in the two surviving patients. While the abnormal shaped QRS complex from the thump in Figs. 1 and 3 are good examples of the relation between thump and electrical activity, this cannot be seen in Figure 2. Here it is questionable if there is any relation between the suggested moment of the thump and the QRS complex at that position, given the shape that appears identical to all other QRS complexes. Nevertheless, it is possible that in asystole caused by a conduction disturbance (a small minority in out-of hospital cardiac arrest) the thump may have played a role in the good outcome in two of three patients.[3]


Are these high grade heart blocks or are they cardiac arrests?

We do not know.


Footnotes:

^ 1 Utility of pre-cordial thump for treatment of out of hospital cardiac arrest: A prospective study
Pellis T, Kette F, Lovisa D, Franceschino E, Magagnin L, Mercante WP, Kohl P.
Resuscitation. 2009 Jan;80(1):17-23. Epub 2008 Nov 17.
PMID: 19010581 [PubMed - indexed for MEDLINE]


^ 2 Utility of pre-cordial thump for treatment of out of hospital cardiac arrest: A prospective study
Pellis T, Kette F, Lovisa D, Franceschino E, Magagnin L, Mercante WP, Kohl P.
Resuscitation. 2009 Jan;80(1):17-23. Epub 2008 Nov 17.
PMID: 19010581 [PubMed - indexed for MEDLINE]
The same study.


^ 3 Precordial thump: friend or enemy?
Koster RW.
Resuscitation. 2009 Jan;80(1):2-3. No abstract available.
PMID: 19103396 [PubMed - indexed for MEDLINE]

.

Video: Diagnosis Wenkebach

Adam Thompson, EMT-P | 7:32 PM | , | 6 comments

For your viewing pleasure:



This is something my training captain emailed to me about a year ago. It has always stuck in my head as the best medical-related study song I have ever heard or seen. Hope you enjoy.

PS. I will be working on a cardiology video tutorial. From anatomy to ECGs, in plain English. I am going to try and teach ECGs a little differently. This is something I always wanted as a student, I get tired of hearing people recite powerpoints. This is going to take a while, but keep a lookout.

Drug Math Tutorial Part IV

Adam Thompson, EMT-P | 10:56 PM | | 0 comments


Okay, now that you have the correct method to work out any prehospital drug calculation (once you learn it well), I am going to teach you a few tricks and other methods.

The first trick I am going to teach you is for Dopamine. This trick will yield you a starting dose of 5mcg/kg/min using 1600mcg/ml concentration and a mini drip (60gtts/ml). This will give you a starting point to titrate from. It is a pretty easy method and it works every time (well every time I have used it).

  1. First, take your patients weight in pounds (that's right, pounds!).
  2. Then drop the last number off the weight
  3. Then subtract 2
  4. This will be your gtts/min.
Lets try it:
148 lbs
drop the last number
14
subtract 2
14 - 2 = 12
12 gtts/min.
Okay, now lets try this with the master formula:

5mcg/kg x 67kg x 60gtts/ml
400mg/250ml x min

5mcg/kg x 67kg x 60gtts/ml
1600mcg/ml x min

5 x 67 x 60gtts
1600 x min

Your answer will come out to 12.5625
Pretty close huh?

Try this with a few other weights and see what you come up with. This is easier than the dopamine clock method, so I am not going to teach that. I will show you the clock for lidocaine though.

The Lidocaine Clock
4mg/ml
Please excuse my horrible drawing. I am going to explain this method for those who have not adopted Amiodarone as the end all save all, and might still have enough Lido to do this. Or for the future, since I have a small feeling that the next set of AHA proposed ACLS guidelines will be bringing Lido right back where it was.

This is how you use the clock method.

Notice how the numbers 15, 30, 45, & 60 all sit in the drawing the same place they would on a clock?
  1. First you must mix your bag, 2gm in 500cc, or 1gm in 250cc
  2. Use a mini drip (60gtts/ml)
  3. This will give you a concentration of 4mg/ml
  4. Look up the dose you need per min. (example 2mg/min)
  5. Run your dose at the setting according to the clock.
So if your dose is 2mg/min you will run your drip at 30gtts/min. (1gtt/2sec)
If your dose is 4mg you will set your drip at 60gtts/min (1gtt/sec)

Get it? Hope so, its pretty simple.


Another thing I wanted to mention in this part was volume dosages. I kind of touched on this with one of the Q&As for part III. When administering an amount of fluid over time, you can ignore the drug dose in the formula. The math becomes much simpler.

Amiodarone: 150mg in 100cc(D5W) over 10 minutes.

For this medication you want to use a macro drip(10gtts/ml) just because its too hard to count the mini drip dose and most people just end up leaving it wide open (which goes in at about 10 min coincidently).

So for this dose forget the drug portion. You need to get 100cc of fluid in over 10min using a macro drip.

1. For this, just multiply your total fluid by your drip set.

100ml x 10gtts/ml = 1,ooo

2. Then simply divide by the time that you need to get it in.

1,000/10 = 100
answer: 100gtts/min
This is easier than trying to plug it in to the master formula. Plug in a mini drip and see why we don't use that. I think you would have to count 600gtts/min.

Try using these methods in conjunction with the master formula.

Drug Math Answer Key

Adam Thompson, EMT-P | 7:47 AM | | 0 comments

Answers to part II
1. 500 mcg / 50 ml
Answer: 10mcg/ml

2. 25 mg / 250 ml (first convert this to mcg)
Answer: 100mcg/ml

3. 10 mg / 2 ml
Answer: 5mg/ml

4. 500 mg / 250 cc
Answer: 2mg/ml
Answers to part III
mini drip = 60gtts/ml
macro drip = 10gtts/ml

1. Your dose is 20mcg/kg/min and your concentration is 500mg in a 50cc vial. Use a mini drip.
Plug your numbers into the formula. Remember, the time portion of the dose goes on the bottom.
20mcg/kg x 70kg x 60gtts/ml
500mg/500ml x min.
First convert concentration to mcg because the dose is in mcg
20mcg/kg x 70kg x 60gtts/ml
500,000mcg/500ml x min.
Next reduce your concentration
20mcg/kg x 70kg x 60gtts/ml
1000mcg/1ml x min.
Next, cross out a zero up top for every zero on the bottom.
20mcg/kg x 70kg x 60gtts/ml
1000mcg/ml x min.
Then cross out every variable that repeats itself
20mcg/kg x 70kg x 60gtts/ml
1000mcg/ml x min.
Then rewrite the formula without all the stuff you just crossed out.

