Pacing Vs. Airway Management

[Bjorn, Pret]

Gavin,

Try spilling the beans up front next time.  In this context, the answer
to your question is all the more clear: pace the patient.

Rigid prehospital protocols save lives and protect careers every couple
of minutes.  Had you complained like this in your original message, you
would have received a starkly different set of responses, be assured.  

Don't use us as your cherry orchard from which to pick "different
opinions" without disclosing the conditions.  It's an infuriatingly
slimy way to make your case.

Pret

-----Original Message-----
From: trauma-list-bounces at trauma.org
[mailto:trauma-list-bounces at trauma.org] On Behalf Of Gavin SUTTON
Sent: Monday, May 19, 2008 3:55 AM
To: trauma-list at trauma.org
Subject: Re: Pacing Vs. Airway Management


Dear All

Thanks very much for your responses. I think the most important point I
wanted to make by posting this case was that we all have different
opinions on what should be done first. The on-scene symptomatic
presentation of the patient would be the greatest guide to what would be
the best possible regime of treatment at the time. I am rather outspoken
against having very rigid pre-hospital protocols, as I truly believe
that one tends to manipulate patient condition to conform with these
protocols rather that re-arranging the protocol to suite the patient. I
therefore am a greater supporter of broader guidelines than protocols.

Now to spill the beans...

This was a simulation that was run for our EMS College's final
Paramedic Patient Simulation Examination. I will post the full document
shortly, and would appreciate your comments on it. The examination
itself opened up much debate around what was normal and abnormal in
terms of treatment. My experience has shown me that there is no 'normal'
in the pre-hospital setting and patients, depending on personal
attributes all require personalized treatment plans.

Once again, thanks to all

Gavin 

Gavin Sutton
Head: Department of Training
Emergency Medical Services
Western Cape Department of Health
South Africa

Tel. +27 21 938-4118
Fax.+27 21 938-4269



>>> Ivan Hronek <ivanhronek at yahoo.com> 05/18/08 5:59 AM >>>
Agreed, if the chest-compression only CPR has similar results in
witnessed arrest as conventional CPR with ventilation (see below) then
circulation should be kick-started first...as you say - analogous to a
witnessed VF/VT situation.
AHA Promotes Chest-Compression-Only Bystander-Initiated CPR 
>From Heartwire - a professional news service of WebMD
March 31, 2008 - "Mouth-to-mouth" assisted breathing may be an iconic
part of cardiopulmonary resuscitation (CPR) to anyone who owns a TV set,
but - according to a new "science advisory" statement from the
American Heart Association (AHA) - it doesn't necessarily improve
outcomes after cardiac arrest and is probably a major reason
bystander-initiated CPR isn't more common [1]. The organization, viewed
by much of the public as a leading authority on CPR, wants it to know
that chest compressions are sufficient in the many cases that are
witnessed and consistent with ventricular fibrillation or myocardial
infarction (MI). For the untrained, that means adults who suddenly
collapse.
"The message we want people to get is that any CPR is better than no
CPR," Dr Michael Sayre (Ohio State University, Columbus), who chaired
the AHA statement's writing committee, told heartwire. "If people have
not been trained, we hope that if they see an adult suddenly collapse,
they will initiate chest compressions. If they've been trained, the
message is, do what you've been trained to do, as long as you feel like
you know what you're doing."
The AHA scientific advisory statement, which is labeled for the public
as a "call to action for bystander response" and uses the terms
"hands-only" and "compression-only" CPR interchangeably, was published
online March 31, 2008 in Circulation and is expected to run in the
journal's April 29, 2008 issue. The document is intended to "amend and
clarify" the group's most recent formal CPR guidelines, which were
released in 2005 [2]; the next one is slated for 2010.
The difference is the new document's recognition that outcomes with
compression-only and traditional CPR are likely to be the same and in
its granting the two equal status for the vast majority of cases of
witnessed cardiac arrest.
"We don't believe that one is necessarily better than the other. The
evidence that we have now seems to suggest that they are equivalent for
this group of patients: adults who suddenly collapse," according to
Sayre.
The 2005 document, he added, had relegated compression-only CPR to
backup status. "Before, quite frankly, the message was 'if you don't
remember what to do, oka
y, you can do [only] chest compressions.'"
The AHA's new message
 
