EMS

EP.5 Managing Cardiac Arrest as a Paramedic Student

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Welcome to the paramedics Guide to the Galaxy! Today I have an interview with a fellow Paramedic student,  Patrick Guziewicz. (@guziewiczp)

Patrick's take home points:

  • EMS is a team sport, be confident, stay humble.
  • Bystander CPR is ESSENTIAL to increase OHCA survival.
  • The paramedic running the code needs to run the code. Not the IV, IO, Drug box, Or monitor.
  • Early Chest compressions and Defib are the priority. 

Nicholas' take home points:

  • Some of the Greatest Atrocities in history were made "Just following orders"

Check us out on Facebook, Google+, and Itunes!

Cheers!

Nicholas (@nikolace)

EP.4 Cardiac Arrest... When to Transport.

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Thank you for tuning into the MaineCrit podcast and checking out the show notes!

 

 

Cardiac Arrest... When to Transport.

 

First, Transporting a patient in cardiac arrest is NOT beneficial unless the receiving facility is prepared and equipped to continue the resuscitation by treating reversible causes that EMS cannot. This is for EMS and ED providers.

The Case:

A 42 year old man awoke in the middle of the night with sudden, sharp chest pain and shortness of breath.  He had no previous cardiac history and appeared very fit.  His wife called 911.  EMS arrived to find their patient in severe extremis and poorly perfused. He progressed to PEA arrest and the crew performed high quality CPR immediately. Advanced airway Obtained IV access. Several rounds of epinephrine. They worked the code for 20 minutes per protocol but did not get ROSC in the field so they called it.

 

The patient had minor surgery within the last week...

 

The hospital was half a mile away...

Take Home Points:

  1. Most patients who suffer an OHCA will not survive intact unless ROSC occurs in the field.
  2. There are reversible causes that most EMS systems cannot treat but an Emergency Department can.
  3. There will be a small subset of viable patients that may be saved if transported expeditiously.
  4. It is possible to transport patients in cardiac arrest safely with manual CPR and, perhaps someday, mechanical chest compressions and ventilation will open up additional options for longer transports to tertiary hospitals.
  5. We must give every patient a chance for a successful outcome if such a chance exists.  That is what Resuscitationist do!  We must not give up unless there is nothing else that can be done.

 

References/Sources

SMACC/Cliff Reid - When Should Resuscitation Stop

ED ECMO - Annie (May 2013), 60+ minutes of CPR

Dr. Smith's ECG Blog - 68 minutes with chest compressions, full recovery.

Continuous mechanical chest compression during in-hospital cardiopulmonary resuscitation of patients with pulseless electrical activity

Double Bolus Thrombolysis for Suspected Massive Pulmonary Embolism during Cardiac Arrest

A simplified and structured teaching tool for the evaluation and management of pulseless electrical activity.

Medic to medicine part 2, with Michael Lauria.

Cricothyrotomy, Training, and mental simulation.

#FOAM

Twitter references:

Minh Le Cong @ketaminh

Scott Weingart @emcrit

Cliff Reid @cliffreid

Anand Swaminathan @EMSwami

Social media

Last Mile Health

SMACC

Thank you so much for listening! Stay tuned for more material from MaineCrit!

Medic to Medicine: Michael Lauria

Review our show notes as you listen to the podcast!

Michael Lauria, Paramedic and MS-1

MaineCrit traveled down to Hanover, NH

 to interview flight paramedic and MS-1, Michael Lauria(@ResusPadawan)

Toughness Part I with Michael Lauria

Scott Weingart's interview with Michael on Mental toughness.

The Importance of GRIT

John Greenwood's post about GRIT on IteachEM.

Hofstra North-Shore

"New Med Students Training as EMTs"

Victoria Brazil - Evidence-Based Education- What Works

SMACC Gold lecture on what works in education. The answer is yes. The answer is also no.

Mental practice: a simple tool to enhance team-based trauma resuscitation

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PubMed

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Full article: Mental Practice for Trauma Resuscitation http://t.co/k1zOBjPRt8#FOAMed@CJEMonline@ResusPadawan@EMSwami@Inject_Orange — Christopher Hicks (@HumanFact0rz) April 11, 2015

And finally, Dat library...

Just a small piece. 

Shock Essentials in 8 Minutes

Shock:  Inadequate perfusion at the cellular level.

“The rude unhinging of the machinery of life” ~

Samuel D. Gross

Adequate Perfusion requires:

  1. The Pump (heart)
  2. The Fluid (blood)
  3. The Container (vasculature)
  4. Air Exchange (oxygenation / ventilation)

The Pump

  • Adequate Cardiac Output
  • Stroke Volume X Heart Rate (4-8L/minute)
  • Affected by Preload, Contractile Force, and Afterload

The Fluid

  • Volume of blood must fill container

The Container

  • Vasculature is properly sized
  • Pre and post capillary sphincters at local level

Air Exchange

  • O2 into lungs and circulation
  • Elimination of CO2 and waste products
  • REQUIRES:
  • Adequate FiO2 and ventilation
  • Diffusion across alveoli / capillary membrane
  • Adequate number of RBCs
  • Efficient offloading to target cells

Stages of Shock

  • Compensated
  • Decompensated
  • Irreversible

Types of Shock

  • Hypovolemic
  • Cardiogenic
  • Distributive
  • Obstructive

Managing Shock

  • Primary Survey / ABCs
  • O2
  • BVM
  • C  spine
  • Major bleeding
  • Supine / Keep warm
  • IV, monitor

Specific Treatments

  • Fluid challenge
  • Epi / Benadryl (anaphylaxis)
  • Chest decompression (tension pneumothorax)
  • Pericardiocentesis (cardiac tamponade)
  • Dysrhythmias (ACLS)
  • Pressors (fluids first)
  • Narcan (opiod OD)

Take Home Points

  1. Shock:  Inadequate perfusion at the cellular level.
  2. If you think shock, your patient is already there.
  3. Know and treat the root causes.
  4. Set a target MAP.
  5. Be aggressive!

~Chip Getchell