2 x 7 x 6 gtts
min.

Now you know your answer is going to be gtts/min. from here just multiply what is left.
2 x 7 = 14 & 14 x 6 = 84
Answer: 84 gtts/min
now work thatdown to something you can manage
It's almost 3 gtts every 2 seconds

2.Your dose is 10mcg/min and you have a 250cc vial with 25 mg. Use a mini drip.

Answer: 6gtts/min (better use a IV pump)

3.Your dose is 2mcg/min and you put 1mg in a 250cc bag. Use a mini drip.

Answer: 30 gtts/min. (1gtt/2sec.)


4.Your dose is 150mg/10min you have a 100cc bag and a macro drip.
This was a trick question. For this one, all you have to worry about is getting 100ml of fluid in over 10 min. using a 10gtts/ml drip set. So your dose is 100 x 10. The 100 comes from the 100ml portion and the 10 comes from the time. Giving a certain amount of fluid over a time period is slightly different. You can use the formula if you plug it in correctly, but I will show easier ways in further posts.
100 x 10 x 10gtts/ml
100ml x min.
Answer: 100ml/min. (about 3gtts/2sec.)

5.Your dose is 0.25mg/kg for a 132 pound and you have a 5cc vial with 25 mg. This is a common dose for Cardizem. If you divide your patient's weight(in kg) by 4 you will have your dose in mg. Then divide by 5 because for every 5mg its one ml.
60kg/4 = 15
15mg/5 = 3
Answer: 3ml (15mg)

Precordial Thump - For Asystole?

Rogue Medic | 9:33 PM | , | 8 comments






In The Precordial Thump, Adam Thompson, EMT-P writes about an article[1] by Dr. Keith Wesley in JEMS. Dr. Wesley was reviewing a study of the use of precordial thump (PT is the abbreviation used in the study, but since PT is commonly used for other medical terminology, I prefer to write it out) as the initial therapy for all cardiac arrest not yet treated by EMS. As with much in EMS, the answers are not abundant, but there is a lot that is interesting.


Here is the way the study worked:

This study was part of a larger epidemiological investigation of OOH-CA , conducted between March 2004 and November 2005. The study protocol pertinent to PT was as follows: all patients in CA (confirmed according to the 2000 ILCOR guidelines) for whom it was decided to attempt CPR were regarded as qualifying for this study. After placing defibrillation pads on the victim, a pre-cordial chest thump was delivered, regardless of the presenting rhythm. All EMS personnel was trained in Advanced Life Support, but did not receive specific training or instructions on how to perform PT, to obtain data pertinent to the typical ‘real-life’ conditions. Whenever any other resuscitative manoeuvre preceded PT, the protocol was considered violated, and the case was not included in the PT study cohort (see Table 1 for detail).[2]

CA = Cardiac Arrest
OOH-CA = Out-Of-Hospital - Cardiac Arrest (as opposed to in hospital CA)
ILCOR = International Liaison Committee on Cardiopulmonary Resuscitation
CPR = CardioPulmonary Resuscitation


Whenever any other resuscitative manoeuvre preceded PT, the protocol was considered violated, and the case was not included in the PT study cohort.

This is important in understanding all of the data. Unless EMS showed up and thumped the patient before doing anything else, the patient was placed in the other or no thump category. They could have thumped the patient dozens of times, but if they did not deliver one thump immediately after confirming cardiac arrest the patient was not considered to have been thumped. This is not necessarily a bad way to divide the treatment groups, but where is the information on these cases? Did they not happen at all? I can't tell from the information provided. The researchers should include enough patients to allow for these protocol deviations. They should also prospectively describe the various subgroup analyses that will look at the various ways the patients will be treated. I cannot find these in the paper.

This study does show that the intention-to-treat analysis of data is more than a little misleading. Intention-to-treat analysis of data is looking at what the study protocol indicated for treating the patient, rather than looking at the actual treatment the patient received. Just having to mention this in a study shows a significant problem persuading participants to follow the protocol. Had they used intention-to-treat analysis, they could have claimed 100% use of precordial thump as the initial EMS treatment. The actual compliance was 40%. There was no use of intention-to-treat analysis in this study, but it was used in the Gausche pediatric intubation study.[3]

All EMS personnel was trained in Advanced Life Support, but did not receive specific training or instructions on how to perform PT, to obtain data pertinent to the typical ‘real-life’ conditions.

It is true that many paramedic programs will not provide any specific instruction on performance of the precordial thump, even though it may be in the paramedic scope of practice where the school is located. This foolishness should not be used to justify shortcuts in the protocol design. Some training is essential. If the precordial thump is found to be very effective in treatment of cardiac arrest, then you can expect a lot more attention will be paid to instruction of precordial thump. How do we know what was being done by the medics in the study? There is no standard precordial thump being delivered. The precordial thump, in this study, is whatever you think a precordial thump should be.

This is not controlling for variables, but introducing variables. Good research is about controlling for as many variables as possible. In this area, good research may not have a lot to do with the real world, but it does have to do with finding out what may work. If precordial thump is found to be worthy of further study, then more consideration of real world limitations conditions ought to be addressed.

What are the participants doing, when they are thumping? If you are familiar with the instruction of CPR, and you have seen CPR certified health care professional performing what they believe to be CPR, then you know that some of the simplest things can be open to interpretation. What are the participants doing, when they are thumping? I suspect that they received written instructions on how a precordial thump should be delivered. How literate are the paramedics? How well written are the written instructions? Do those writing the written instructions understand what a precordial thump should be? Should a precordial thump be delivered in the way that most people thump patients?

This study raises a lot of questions, but is too small and uncontrolled to answer them. Still, it is interesting, otherwise so many people would not be writing about it. This study was done according to the 2000 guidelines, so we should expect that the numbers discharged neurologically intact would be much higher now, even with the prolonged response times.

