Monday Morning Medical Director’s Message
This month, we are focusing on cardiac arrest care. Over the last two weeks, we discussed the two cornerstones of cardiac arrest care: chest compressions and defibrillation. This week, we will focus on where we should be delivering this care. Cardiac arrest = stay and play
In most medical situations, the sicker the patient, the more we need to do before extrication. Patients don't get sicker than when they are in cardiac arrest. In cardiac arrest, the earlier interventions are performed, the more effective they are. The patient is more likely to respond to defibrillation, return of spontaneous circulation (ROSC) patients are less likely to have devastating brain injury, etc.
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If we delay these interventions to extricate a patient (even if extrication is short), we are not using interventions when they are most likely to be effective. In addition, the process of extrication takes focus. No matter how good you are at cardiac arrest care, you are better when you are not distracted by extrication. If an advanced life support crew is on scene, the advanced cardiac life support (ACLS) care provided in the field is often the same ACLS care provided in the hospital (some rare exceptions to this). For this reason, the default should be that medical cardiac arrest patients are worked on completely in the field. In EMS, we bring the care to the patient, not the patient to the care.
Reasons to transport a patient in cardiac arrest or to extricate early
There are some reasons where it would be reasonable to pursue extrication and transport before the ROSC is achieved. These are discussed below:
- Public arrest: Pronouncing a patient in a very public place is not always the best (i.e., at a large sporting event or in the middle of a supermarket). In these situations, we should still stay and play and work the patient on scene. This gives the patient his/her best chance of a good outcome. However, if we have done all the major interventions and not yet achieved ROSC, we should extricate and transport while still in arrest, since this would not be a venue for field termination of resuscitation.
- EMS responder safety concern: If we are providing cardiac arrest care and notice that the scene is becoming unsafe, we should immediately extricate the patient. While we should never enter an unsafe scene, sometimes we become aware of safety concerns that were not initially noticed. While it is not optimal for the patient to be extricated before key interventions have been performed, our safety is the priority.
- Patient meets criteria for extracorporeal membrane oxygenation CPR (ECPR): Some hospitals offer ECPR as a treatment for patients in cardiac arrest who have specific criteria present that indicate they could benefit from this limited intervention. This is a time-sensitive intervention, so patients must be able to be transported to centers that can do ECPR within a very short timeframe. For patients who meet the specific inclusion criteria and can be brought to the ECPR center within the specified time, patients can have fantastic outcomes. This would be a very good reason to prioritize extrication over on-scene care since the hospital would offer a time-sensitive treatment that we cannot offer on-scene.
- High suspicion for specific causes of cardiac arrest that we cannot treat: This includes arrest from hyperkalemia, pulmonary embolism (PE), pericardial tamponade, and hypothermia. In an arrest from hyperkalemia, patients often need much more calcium than we have on-scene. It would be reasonable to transport this patient to get additional calcium in the hospital. For an arrest from a PE, the patient would need a very strong blood thinner known as tPA, or tissue plasminogen activator, to attempt to break down the clot and achieve ROSC. If the patient arrested from pericardial tamponade, the patient would need a pericardiocentesis, which is not within the scope of practice for EMS. For patients who arrested from hypothermia (not to be mistaken with patients who arrested and then became hypothermic), we often need to perform CPR until the patient is warmed to 32 degrees Celsius, which can take hours. It might not be possible to warm the patient up to this temperature in the field, so transport while in arrest would be indicated. While any of the above COULD be possible, we should only prioritize extrication and transport if we have objective evidence that one of the above is actually likely.
Cardiac arrest patients are as sick and critical as they come. The mainstay of treatment for critically ill medical patients is to resuscitate as soon as possible. This means we bring the care directly to the patient and provide as much cardiac arrest care as possible before extrication.
Be safe and keep up the awesome work!
Jordan Singer, MD