Adrian - the 4 H's and 4 T's are not isolated to PEA cases - the ALS course teaches that they should be considered for ALL cases of cardiac arrest. Andy Adrian Fogarty <[log in to unmask]> wrote: Sorry, but that logic just doesn't follow Michael i.e. your assertion that many in-hospital arrests are preventable so therefore they must be reversible. Preventability and reversibility are two distinct entities. For example, RTAs are preventable, strokes are preventable, cancer is preventable, yet none of these conditions are what one would normally consider reversible. What Lewis is saying, I believe, is that many patients can be prevented from reaching "end-stage" at which point they subsequently arrest, but by the time they do arrest then it's too late to do anything about it, for obvious physiological reasons that I'll allow someone else to explain (I'm sure Matt or Rowley will oblige in a suitably long and complex email)! And as for the four Hs and four Ts, this mnemonic refers only, of course, to the preventable causes of EMD (PEA) that are traditionally taught on ALS courses. These causes probably, however, only account for a minority of all cases of EMD seen in practice. Most causes of this condition are inherently untreatable, for example, massive MI leading to global ventricular akinesia, septal rupture, ventricular rupture etc. Adrian Michael Bjarkoy <[log in to unmask]> wrote: Hello Lewis Agree on many levels with your comments. Many hospitals in England now have an alert system to identify patients who are in a peri-arrest condition and hopefully the arrest event is avoided. If the Resus Council are to be believed then the patients who suffer a cardiac arrest in hospital have a greater chance of being in PEA/Asystole (Gwinnutt. C et al. Resuscitation. 2000;47: 125-135). 30-70% of the cardiac arrests can be avoided by utilising Medical Emergency Teams (ALS Causes and Prevention PowerPoint presentation. Sept 2003). Therefore if they can be avoided they are probably reversible and therefore should be more salvageable in hospital than an out-of-hospital PEA/Asystole. Potential reversible causes: Hypoxia - basic and then advanced airway management to secure intact gag reflexes. .Hypovolaemia - ID cause ! and go to theatres .Hypo/hyperkalaemia & metabolic disorders - ID blood gas abnormality and administer calcium, Sodium Bicarb etc .Hypothermia - passive/active/ invasive rewarming. .Tension pneumothorax - needle thoracotomy and then chest drain .Tamponade- pericardiocentisis .Toxic/therapeutic disorders - ID via TOXBASE specific drug treatment and administer .Thrombo-embolic & mechanical obstruction - surgery/thrombolytics Of the 4 Hs and 4 Ts many of the treatments are out of the scope of paramedics at present as they don't have an education in the UK which reflect the UK Resus Council guidelines I agree with your sentiments, I too find the concept of placing such things as paralytics or allowing central lines in the UK Prehospital environment very scary and I would be the first to support anyone who wishes to introduce it at this moment in time. So I ask myself if I have contraindicated myself? I don't think so. I referred to Medic One in Seattle as they have been applying Mobile Intensive Care Paramedicine for a few decades now and therefore can be regarded as a true reflection what can be achieved if given the correct education and have the support of the medical community. Seattle paramedics have a 9 month full time clinical course along side of the medics in ER they are regarded as part of the ER team and as such there is no suspicion regarding their competency. All their calls are scrutinised by the medical director as such quality is assured. The paramedic / EMT ratio is weighted in the favour of EMTs and therefore exposure to ALS calls per paramedic is greater. They only go on ALS calls and therefore are current and competent. The majority of their extended procedures and drugs are targeted toward non-trauma cases. These guys are no different to myself and my colleagues with the exception of education and drug/skill interventions available to them. If there is to be any hope for the victims of out of hospital PEA/Asystole arrests then we need to be more aggressive in our management. If the evidence states that these patients are no-hopers, then where is the ethical/legal issues which the medical community are concerned about, regarding extending our skills in the UK to match that of Seattle - or nearer to home - the UK A&E depts? Mike Bjarkoy ----- Original Message ----- From: "JONES Lewis, Locum Consultant - A&E" To: Sent: Monday, December 06, 2004 11:08 AM Subject: Re: Defining who will not survive out of hospital cardiac arrest where is the evidence that in hospital asystole or PEA do better than prehospital arrests? in my current trust outcomes for PEA and asystole are less than 3% to return of spontaneous circulation (which is a useless outcome measure anyway). t! his is because the arrest is the result of a slow deterioration in the physiological state and often irredeemable. the disease process in the community will be different as the event will often be acute (trauma, PE etc.) and this theoretically should be treatable. I will no doubt be unpopular for the following comment but I have nearly 2 years anaesthetic and critical care experience and still find muscle relaxants scary things in the acute setting and the idea of their use in the prehospital setting by people with less experience than me who will have the need to use them a lot less than me, and therefore clinical governance issues with skill retention will come into play even more scary. To compare the states with their trauma load to the UK with our case mix is not really a fair comparison at this time. I guess these comments will (in some cases) simply reinforce the notion that the medical community is too conservative but I feel these vi! ews should be debated or no progress will be made. Lewis -----Original Message----- From: Accident and Emergency Academic List [mailto:[log in to unmask]]On Behalf Of [log in to unmask] Sent: 04 December 2004 16:15 To: [log in to unmask] Subject: Re: Defining who will not survive out of hospital cardiac arrest In message <009d01c4da04$dac674e0$9d74353e@Souix> Michael Bjarkoy writes: > Hi Rowley > I have been thinking about this for a while and here are a few > observations. > > AMI arrested patients are usually in VF in the first instance. Non > shockable > arrests are often (but not always) due to other mechanical causes such as > trauma, OD, hypovolaemia (basically the 4 Hs and 4Ts). > > If we accept that in a hospital setting the patient has a better prognosis > for the non-shockable side of the arrest f! lowchart than in a prehospital > setting we should not just accept that it is a fact of life (or death) but > challenge the flaws in the system which allows this to be. > > Since the ambulance dispute in the late 1980s we have had to accept the > notion that there must be one paramedic on each ambulance. The result is > mediocrity in education and application of care. If look toward a system > (Medic One, Seattle) where success for non-shockable arrests are better we > could learn some of valuable points. > 1. Educate paramedics along side physicians in hospital by experienced > physicians > 2. Reduce paramedics to less than 20% of the workforce > 3. Have 2 paramedics on a Medic Unit > 4. Release paramedics from protocols and guidelines and allow autonomous > practice > 5. Reduce the type of incidents that paramedics go to ALS only > 6. Give them the range of drug and invasive skill inter! ventions that > reflect > an A&E dept > 7. Offer a comprehensive in hospital continuing education > > If the above is implemented then the success rates from out of hospital > arrests for non-VF/VT patients will increase. > I disagree (now there's something unusual!!). Success rates increase with increased bystander CPR and increased access to early defibrillation - neither related to paramedic education. And not sure that an in-hosp education programme is the way to go ... ? And think that "ALS-only" calls is not the way to go either - what exactly is an ALS-only call? Some of the "minor" calls need far more experience to be left at home safely. No evidence that a second ALS staff member on a unit improves outcomes. ;) Cheers Anton -- This email has been electronically scanned using DynaComm i:mail filtering software. If you have any questions please email [log in to unmask] Tony Daniel Sam Shayer Information Security Team --- This message has been thoroughly scanned by and is certified virus free by MacAce.net. --- avgxmacgbh > ATTACHMENT part 2 application/pdf name=Seattle Airway.pdf