Table 1.
Summary of population characteristics of victims treated according to the study protocol by pre-cordial thump (PT) [Thump] before any other resuscitatory intervention, compared to the sub-cohort excluded for protocol violation (non-PT) [No Thump]. Data is presented as patient numbers and percentage of total. VF/VT: ventricular fibrillation/tachycardia (VT observed in one PT and no non-PT cohort case); PEA: pulseless electrical activity, time: mean delay between emergency medical support contact call and first intervention by emergency medical service (EMS) personnel (in brackets: minute-bin of 25th and 75th quartile); EMS-witnessed: EMS-witnessed cardiac arrest; ROSC: return of spontaneous circulation; discharge: discharged alive from hospital.[2]


Here is the information from Table 1. I could not get the html to work, so this should at least keep the information organized:


Thump: 144 patients

No Thump: 219 patients


Thump: 74 (51%) Male

No Thump: 131 (60%) Male


Thump: 73 ± 16 Years Old

No Thump: 69 ± 19 Years Old


Thump: 24 (17%) VF/VT

No Thump: 42 (19%) VF/VT


Thump: 42 (29%) PEA

No Thump: 59 (27%) PEA


Thump: 78 (54%) Asystole

No Thump: 118 (54%) Asystole


Thump: 9:48 minutes response - (6/12) 25%/75% Quartiles

No Thump: 9:24 minutes response - (5/11) 25%/75% Quartiles


Thump: 11 (8%) EMS Witnessed

No Thump: 19 (9%) EMS Witnessed


Thump: 21 (15%) Bystander CPR

No Thump: 55 (25%)* Bystander CPR


Thump: 31 (21.5%) ROSC

No Thump: 43 (19.6%) ROSC


Thump: 8 (5.6%) Discharged Alive

No Thump: 14 (6.4%) Discharged Alive


* Significant difference between PT [Thump] and non-PT [No Thump] cohort (p < 0.05).[4]


Let's look at some of the ways that small numbers can lead to data that encourage misrepresentation.

The cardiac arrests witnessed by EMS:

The success rate of PT for ROSC was as high as 27.3% (3 of 11; Table 2), highlighting the need for early application of PT. Overall survival among EMS-witnessed CA victims was 36.4% (4 of 11); one half of these were cardioverted by PT.[2]


Treatment of 11 patients with witnessed cardiac arrest does not give a large enough sample to draw any conclusions other than this is interesting and deserves more study. By more study, I mean a much larger study. In this study, only 40% of patients were treated according to the study design. So, we should anticipate that about two thirds of patients attempted to be enrolled will be excluded, just by those on scene not delivering a precordial thump first. 144 cardiac arrest patients is not a lot of patients for any kind of study of response to treatment. There are parts of New York City, that would have each medic responding to more than 144 cardiac arrests in a year. While the intent of the researchers is good, the numbers do not support any interpretation of effect on survival.

The results include a paragraph each on six patients with changes in rhythm after precordial thump. 2 of these patients were discharged neurologically intact. 2/144 ≠ an acceptable outcome. Not even if your average response time is almost 10 minutes (mean time to precordial thump was 9:48).

Then there are the survival numbers. 22 survivors to hospital discharge. 8 of these survivors are in the thump group. A paragraph each on 6 patients who had changes in rhythm immediately after precordial thump. Only 2 of those 6 patients survived to hospital discharge. There are 6 patients resuscitated, with apparently good outcome, who are only mentioned in passing. What does this mean? I suspect that it means that these patients were initially treated with a thump, but did not have a rhythm change right after the thump, then they received conventional treatment and had ROSC after the conventional treatment was begun.

Were the patients unresponsive to precordial thump not treated the same as if they had not received a precordial thump? This does not appear to be that much different from the double standard that the acupuncture researchers applied, however unintentionally, in the studies I wrote about in Eureka - Conventional Treatment Plus Placebo Beats Conventional Treatment Alone. Precordial thump is proposed as a complementary treatment - not an alternative treatment.

Some patients received precordial thump, but did not respond immediately after the thump, then may have responded after other treatment. These patients do not get enough discussion. Did 20% of the thumped patients have ROSC by other means? Did they survive to discharge? Did the thump cause any change in response to treatment?

Statistically, shouldn't there have been other ROSC patients surviving to discharge?

Given the sample size, the rate of ROSC, and the survival to discharge rate, there are not enough patients in the sample to answer that question. They state that this is a part of a larger study, so maybe there will be publication of data on a much larger group of precordial thump patients.

Among patients who were discharged from hospital alive, PT was the original cause of ROSC in two of eight cases. Patients in whom ROSC was caused by non-PT interventions had a survival rate of 21.4% (6 of 28), compared to 2/3 among those in whom ROSC occurred upon PT.[2]


Reading the full study does not answer these questions. I will repeat what I stated at the beginning. This study raises a lot of questions, but is too small and uncontrolled to answer them.


Here is everything the Pennsylvania ALS protocols have on precordial thump use.

4. Precordial thump may be used when ALS personnel witness VF arrest in a monitored patient.[5], [6]


Precordial thump is in the protocols, but not in the scope of practice? Are medics in Pennsylvania trained in this? How do you QA/QI/CYA something like this?


Finally, what do the ACLS guidelines have to say about precordial thump?

Precordial Thump for VF or Pulseless VT
There are no prospective studies that evaluated the use of precordial (chest) thump. In 3 case series (LOE 5),104–106 VF or pulseless VT was converted to a perfusing rhythm by a precordial thump. In contrast, other case series documented deterioration in cardiac rhythm, such as rate acceleration of VT, conversion of VT to VF, or development of complete heart block or asystole following the use of the thump (LOE 5105,107–111; LOE 6112).

The precordial thump is not recommended for BLS providers. In light of the limited evidence in support of its efficacy and reports of potential harm, no recommendation can be made for or against its use by ACLS providers (Class Indeterminate).[7]


While they do not mention asystole, the results of the studies published since these guidelines were published suggest that the biggest change should be adding asystole to the list of things for which no recommendation can be made for or against its use by ACLS providers (Class Indeterminate).

Reading the full study does not answer questions. I will repeat what I stated at the beginning. This study raises a lot of questions, but is too small and uncontrolled to answer them. Interesting. Not useless, but really only useful in encouraging more research and suggesting that some of what we believed about precordial thump (only for VF/VT - not for asystole) is wrong.


Footnotes:

^ 1 To Thump, Or Not To Thump
JEMS.com
Keith Wesley, MD, FACEP
Street Science
2009 May 11
Article


^ 2 Utility of pre-cordial thump for treatment of out of hospital cardiac arrest: A prospective study
Pellis T, Kette F, Lovisa D, Franceschino E, Magagnin L, Mercante WP, Kohl P.
Resuscitation. 2009 Jan;80(1):17-23. Epub 2008 Nov 17.
PMID: 19010581 [PubMed - indexed for MEDLINE]


^ 3 Effect of out-of-hospital pediatric endotracheal intubation on survival and neurological outcome: a controlled clinical trial.
Gausche M, Lewis RJ, Stratton SJ, Haynes BE, Gunter CS, Goodrich SM, Poore PD, McCollough MD, Henderson DP, Pratt FD, Seidel JS.
JAMA. 2000 Feb 9;283(6):783-90. Erratum in: JAMA 2000 Jun 28;283(24):3204.
PMID: 10683058 [PubMed - indexed for MEDLINE]]
Free Full Text . . . . Free PDF


^ 4 Utility of pre-cordial thump for treatment of out of hospital cardiac arrest: A prospective study
The tables is my pathetic recreation of one table from the study. I have changed the wording that I felt was not clear, or that lost some context separated from the rest of the study.
Same as Footnote [2]


^ 5 Ventricular Fibrillation / Pulseless VT
Pennsylvania Adult Statewide ALS Protocol
Note # 4
23/121 enter 23 in the page count window.
Nov. 2008 posting of PA ALS Protocols


^ 6 Prehospital Practitioner Scope of Practice
PA Bulletin
[38 Pa.B. 6565]
[Saturday, November 29, 2008]
I would point to a particular part where it isn't, but that is the point. It isn't there, anywhere. Pennsylvania can be very strict in punishing violations of scope of practice, yet here they seem to encourage it.
Nov. 2008 posting of PA Scope of Practice


^ 7 Precordial Thump for VF or Pulseless VT
2005 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care
Part 7.2: Management of Cardiac Arrest
Interventions Not Supported by Outcome Evidence
Free Full Text . . . . Free PDF page 8/10


.

"911, what's your emergency?"

Adam Thompson, EMT-P | 5:51 PM | , | 0 comments

This is an editorial I wrote a while ago and just found on the computer, it goes along the same lines as a couple of my other posts regarding "BS" calls. This topic always seems to strike some opinionated discussion. As a disclaimer, let me just say that I don't advocate people calling 911 if they don't need it. I just don't see the point in complaining about it. If you have a problem with the BS call volume, start being proactive, don't let your bedside manor be a reflection of your stress.


Medic 1, please respond to a residence for a 23 y/o male complaining of a nose bleed.

Why did you decide to take the long path towards an EMS career? Was it an episode of Rescue 911 or Emergency? Did September 11th open your eyes, and make you want to be a hero? Maybe you liked the thought of shift work, and being behind a desk wasn’t something that you thought would excite you. Whatever the reason may be, I am almost certain, that at some point, the thought of helping another human being was part of this job choice.

Now think about when you were in EMT or paramedic school. Do you remember training for the cut finger calls? What about the “I’ve had an ear ache all day” calls? Probably not, if you were like me, there is a good chance that you were probably trained for the cardiac arrest calls, the major trauma calls, and pretty much everything priority one that required lights, sirens, meds, and diesel fuel. I guess the thought is that if you’re trained for the worst calls the rest will come easy, right?

I remember what a rude awakening it was once I got on the job, to realize that every patient that calls 911 isn’t dying (what a bummer).

I think that these could be the major reasons that we develop these complexes regarding calls that we may not consider emergencies. We will hear those tones drop and the next words out of the dispatchers mouth will dictate whether we yell in anger, laugh at what we might think is stupid, or run out of the station while tying our boots. Have you ever thought about why we react this way? Consider the previous paragraph and you might be closer to the answer. We want the excitement of those calls our instructors promised. Basically we want people that we run on to be really sick or hurt so we can fix them.

IT’S NOT YOUR EMERGENCY

…It’s theirs. It’s hard to think that way, but try to go back to the days when you had no medical training at all. Think about everything you didn’t know and how you would react to the most insignificant symptom. Some of us were raised differently. Maybe your parents would just drive you up to the hospital when you were sick, but Sally’s parents, down the street, would call for an ambulance. This translates to us, and how we respond to the same type of situations now that we are the adults.

Rescue 7 respond to a residence for a 67 y/o female complaining of chest pain, shortness of breath, arm numbness, painful urination, head ache, abdominal pain, and a partridge in a pair tree.

You also should consider that the patients out there are getting smarter and dumber all at the same time. While the media is doing a good job improving the recognition of once commonly missed symptoms, they are also creating more and more hypochondriacs. We have to take the positive with the negative; calling 911, even if the number of unneeded responses is increasing, saves more lives.

It isn’t our emergency, and we aren’t the persons calling for assistance. These patients of ours were most likely scared, and felt they needed a professional piece of mind. They don’t know that you may be missing your meal, much needed sleep, or the American Idol results. They just want help. We get these people when they are at there worst, and we need to appreciate that situation before we judge it.

SAVING LIVES BY CHANGING LIVES

Rescue 3 respond to a residence for an 84 y/o female complaining of general illness.

Upon your arrival you find this patient asymptomatic in a house all alone. Her husband passed away about three weeks ago and you can tell this is just a lonely old lady that may have been scared.

At my agency we call these BLS calls, sometimes without the letter L. These “BS” calls have opened my eyes. When I first started this job I use to ignore the patients emotions, and concentrate on beating the reaper. I was always looking for those priority one ALS symptoms, preparing for the worst. Now I still feel I am prepared, but the back of my ambulance has become more of a social environment.

Always greet your patient, with consideration of their mental status of coarse, and give them your name. I have realized that if you make a good first impression, and a great last impression, all the stuff you do in between won’t matter. This doesn’t mean you can botch treatments, but if you keep your patient happy, your medical care will almost always seem phenomenal.

Hold this ladies hand and tell her that you aren’t going to let anything happen to her. Just give her someone to talk to. You never know, a call like this could always turn sour so never overlook the symptom of loneliness.

Medic 22 respond to Larry’s 8th street motel for a 17 y/o male possible overdose

Ok, so this call is a bit more serious. How do you handle these calls? Do you judge this patient? Do you make this patient feel guilty?

I use to do the exact same thing. Take the time and really consider the situation. We have all done stupid things when we were younger, and if it wasn’t for certain factors in our lives we may still be doing them. There is something called the teachable moment; it is the moment during a life-changing event where your fear and realization of consequence may open up your eyes to reason.

These patients may ignore everything you say to them. They might even argue with you or become angry. It is important to me that I do everything in my power to remain a patient advocate, and this is a prime example. One day you may encounter a patient whose life you might save without a medication, without ventilation, and without chest compressions. You might not ever know that you saved this persons life, and they may never realize how much you helped them, but without you they’d be under a whole lot of dirt in a wooden box. Now think about that for a moment. Do you need to be called a hero, or do you just want to be one?

What does it hurt to give a young patient a piece of mind? Tell them that there are people that care about them. Give them a story that relates to the situation, even if you have to embellish, as long as it sounds genuine. You just may get through to one of them, and that’s all it takes.

