Work cardiac resuscitations in the field, not the ambulance



SEATTLE – In almost all cases, it’s best to stay on the scene to work a cardiac arrest resuscitation until the return of spontaneous circulation or efforts are stopped because of futility, according to Dr. Brent Myers, director of emergency medical services in Raleigh/Wake County, N.C.

The probability of neurologically intact survival is at least 10-fold higher, and by some estimates up to 35-fold higher, when resuscitation is achieved in the field, instead of en route to the emergency department, Dr. Myers said at the annual meeting of the American College of Emergency Physicians. Neurologically intact survival quadrupled to 11.5% for patients in ventricular fibrillation and to 40.8% for those with ventricular tachycardia after the approach was adopted in Wake County, he reported. (Ann. Emerg. