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.
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" <[log in to unmask]>
To: <[log in to unmask]>
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
<[log in to unmask]>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 sk!
ill
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
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