Now there may be certain demographics that different people can relate to better. I’m younger so the teenagers, and twenty year old patients listen to me better than the forty year olds. If you are older you may have better luck teaching another older adult about heart disease than you will teaching a young adult about drinking and driving.

THE BIG PICTURE

I have partners say to me all the time, “I may bitch on the way to the call, and after the call, but never in front of a patient”. Now that is a good thing, but why complain at all? This is the job we chose right, so why not make-work enjoyable? If you moan and groan about every “BS” call you will get burnt out quicker, and end up hating this job. Also, if you are in BS mode, and it ends up being a true emergency, you are a step behind.

My response to most people is an easy one that took me a while to figure out myself. My agency has about forty ambulances and 300 employees. We run approximately 75,000 calls a year. I would guess that maybe out of those 75,000 calls, maybe 20,000 are true emergencies. If we didn’t have people call for anything but true ALS emergencies our call volume would be greatly diminished. This would mean that our employers could manage this organization with fewer ambulances, and in turn they would require less employees to operate these ambulances. Now do you get where I am going with this? I probably wouldn’t have a job without these “BS” calls, and that’s why we call it job security.

I am not an advocate of 911 abuse, just an optimist. I will educate patients every chance I get, and tell them when it is appropriate to use our service.

There are other things that you can do to be a part of the solution. Many agencies have started programs designed to educate their citizens on when to, and when not to call 911. Even though we may need these calls to survive, too many of them can be detrimental. If your department has a limited number of transport units, priority dispatching could help with this problem. The thought of responding to a stubbed toe when someone is having a stroke next door can be unsettling.

My department has started a 211 program. When we respond to a citizen that might not qualify as a medical patient, but may need other help, we utilize this system. This 211 program has given us a direct connection to the United Way, and they then assist the citizen with whatever need they may have.

Another part of why we feel the way we do about the serious calls is quite possibly the recognition we receive. Medals are given, you sometimes make it on the media, and doctors, nurses, and coworkers pat you on the back. These things just make you feel like all your hard work and training isn’t going unnoticed. Well, the next time you see a fellow medic holding an old man’s hand, keeping him calm, and providing reassurance, pat him on the back and say “good job” afterwards.

OKAY, I GET IT, SO WHAT?

We may not be saving lives as much as we thought that we would be when we first considered this great career, but we are needed. We do save a few, and we help many, and that may be just as important.

Medic 27, respond to 8th Ave. and Palm for an age unknown male, unknown distress under the overpass.

Now, how will you respond?

Drug Math Tutorial Part III

Adam Thompson, EMT-P | 8:59 AM | | 3 comments

This part is going to explain a universal formula for dose administration.


What is it?
The Master Formula is a formula that can be used for all drug calculations. It was developed by my paramedic instructor(well published by him, probably developed long before him) and is currently a standard in many educational facilities.

How do I use it?
You plug the appropriate numbers into the previously defined variables. This means that if you are not administering a weight based medication & dose that you do not need to use that portion of the formula. I will explain in the fallowing.


Why do I need to do math?
Luckily, most drug manufacturers package prehospital medications in single-dose containers(vials, ampules, syringes). Unfortunately, some medications are weight-based, and nearly every pediatric dose requires titration by weight. This means that math still has its place in EMS.

The point of doing the math is to end up with an answer in milliliters or drops per minute (gtts/min). This is because our syringes & bags of fluid are measured in milliliters, and we need to figure out how many ml or gtts/min will equal the dose we want to deliver.


The Master Formula:


DD x Wt x SS
C x T

DD = Desired Dose
Wt = Weight
SS = Solution Set
C = Concentration
T = Time

Solution Sets
Mini drip: 60gtts/ml, means every 60 drops equals 1 ml(1cc)
Macro drip: 10gtts/ml, means every 10 drops equals 1ml(1cc)


You are ordered to administer 20 mg of Cardizem to your a-fib patient.
Your Cardizem comes in a 5 cc vial. On the label of that vial it says 25 mg.
How are you going to deliver this med?


Desired Dose(DD): 20 mg
Concentration(C): 25 mg/5 ml




I bet you can do this one in your head, but I am going to write it out for you(and those people who may need a math refresher). Place your desired dose(DD) over the concentration(C). Since this wasn't a weight-based dose, we don't need the Wt part of the formula. Since this is a bolus and not an infusion, we won't need the SS or T part of the formula. So we need to write this out DD/C.
20 mg
25 mg/5 ml


Now you have to reduce C to 1 ml.
25 mg /5 ml = 5 mg /ml



Now rewrite your formula with the C minimized:
_20 mg_
5 mg/ml




Now, when using this formula, you can cross out any variable, such as mg, that repeats itself. So if you see "mg" behind a number above the line, and you see "mg" behind a number below the line, just cross them both out. If both variables are on the top or on the bottom, you can cross them out as well. So basically anytime you see the same thing twice like kg, ml, mg, or mcg, just cross them out.
20 mg
5 mg/ml



Now rewrite this without crossed out variables:
_20_
5 /ml

If it makes it easier, you can circle all the single variables left. In this case ml is the only one. So now that you have reduced your variables, you need to reduce the numbers. In fractions, if the top and bottom number are both divisible by the same number, you can reduce them. Since 20 and 5 are both divisible by 5 you want to divide them both by 5.


20 divided by 5 = 4
5 divided by 5 = 1
_4_
1 /ml

Now, a mathematician would tell you to multiply the top and bottom by the remaining variable.

4(ml)
& 1/ml(ml)

= 4ml/1

= 4ml


I am just going to tell you that whenever you see 1/ml on the bottom of your formula. You can just bring the ml to the top.
So your answer will be 4 ml.


After getting your answer, ask yourself, "does this make sense?". Well does it?


25 mg of Cardizem in 5 ml, and you want to give 20 mg. Is 4 ml a reasonable answer? YES!!




Lets try Dopamine.
Your dose for Dopamine starts at 5mcg/kg/min.

This tells us that we will be using the weight (wt) portion of the formula.

First we plug the dose, and weight into the formula. Lets say our patient is 110 lbs. That equals 50 kg, because 1 kg = 2.2 lbs.
5 mcg/kg x 50 kg x SS
C x min.

• Notice that the time portion of the dose replaces Time (T) on the bottom of the formula.

• Now we still need our solution set (SS) and concentration (C).

• We will be using a 60gtts/ml(mini drip) drip set.

• Dopamine comes packaged 400mg in a 250ml premixed bag.
5mcg/kg x 50kg x 60gtts/ml
400mg/250ml x min.

