April 19, 2014

Cardiac Arrest

In this episode we talk with Dr. Scott Weingart about new developments in caring for patients in cardiac arrest including:

  • End tidal CO2 monitoring
  • Therapeutic hypothermia
  • Should all post arrest patients with return of spontaneous circulation go to the cath lab?
  • A logical approach to managing the airway during cardiac arrest resuscitation

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Airway control in a cardiac arrest

What’s one of the first things that happens when a patient gets transferred from the paramedic stretcher to the ED bed? The extraglottic airway comes out and the patient gets intubated. Considering the circumstances, is doing this action within the first few minutes of a resuscitation the best use of your time, and more importantly, the patient’s time? We have a tendency to think of non-endotracheal tube airway devices as inferior and often that is the case. But is it the case here? What advantage do you get from changing out a functioning supraglottic/extraglottic airway device in the early stages of cardiac arrest resuscitation? Probably not much.

What do we always fret about when rushed placing an ET tube? Esophageal intubation. If that happens, things just went from under control to FUBAR in a hurry. At a time when you want to focus in getting good uninterrupted chest compressions, giving electricity, and sorting out what’s going on, getting definitive tracheal airway control has a low return on investment. If the patient is just being bagged with a BVM (bag valve mask), go ahead and put in a device that doesn’t require an all stop – such as an extraglottic airway device. That DOES have a return on investment because it gives you an extra set of hands now that the person who had to hold the BVM on the face is now free. Perhaps more importantly – getting a good, consistent BVM facial seal in a code is challenging. It seems easy in practice, but in the heat of battle it is not. it’s hard.

Important links:

  • The ERcast Emergency Orthopedic Conference is being held on April 21, 2012. Click HERE for the brochure PDF file
  • More on therapeutic hypothermia: August 2010, ERcast
  • Interested in learning more about current decisions from the US Supreme Court? Check out Rich Orman’s new podcast US Supreme Court Review
  • A good primer on “Post Cardiac Arrest Syndrome” can be found HERE
  • Scott’s site emcrit.org
  • DIRECT DOWNLOAD of this episode

 

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Comments

  1. Rob -- It is already March 18. Are you still writing 2011 on your checks. Assuming the brochure is correct, your ortho conference is on April 21, 2012 (not 2011).

    • Rob Orman says:

      It’s usually about May or June by the time I catch up with the proper year on my checks. Thanks for pointing out the date correction. The conference is indeed happening in 2012.

      • You chumps still using checks? Catch up with the times, folks. Coins. Big metal coins. Fetch me my man-purse, yo!

  2. Great podcast! I’d add to the show-notes that ETI does not require a pause in compressions, especially if you have video assistance.

    The ED is lucky to have enough people and equipment to theoretically never stop compressions! Capnography, ultrasound, labs, and doctors to tell folks its ok to keep pushing during defibrillation :)

    If there is one place in the US where you can work an arrest with compression fractions >90% it should be in a hospital.

    I teach EMTs/Paramedics that they can do anything they want in a code as long as chest compressions aren’t interrupted: dress up your patient, paint their nails, do their hair…just don’t stop compressions.

  3. Rob Theriault says:

    Love your Podcasts! Question for you: The literature suggests that if you have an ETCO2 greater than 15 mmHg there’s an almost garantee of a ROSC and survival with a good CPC score. With the changes in CPR standards I have found that the improvement with ETCO2 has been dramatic. Most of my patients are above 20 mmHG. While we’ve seen a threefold survival increase in the region where I work as a paramedic , not nearly as many survive neurologically intact as one would think. Sorry for the long winded lead up to the question but here it is: Do you think we have to reanalyze ETCO2 as a benchmark for OHCA? Apart from its predictive value for ROSC is it perhaps not a good prognostic tool for survival in your opinion?

    • Rob Orman says:

      Rob- I asked Scott for some some commentary regarding your question…His take is that it is the low value that is important.
      A high value would only cause continuation an otherwise seemingly futile resus if there were something else to go on (pt switched from asystole to PEA or similar). A low ETCO2, on the other hand, means time to think about stopping.

    • I’ve only seen the correlation between high intra-arrest ETCO2 and survival to discharge with VF/VT arrests (end anecdote). Otherwise the only correlation appears to be the likelihood of ROSC.

  4. David Wirtz says:

    Thanks for the great discussion. Do you have a suggestion for how to handle the patient who you’re pretty sure is dead but there’s still a flicker of movement on the cardiac ultrasound?

  5. GREAT podcast! Expert commentary from Scott and superbly moderated by you Rob (to the point of you being able to tease out allowance for intubation as a “last ditch effort” by the ER resident -- which I do think IS justified -- even though one can now make a case as to whether this is truly needed if you have an effective supra-/extraglottic airway in … ).

    Only point I’d add about ET CO2 monitoring:
    - Giving Epi may transiently decrease ET CO2 value (redistribution of blood flow from epi-induced vasoconstriction).
    - Giving Bicarb may transiently increase ET CO2 reading during cardiac arrest.

    Again -- GREAT PODCAST!

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