I went to my monthly regional educational and medical advisory meetings yesterday. I was able to get the committee to agree to issue protocols immediately to permit paramedics to start utlilzing some of the changes recommended by the new AHA guidleines, while waiting until January to implement others.
The immediate changes:
CPR
Place emphasis on continuous quality CPR, with compressions at a rate of 100 per minute, 1 1/2" to 2" deep, allowing full chest recoil. Try to keep compression interruptions to less than 10 seconds. Compress while charging. Compress while intubating if possible. Non-intubated patients should receive CPR at a rate of 30:2, intubated patients should receive continuous compressions.
Ventilations for patients in cardiac arrest should be no more than 8-10 per minutes with each ventilation lasting no more than 1 second and containing only enough tidal volume to make the chest rise. Intubated patients not in cardiac arrest should be ventilated at 10-12 per minute. Do not hyperventilate.
Defibrillation
Instead of three stacked shocks, use 1 shock at maximum setting. After shocking, immediately do 2 minutes of CPR before checking for rhythm.
Patients in ventricular fibrillation who have suffered an unwitnessed arrest or for whom response time is greater than 4 minutes should have 2 minutes of CPR prior to defibrillation.
Intubation
Patients in ventricular fibrillation may have intubation delayed.
A Combi-tube and an LMA are considered 1st line airways along with ET.
Traumatic arrests should be intubated en route to the hospital if at all.
Drugs may only be given down the ET tube if IV access or IO access is unavailable.
IO
Adults may receive IO provided the device used has FDA approval. IO access should only be obtained on patients in extremis.
Asystole/PEA
Pacing is no longer recommended in cardiac arrest.
Additional changes to regional protocols, as a result of the new AHA guidelines will be implanted with regular protocol updates scheduled for January 1, 2007.
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The new guidelines were produced by the International Liaison Committee for Resuscitation, after comprehensive review of scientific evidence from published studies.
Research shows the CPR currently being performed results in excessive ventilations (which decreases cardiac output), frequent interruptions of compressions and chest compressions too shallow and slow to produce results.
Hyperventilation increases intrathoracic pressure, which inhibits venous return. Since venous return determines cardiac output, hyperventilation reduces cardiac output, causing reduced oxygenation.
The new guidelines are about maintaining blood flow. Push hard, push deep, allow the chest to fully recoil. Minimize interruptions. When compressions stop, blood flow stops. Do not hyperventilate. When a patient is hyperventilated blood flow is compromised.
The question of shocking or doing CPR first is related to the patient’s physiological state. In the first 4 minutes of ventricular fibrillation, the patient is in the “electrical phase” of arrest, during which time the body has adequate oxygen and energy stores, a normal PH, and is unlikely to have suffered heart damage. The science shows this phase responds best to electricity. Intubation is not the priority during the electrical phase.
During the next six minutes, the body is in the” circulatory phase.” The v-fib is now fine or absent. There is inadequate oxygen in the heart, inadequate energy, acidosis, and heart ischemia. Effective circulation is needed to deliver oxygen to the hypoxic tissues to improve chances of successful defibrillation. Evidence suggests defibrillation before CPR in this phase may be detrimental.
Know the phase of arrest your patient is in.
The Committee also passed a lights and sirens document I put together for them without more than a minute of discussion. I was amazed. Sometimes documents takes years to get passed.
LIGHTS AND SIREN USE
GUIDELINES
Ambulances should use emergency lights or sirens only when transporting or responding to a call involving a patient believed to need immediate medical intervention.
Patient Response
Ambulances should respond lights and sirens only when directed by their dispatch center based on EMD criteria. Should additional information suggesting that the call no longer merits a lights and sirens response be received by the dispatch center while the ambulance is enroute to the scene, the ambulance should be downgraded to nonlights and sirens mode.
Patient Transport:
The crew member responsible for patient care during transportation will advise the driver of the appropriate mode of transportation based upon the medical condition of the patient.
When transporting the patient, the need for immediate medical intervention should be beyond the capabilities of the ambulance crew using available supplies and equipment.
Such conditions include, but are not limited to:
1. Unstable airway or severe respiratory distress
2. Shock
3. Patient with anatomic or physiologic criteria for Level One Trauma Center
4. Acute Stroke within the last three hours
5. Status Epilepticus
6. ST Elevation MI
7. Cardiac arrest with persistent ventricular fibrillation, hypothermia, overdose/ or poisoning
When in doubt, contact medical control.
Mode of transport for interfacility transfers should be based upon the directions of the referring physician or medical control physician who provides the orders for patient care during the transport. Generally, interfacility transport patients have been stabilized to a point where the minimal time saved by L&S transport is not of importance to patient outcome.
Lights and sirens use should be documented and justified on the patient care report (e.g., “flail chest”, “systolic BP<90”,>
Notes: In most cases (up to 95% of EMS incidents), EMS personnel can stabilize the patient’s condition to a point where the small amount of time gained by L&S transport will not affect the patient’s medical condition or outcome. In previous studies and in most situations, L&S transport generally only decreases transport time by a couple of minutes or less.
The American Heart Association gives a class III recommendation to L&S transport of patients in cardiac arrest. A Class III indication is not helpful and is potentially harmful. Providing CPR during L&S transport may increase the risk for injury to EMS personnel.
Exceptions to these policies can be made under extraordinary circumstances (e.g., disaster conditions or a back log of high priority calls where the demand for EMS ambulances exceeds available resources). These exceptions should be documented.
(The above document was adapted from Pennsylvania Guidelines.)
I've been on these committees for several years now. While because the regional paramedic committee is no longer functioning, I am no longer the official paramedic representative, I go to all the meetings, and I have great input. I come from the street, I do my homework, and they listen to me, even if they don't always agree. We do get things done. Being a part of these committees is among the most rewarding part of being a paramedic.