Since our dose is in micrograms we need to convert our concentration from milligrams to micrograms.

• 1mg = 1000mcg
5mcg/kg x 50kg x 60gtts/ml
400,000mcg/250ml x min.

Next we need to get our concentration simplified to per 1ml (1cc). This means that you divide both sides of the concentration by the volume (milliliters).

• 400,000 divide by 250 = 1,600

• 250 divided by 250 = 1, We do not show the numeral 1 when there is a variable fallowing it(1ml = ml).
C = 400,000mcg/250ml = 1,600mcg/ml

• Now we can plug our simplified concentration into the formula.
5mcg/kg x 50kg x 60gtts/ml
1600mcg/ml x min.

• Now it’s time to start simplifying our formula.

• First you can eliminate all variables that you see twice

• Since mcg is on the top and the bottom we cross them out
5mcg/kg x 50kg x 60gtts/ml
1600mcg/ml x min.

• Do the same with kg & ml. If it makes it easier for you, circle the variables left.
5mcg/kg x 50kg x 60gtts/ml
1600mcg/ml x min.

• Now you can rewrite the formula without the crossed out variables.

• This will show you what form your dose should end up in. In this example gtts/min.
5 x 50 x 60gtts
1600 x min.

• Now you can just do the math.

• The easiest way is to cross out the zeroes. Cross 1 zero off the top and 1 off the bottom. Then do it again. You will be left with 16 on the bottom.
5 x 50 x 60gtts
1600 x min. =

5 x 5 x 6gtts
16 x min.

• Since 6 is on the top & 16 is on the bottom and they are both divisible by 2, divide both by 2.
5 x 5 x 3gtts
8 x min.
• This is as far as you can simplify so multiply the top then divide the product by the bottom.

5 x 5 x 3gtts
8 x min.

5x5 = 25
&
25x3=75

75gtts
8min.


In division we divide the top number by the bottom number.

75 divided by 8 = 9.375. Round to the nearest whole number.

Answer: 9 gtts./ min.


Practice this formula on a few more doses.

mini drip = 60gtts/ml
macro drip = 10gtts/ml
  1. Your dose is 20mcg/kg/min and your concentration is 500mg in a 50cc vial. Your patient is 154 pounds. Use a mini drip.
  2. Your dose is 10mcg/min and you have a 250cc vial with 25 mg. Use a mini drip.
  3. Your dose is 2mcg/min and you put 1mg in a 250cc bag. Use a mini drip.
  4. Your dose is 150mg/10min you have a 100cc bag and a macro drip.
  5. Your dose is 0.25mg/kg for a 132 pound and you have a 5cc vial with 25 mg.

The Precordial Thump

Adam Thompson, EMT-P | 9:22 AM | , , , | 5 comments

When I was in school, I was taught that the precordial thump(PT) is only used in witnessed ventricular fibrillation or ventricular tachycardia arrest. It was a first line treatment and most-likely feeble attempt to convert the patient into a perfusable rhythm. It was taught as harmless.

I recently read an article from JEMS online: To Thump or Not To Thump(1)
Here are some things that stood out:

In the unwitnessed arrests, only two patients had changes in their rhythm associated with PT. One was in PEA that converted to asystole, and no return of spontaneous circulation(ROSC) was achieved. The second was in V Tach and converted to PEA without ROSC.

PT was performed three times in witnessed arrests, and all three had ROSC. In all three cases the patients developed asystole, and PT resulted in the spontaneous return of a pulse. They subsequently received pacemakers.
Amazing. First of all, every witnessed arrest was asystole. I wonder if these patients were bradycardic or severely hypoxic. Secondly, PT works for asystole?
[t]he fact that the cases where PT worked were on patients in asystole is astounding. Not only is this a remarkable finding, but one that would have otherwise generated several case reports. Most providers have been taught that PT is only for V Fib/V Tach and that a patient who goes into asystole gets CPR, pharmacology and pacing
My thoughts exactly. Actually we don't pace asystole anymore, but this article made me research why. I mean if a PT will convert patients why not defibrillation or pacing?

From the New England Journal of Medicine(2):

Background: Transcutaneous cardiac pacemakers generate electrical stimuli that pace the heart through external electrodes that adhere to the chest wall. Transcutaneous pacing has been useful in some patients with bradycardia, but its efficacy in patients with asystole and full cardiac arrest has been limited, possibly because of delays in the initiation of pacing. We studied the efficacy of early transcutaneous pacing in patients with out-of-hospital asystolic cardiac arrest.Conclusions: Transcutaneous pacing appears to offer no benefit in patients with asystolic cardiac arrest, even when it is performed as early as possible by EMTs in the field. Our data suggest that the widespread implementation of early transcutaneous pacing for out-of-hospital asystolic cardiac arrest would be ineffective.
So pacing won't work, how about defibrilation?
From The American Journal of Emergency Medicne(3):

Standard drug therapy for asystole during cardiac arrest includes epinephrine, atropine, and calcium chloride (CaCl). Recent studies have shown that ventricular fibrillation (VF) can appear to be asystole when recorded from the chest surface. To determine the efficacy of these drugs and electrical countershock for asystole, a group of 83 adult nontraumatic cardiac arrest victims (55 men, 28 women, mean age of 64 +/- 14 years) were studied. Asystole appeared at some time during arrest in 44 patients (53%) and was the initial rhythm in 24 (29%). The rate of survival to hospital discharge was significantly higher in patients whose initial rhythm was VF (46%) than in patients whose initial rhythm was asystole (0%). Epinephrine, CaCl and atropine infrequently changed the rhythm from asystole. Electrical countershock infrequently altered the rhythm from asystole when it appeared as the initial rhythm. However, countershock was significantly more effective than epinephrine (P less than 0.003), atropine (P less than 0.04), or CaCl (P less than 0.03) in altering the rhythm from asystole, which appeared later in resuscitation. Ventricular fibrillation was the most common rhythm appearing after countershock for asystole. Countershock appears to be superior to epinephrine, CaCl, and atropine for treating asystole during the course of resuscitation, suggesting that the rhythm diagnosed as asystole may actually be VF in many cases.

Okay, I actually think that this just proves that some of us aren't very good at identifying asystole. Remember that more than one lead rule? I don't think this study proves that shocking asystole works, but what if the patients in the PT study from JEMS were actually in v-fib? If this study is right, they may have misinterpreted the rhythym and successfully converted v-fib with a PT.