In the case of an adult who is observed to collapse suddenly, the
recommendation is to call 911 and perform chest-compression-only CPR if
the rescuer is:
	* A bystander without CPR training. 
	* A bystander "previously trained in CPR but not confident in
his or her ability to provide conventional CPR, including high-quality
chest compressions (ie, compressions of adequate rate and depth with
minimal interruptions) with rescue breath."
For a rescuer trained in CPR who is "confident in his or her ability to
provide rescue breaths with minimal interruptions in chest
compressions," either compression-only or conventional CPR, with a ratio
of 30 chest compressions to two ventilations, is recommended.
Regardless of technique, CPR should continue until the arrival and
setup of an automated external defibrillator or arrival of emergency
medical service personnel.
Based on evidence both predating and published after the 2005
guidelines, "adult victims of out-of-hospital cardiac arrest who receive
bystander hands-only (compression-only) CPR or conventional CPR have a
similar chance of survival." The AHA emphasizes that its new
recommendation for bystander intervention "does not apply to unwitnessed
cardiac arrest, cardiac arrest in children, or cardiac arrest presumed
to be of noncardiac origin."
"I think this 'call-to-action' statement is an extremely important step
forward, and I am happy that this change did not have to wait until the
AHA's 2010 guideline update," Dr Gordon A Ewy (University of Arizona
College of Medicine, Tucson), said to heartwire. "We are absolutely
delighted that they are moving ahead with this," he said, noting that
his center has "unofficially recommended continuous-chest-compression
CPR for bystanders since 1993."
Ewy has been a vocal supporter of compression-CPR to the public and his
colleagues, in the literature, and on heartwire. His work in patients
and animal models suggests that outcomes are actually superior with the
compression-only technique.
Professionals such as doctors, nurses, and others in healthcare, as
well as emergency-response workers of all kinds, should continue to
learn conventional CPR, he said, because they are more likely to
encounter victims with respiratory arrest. But that isn't so with the
public, according to Ewy. Overwhelmingly, he observed, most of the
public who learns standard CPR will never have an opportunity to use it
on victims who might benefit from assisted ventilation, who account for
a fraction of witnessed arrests, "whereas chest-compression-only [CPR]
can be taught very easily, and people are more likely to do it."
The new AHA document's position is that "all victims of cardiac arrest
will benefit from delivery of high-quality chest compressions" while
some cases of cardiac arrest - including "pediatric victims and
victims of drowning, trauma, airway obstruction, acute respiratory
diseases, and apnea (such as that associated with drug overdose)" -
will need "other interventions." The organization, therefore, continues
to urge the public to become trained in the range of skills taught in
standard CPR classes.
Both Sayre and Ewy believe the public will, in general, be able to
identify when compression-only CPR is appropriate. The AHA, according to
Sayre, addresses that by recommending it for adults who suddenly
collapse. "That indicates that it's very likely to be of cardiac
etiology, and probably ventricular fibrillation, causing it. . . . We
tested this message in focus groups, and it seemed like the people in
the focus groups get the difference."
Ewy said "the public could be taught very easily that witnessed,
unexpected collapse in a nonresponsive person, with abnormal breathing,
is cardiac arrest." All they will need to learn is that "abnormal"
breathing means no breathing or a "gasping-snoring-agonal-type
respiration."
But, he said, "Let's say they can't tell the difference. Doing
chest-compression-only [CPR] will save more
 people for the simple fact
that it's easier to do, and people are more likely to do it."
Addressing that issue, Sayre observed that "one of the barriers [to
bystander-initiated CPR] that we've identified in the past is a
perception that CPR is too complicated. 'How am I going to remember all
that? If I do it wrong, will I make the guy worse?' And that's clearly
not what we want people to do. We want people to act. So by making it
simple, we're hopeful that it will be a big improvement over what we're
getting today."
The AHA statement acknowledges that even professional
emergency-response workers appear to take longer to initiate
conventional CPR, compared with compression-only resuscitation, and that
"eliminating the expectation of mouth-to-mouth contact during CPR is
likely to improve esthetics and address the expressed concern of
potential bystanders about infection."
Strikingly, the new AHA document is published soon after yet is at odds
with another "scientific statement" to which the organization signed its
name, one that specifically focused on "reducing barriers for
implementation of bystander-initiated CPR" [3]. As reported by heartwire
upon its publication just over two months ago, the document was heavy on
proposals for expanding public education in standard CPR. But it
relegated the topic of compression-only CPR to a single sentence in a
paragraph headed "Future Directions," citing it as an example of ideas
that "remain an area of active scientific investigation."
The earlier and current documents, both official AHA statements, "are
in complete contrast. It's inexplicable to me," said Ewy. As quoted
previously by heartwire, Ewy said the earlier statement "only serves to
confuse the public and harms AHA credibility."
Sources
	1. Sayre MR, Berg RA, Cave DM, et al. Hands-only
(compression-only) cardiopulmonary resuscitation: A call to action for
bystander response to adults who experience out-of-hospital cardiac
arrest. A science advisory for the public from the Emergency
Cardiovascular Care Committee, American Heart Association. Circulation
2008; DOI: 10.1161/CIRCULATIONAHA.107.189380. Available at:
http://circ.ahajournals.org. 
	2. ECC Committee, Subcommittees and Task Forces of the American
Heart Association. 2005 American Heart Association guidelines for
cardiopulmonary resuscitation and emergency cardiovascular care.
Circulation 2005; 112 (suppl):IV1-IV203. 16314375 
	3. Abella BS, Aufderheide TP, Eigel B, et al. Reducing barriers
for implementation of bystander-initiated cardiopulmonary resuscitation.
A scientific statement from the American Heart Association for
healthcare providers, policymakers, and community leaders regarding the
effectiveness of cardiopulmonary resuscitation. Circulation 2008; DOI:
10.1161/CIRCULATIONAHA.107.188486. 18195177.
 
