Adrian Fogarty wrote:
>
> ----- Original Message -----
> From: "Dunn Matthew Dr.
> Subject: Re: Guidelines
>
> > > Last week one of our residents came to me
> > > visibly shaken after responding to such a code as she felt
> > > the attending physician did not treat the patient
> > > appropriately and among other things, gave drugs which were
> > > not indicated and shocked the patient while they were in asystole.
> >
> > This is exactly the problem with ALS: here you have a member of staff
> upset,
> > coming to talk to you (i.e. not working at their best and taking up time
> of
> > 2 doctors) about a breach of guidelines that would not make any difference
> > to patient outcome...The trouble with guidelines is that once they are
> there,
> > people think they are a) correct and b) important.
>
> Precisely. Anyway, I can't see why the resident was upset; after all, the
> patient was in asystole! (I don't "treat" asystole any more.)
>
> AF
Dear Adrian,
We have found that some patient presenting in asystole do indeed survive
- unsurprisingly, an unwitnessed arrest is never a good prognostic
indicator. We also tend not to move patients until we have achieved an
ROSC - and are moving towards ETCO2 in the field to assist with
decisions to terminate resuscitation.
Anton
Am J Cardiol 2000 Sep 15;86(6):610-4
Can we define patients with no and those with some chance of survival
when found in asystole out of hospital?
Engdahl J, Bang A, Lindqvist J, Herlitz J.
Division of Cardiology, Sahlgrenska University Hospital, Goteborg,
Sweden.
We describe the epidemiology, prognosis, and circumstances at
resuscitation among a consecutive population of patients with
out-of-hospital cardiac arrest (OHCA) with asystole as the arrhythmia
first recorded by the Emergency Medical Service (EMS), and identify
factors associated with survival. We included all patients in the
municipality of Goteborg, regardless of age and etiology, who
experienced an OHCA between 1981 and 1997. There were a total of 4,662
cardiac arrests attended by the EMS during the study period. Of these,
1,635 (35%) were judged as having asystole as the first-recorded
arrhythmia: 156 of these patients (10%) were admitted alive to hospital,
and 32 (2%) were discharged alive. Survivors were younger (median age 58
vs 68 years) and had a witnessed cardiac arrest more often than
nonsurvivors (78% vs 50%). Survivors also had shorter intervals from
collapse to arrival of ambulance (3.5 vs 6 minutes) and the mobile
coronary care unit (MCCU) (5 vs 10 min), and they received atropine less
often on scene. There were also a greater proportion of survivors with
noncardiac etiologies of cardiac arrest (48% vs 27%). Survivors to
discharge also displayed higher degrees of consciousness on arrival to
the emergency department in comparison to nonsurvivors. Multivariate
analysis among all patients with asystole indicated age (p = 0.01) and
witnessed arrest (p = 0.03) as independent predictors of an increased
chance of survival. Multivariate analysis among witnessed arrests
indicated short time to arrival of the MCCU (p < 0.001) and no treatment
with atropine (p = 0.05) as independent predictors of survival.
Fifty-five percent of patients discharged alive had none or small
neurologic deficits (cerebral performance categories 1 or 2). No
patients > 70 years old with unwitnessed arrests (n = 211) survived to
discharge.
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