Does PT work?
Back in '84 the Anals..cough..Annals of Emergency Medicine(4) thought so:

Precordial thump is considered a useful manoeuver in cardiac arrest and ventricular tachycardia. On ecg recordings we have observed that the precordial thump has always been followed by an atrial or ventricular depolarization (premature beats), which is responsible for the cardiac electric activity enhancement and for the interruption of reentrant mechanism in ventricular and supraventricular tachycardias.
Resuscitation(5) says otherwise:
INTRODUCTION: Reports about the efficacy of precordial thump (PT)in the termination of ventricular arrhythmias (VA) vary widely.
[...]
CONCLUSION: Efficacy of PT in termination of induced non-tolerated VA is very low even with early application after VA onset.

So what are the risks of a PT?

More from the JEMS article:
PT had neither positive nor detrimental effects in non-EMS-witnessed cardiac arrests, and it was ineffective in tachyarrhythmic cardiac arrest and pulseless electrical activity

But is it harmless?

In the prehospital setting the precordial thump is usually not beneficial, and may be detrimental. Thus its use as the initial maneuver in treating the cardiac arrest patient with VT or VF in this setting cannot be supported. The presence of acidosis and hypoxia may explain why prehospital precordial thump responses differ from those seen in the hospital environment.

It might be detrimental? I also read a study with a case of a sternal fracture following the PT. So what's left?

From the Canadian Journal of Emergency Medical Care(6):

[...]CONCLUSIONS: In a BLS-D system, there is a very low but measurable survival rate for prehospital asystolic cardiac arrest. CRIs of over 8 minutes were associated with 100% nonsurvival, whereas unwitnessed arrests with no bystander CPR were not. These data add to the growing literature that will help guide ethical decision-making for protocol development in emergency medical services systems.

If the medical literarure is going to actually change our protocols, someone has gotta read this one (7):

OBJECTIVES: To study the factors associated with short- and long-term survival after asystolic out-of-hospital cardiac arrest, with a reference to medical futility. METHODS: This is a retrospective observational study conducted in Helsinki, Finland during 1 January 1997 to 31 December 2005. All out-of-hospital cardiac arrests were prospectively registered in the cardiac arrest database. Of 3291 arrests, 1455 had asystole as the first registered rhythm. These patients represent the study population. RESULTS: A short time interval to the initiation of advanced life support (ALS) was associated with a long-term benefit, but a short first responding unit (FRU) response time had only a short-term benefit. Conversion of asystole into a shockable rhythm provided only a short-term benefit. The prognosis was poor if the FRU response time was over 10 min or the ALS response time was over 11 min in bystander-witnessed arrests, and if the duration of resuscitation was over 8 min in emergency medical services (EMS)-witnessed arrests. Bystander-CPR was associated with increased 30-day mortality. The 30-day survival rate after an unwitnessed arrest (n=548) was 0.5%. All survivors in this group were either hypothermic or were victims of near-drowning. CONCLUSIONS: Resuscitation should be withheld in cases of unwitnessed asystole, excluding cases of hypothermia and near-drowning. The prognosis is poor if the FRU response time is over 10 min or the ALS response time is over 10-15 min in bystander-witnessed arrests. The decision of whether or not to attempt resuscitation should not be influenced by the presence of bystander-CPR. Early initiation of ALS should be prioritised in the treatment of out-of-hospital asystole.

Okay, so in conclusion, the results are inconclusive. There has to be more than one study that says the PT will convert a withnessed asystolic arrest for anyone to adopt it as a new treatment. The risks are pretty small, but they exist. We may want to relook AHA's recomondation of the use of the PT on a witnessed VF/VT arrest. The results of multiple studies may indicate that the cardiac ischemia, the patient's in the prehospital enviroment will present with, will probably inhibit the conversion from PT. We have all seen a doc do it though, right?

Just thought I would share my research with you, enjoy!

References:

(1)Wesley K. 2009. "To Thump or Not To Thump The value of the precordial thump"Journal of Emergency Medical Services, Street Science.
(2)Cummins RO, Graves JR, Larsen MP, Hallstrom AP, Hearne TR, Ciliberti J, Nicola RM, and Horan S. 1993. "Out-of-hospital transcutaneous pacing by emergency medical technicians in patients with asystolic cardiac arrest." The New England Journal Of Medicine 328, no. 19: 1377 1382. MEDLINE with Full Text, EBSCOhost (accessed May 15, 2009).
(3)Ornato JP, Gonzales ER, Morkunas AR, Coyne MR, and Beck CL. 1985. "Treatment of presumed asystole during pre-hospital cardiac arrest: superiority of electrical countershock." The American Journal Of Emergency Medicine 3, no. 5: 395-399. MEDLINE with Full Text, EBSCOhost (accessed May 15, 2009).
(4)Miller J, Tresch D, Horwitz L, Thompson BM, Aprahamian C, and Darin JC. 1984. "The precordial thump." Annals Of Emergency Medicine 13, no. 9 Pt 2: 791-794. MEDLINE with Full Text, EBSCOhost (accessed May 15, 2009).
(5)Haman L, Parizek P, and Vojacek J. 2009. "Precordial thump efficacy in termination of induced ventricular arrhythmias." Resuscitation 80, no. 1: 14-16. MEDLINE with Full Text, EBSCOhost (accessed May 15, 2009).
(6)Petrie DA, De Maio V, Stiell IG, Dreyer J, Martin M, and O'brien JA. 2001. "Factors affecting survival after prehospital asystolic cardiac arrest in a Basic Life Support-Defibrillation system." CJEM: Canadian Journal Of Emergency Medical Care = JCMU: Journal Canadien De Soins Médicaux D'urgence 3, no. 3: 186-192. MEDLINE with Full Text, EBSCOhost (accessed May 15, 2009).
(7)Väyrynen T, Kuisma M, Määttä T, and Boyd J. 2008. "Medical futility in asystolic out-of hospital cardiac arrest." Acta Anaesthesiologica Scandinavica 52, no. 1: 81-87. MEDLINE with Full Text, EBSCOhost (accessed May 15, 2009).

Death By BVM

Rogue Medic | 4:47 PM | , , | 10 comments






Over at Street Watch: Notes of a Paramedic, there is an excellent post about airway management. Beach Ball Bellies. The discussion is about the common problem of stomach inflation. Stomach inflation is almost always followed by vomiting. One solution proposed is to allow BLS (Basic Life Support) to use the LMA (Laryngeal Mask Airway) to ventilate cardiac arrest patients.