Clinical Context
Bystanders who witness the sudden collapse of an adult should activate
the emergency system and provide high-quality chest compressions based
on recent recommendations of the AHA Emergency Cardiovascular Care (ECC)
Committee. Ten years ago, the AHA commissioned a working group for
bystander-initiated CPR, and the group recommended then that the current
standards for mouth-to-mouth resuscitation remain as before.
The recent revisions suggest that lay persons should be encouraged to
provide compression-only CPR if they are unable or unwilling to provide
rescue breaths, although the best method of CPR is still compressions
coordinated with ventilations.
This is a review of the current updated ECC recommendations and a
summary of research data needed to further clarify some
recommendations.
Study Highlights
	* Bystander-initiated CPR can more than double survival from
cardiac arrest, but reported prevalence of bystander-initiated CPR from
most US cities remains low at 27% to 33%. 
	* Reducing barriers to bystander resuscitation will improve
outcomes of out-of-hospital cardiac arrest. 
	* Concerns about CPR include fear of causing harm, fear of
infection, and reluctance to perform m
outh-to-mouth ventilation. 
	* Eliminating the expectation of mouth-to-mouth contact during
CPR is likely to improve esthetics and address the expressed concern of
potential bystanders about infection. 
	* Several human studies suggest that performing traditional
1-person CPR with rescue breaths takes longer to initiate than
performing hands-only CPR. 
	* There is good evidence that the provision of chest
compressions alone does not have a negative impact on survival to
hospital discharge vs conventional CPR. 
	* Evidence suggests that adult victims who receive hands-only
CPR or conventional CPR have similar chances of survival. 
	* Delivery of more effective chest compressions with minimum
interruptions of 10 seconds or less (including interruptions to deliver
rescue breaths) is recommended. 
	* The current guidelines recommend a compression-to-ventilation
ratio of 30:2 for adult victims. 
	* Animal studies support the need for rescue breathing in
cardiac arrests precipitated by drowning, trauma, airway obstruction,
and pediatric and prolonged cardiac arrest. 
	* When an adult suddenly collapses and a bystander is not
trained in CPR, then hands-only CPR should be provided until an
automated external defibrillator arrives and is ready for use or
emergency services providers take over care of the person. 
	* If a bystander was previously trained in CPR and is confident
in providing rescue breaths, then conventional CPR with 30:2
compressions to ventilation or hands-only CPR may be provided until an
automated external defibrillator arrives and is ready for use or
emergency services providers take over care of the person. 
	* If a bystander was previously trained in CPR but is not
confident about the ability to provide conventional CPR, then hands-only
CPR should be provided and continued until an automated external
defibrillator arrives and is ready for use or emergency services
providers take over care of the person. 
	* The ECC guidelines encourage the public to obtain CPR training
to learn the psychomotor skills required to care for a wide range of
cardiovascular and pulmonary-related medical emergencies. 
	* The ECC committee acknowledges the need for evidence for
situations in which ventilation alone could be life-saving, situations
in which ventilation is critical to survival after chest compression,
and the impact of performing chest compressions only on pediatric
populations or those having an asphyxial arrest. 
   