First I want to comment on one other skill change Peter mentions. CPAP (Continuous Positive Airway Pressure). I do not see any problem with adding this to the BLS scope of practice. If the dividing line between BLS and ALS (Advanced Life Support) is seen as BLS cannot perform invasive procedures, then CPAP is certainly not invasive. CPAP is only to be used for patients who can control their own airways. The airway is in the control of the patient, not in the control of the basic EMT, not in the control of the medic, not in the control of respiratory, not in the control of the nurse, not in the control of the doctor. So, where is the objection to CPAP use by BLS?

Back to the main problem.

In medicine, there is a lack of airway management skill.

Not just first responders. Not just basic EMTs. Not just intermediate level EMTs. Not just paramedics. Not just nurses. Not just doctors. Everybody.

There are some people with excellent airway management skills, but there are plenty with such pathetic skills that they should wear this patch.



Why do we tolerate incompetence?

We are no different from the rest of the world in overdosing on Cognitive DissonanceTM.

In paramedic schools, do we require that paramedics demonstrate excellence in BVM (Bag Valve Mask) use? Some places do, but many do not. It is usually just a quick demonstration of inflating the lungs on Fred the Head (an intubation mannequin - the head in the picture on the right in the link is Fred, or a relative). The person evaluating the future medics probably isn't even interested, because it is not an effective evaluation and it is not considered important.

It used to be that paramedic candidates had to use a BVM to ventilate a patient through an entire surgical procedure, but that kind of attention to BVM skill does not seem to be important any more. After all, if the NR (National Registry of EMTs) can certify medics for you, why worry about skill? If NR says they have what it takes, they must have what it takes. Too bad what it takes is only the ability to memorize and regurgitate material with no understanding of relevance to patient care. Patients are still regurgitating, because of NR certified airway mismanagement.

There is a demand for people with patches that end with a P, as in EMT-P, P for Paramedic. In order to provide those patch wearers, we need to lower the standards? Maybe. Maybe not.

Fire departments, private ambulance companies, volunteer organizations, hospitals, . . . all demand more employees. The public demands paramedics. The school administrators demand high pass rates. The standards get lowered to satisfy these customers.

We have a problem with the instructors, too. Do they have the ability to perform the skills? Do they understand when the skills are indicated? Do they understand how to teach? Are they being pressured to just run them through the program, because the NR will weed out the bad ones? The last reason was the main one for me, when I stopped teaching paramedic school.

Too many clueless medics being passed, because the final exam is a test that we think will weed out the ones who never learned. But we have been spending more time on test preparation. Test preparation is just how to make it seem that you know what you are doing, even though you do not. We spend a lot of time on test preparation, because the students are not being educated. The less prepared the students are, the more time we spend on gaming the system.

Maybe we should hand out ruby slippers and teach the medics to say, There's no place like trachea. There's no place like trachea. There's no place like trachea.

At the end of paramedic school, there is the NR exam. This is the equivalent of Professor Marvel handing out diplomas. Suddenly, the possession of the paramedic card is expected to produce the competence that the paramedic school could not in all of the hours of training they provided? Sounds reasonable.

There is an excellent article[1] by Kelly Grayson at EMS1.com. This should be read by everyone involved in airway management. In hospital (respiratory, nurses, doctors), out of hospital (first responders, basic EMTs, medics, flight crews), everywhere (if you have anything to do with airway management, you should read this article).

If we do not begin insisting on BVM excellence at the first responder level, we need to teach it over again at the basic EMT level. It is hard to get people to stop using bad habits. If we do not begin insisting on BVM excellence at the basic EMT level, we need to teach it over again at the paramedic level. It is even harder, by then, to get people to stop using bad habits.

I do not have a problem with putting LMAs, King LTs, CombiTubes, . . . in the hands of first responders and basic EMTs. I do have a problem with substituting one form of misunderstanding for another. If they are not competent with the BVM, will they be competent with any alternative airway?

We thought the solution to the problem was insistence on OPA (OroPharyngeal Airway)and NPA (NasoPharyngeal Airway) use. We demand that these devices be used in airway management. But why do we really need them? Sometimes the tongue will continue to obstruct the airway, even with good head positioning. OK, then use these, when they are indicated. They are not indicated for every use of the BVM.

Put an OPA in your mouth. Some of you may not have a gag reflex, but for those of you, who do have intact gag reflexes, didn't it make you want to vomit? For the patients with bad airway management, the OPA really just helps the stomach fill up with air even faster, while stimulating any gag reflex that is present. If I were to write a recipe for vomiting, a recipe that does not include ipecac, this would be it. Fill the stomach, while stimulating the gag reflex. That should not be our goal. Good airway management means using what is appropriate to manage the airway. It does not mean using everything, just because it is in the bag.

Some instructors will tell you that you need to use an OPA (NPA when you cannot open the mouth) whenever you are using a BVM. Airway management is about continual reassessment of the airway. If you cannot tell where the air is going, it does not matter what device you are using. OPA, NPA, LMA, endotracheal tube, . . . it does not matter what the device is. The skill of continual reassessment of the airway is the only essential in airway management.

Airway management is about being able to outsmart the airway. Why are we constantly losing this battle of wits?

It appears that the solution to the problem of Beach Ball Bellies will really come from the elimination of ventilation from the initial management of cardiac arrest. This is something that is overdue, but it is not the solution to airway management problems. This just hides the problem a bit. This just decreases the incidence of the problem.

Removing ventilation from the initial management of cardiac arrest is good for the patient. The AHA (American Heart Association) and ARC (American Red Cross) should be as aggressive in promoting this important change to CPR as they were in promoting fibrinolytics for stroke.[2]

We do not need to lower any standards. We need to raise standards. We have too many paramedics. When there are more paramedics than patients, we usually have too many paramedics. Only in very busy systems do we need to have two medics on a call. Two medics in busy systems, only so they can alternate being in charge of patient care. To minimize burn out. We need to oppose these attempts to make everyone a paramedic, because this leads to a dilution of skills and a lowering of standards. The standards are already too low in too many places. Or are your medics intubating over 95% of patients successfully and managing the airway adequately by alternative means in the rest of cases?


Footnotes:


^ TM Cognitive Dissonance
Wikipedia
How to harm people with a clear conscience. Fool yourself.
Article


^ 1 The Airway Management Continuum
Kelly Grayson
EMS1.com
Article


^ 2 EMS mythology. EMS myth #2. Thombolytic therapy is the standard of care for acute ischemic stroke.
Bledsoe BE.
Emerg Med Serv. 2003 Apr;32(4):63-5. No abstract available.
PMID: 12705219 [PubMed - indexed for MEDLINE]
Free PDF

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