 
 
i   
   
 

 
----- Original Message ----
From: mark miller <markandjac at optusnet.com.au>
To: "Trauma & Critical Care mailing list" <trauma-list at trauma.org>
Sent: Saturday, May 17, 2008 6:43:39 PM
Subject: RE: Pacing Vs. Airway Management

This scenario should be treated in the same manner as a VF arrest. You
have
a (potentially) readily reversible origin of LOC/airway threat (ie CHB
induced hypotension). Fix the brain perfusion first and you may avert
the
need to intubate. Intubation itself could precipitate asystole here.

TC Pacing is an option but seems to be rarely done (in NSW)
pre-hospital and
poorly tolerated. Despite ischaemia, I'd start with small doses of
1:10,000
adrenaline (say 10mcg increments) and volume loading. No harm in
atropinisation but commonly fails. He isn't being poisoned by his GP
(industrial strength BBlocker and CaCBlocker combos are a common cause
of
this situation around here, esp in the elderly) so nothing to reverse
in
that regard. Reperfusion may be in order after you fix this problem.

This is similar to airway management in the postictal patient. I agree
with
Bill G, Treat the underlying, commonly reversible, cause of LOC and
give
them time to "awaken" (on their side, with a nurse and with suction
available). This , I believe, is a safer and much less resource
intensive
option than subjecting them all unnecessarily to RSI and later
extubation in
ED or ICU. The aspiration risk seems small, possibly less (anecdote)
than
the risks posed by intubation becoming "standard of Care" and a
whole
lot of
inexperienced airway operators feeling obliged to tube these guys.

Mark Miller
FACEM


-----Original Message-----
From: Gavin SUTTON [mailto:Gsutton at pgwc.gov.za] 
Sent: Saturday, 17 May 2008 7:22 AM
To: trauma-list at trauma.org 
Subject: Pacing Vs. Airway Management

Just a question if I may... 

Pre-hospital case, 55 year-old male patient with Hx of IHD and
hypertension.
He is on pharmapress and Isordil. He has defaulted for 6 months. His
EKG
shows a sinus rhythm of 110 with ischemia. While the paramedics are
treating
the patient, he becomes unresponsive, the ECG shows 3rd degree HB and
he has
a BP of 80 systolic. He has very poor tidal volume.

What would you do?

1. Begin external pacing immediately
2. Sort out the patient's airway first (intubation) and ventilate with
a
bag-valve-mask resuscitator - 100% O2, and then begin external pacing
if no
improvement
3. Transport to hospital while maintaining basic airway techniques and
ventilation- 45 minutes away

Many thanks

Gavin 

Gavin Sutton
Head: Department of Training
Emergency Medical Services
Western Cape Department of Health
South Africa

Tel. +27 21 938-4118
Fax.+27 21 938-4269

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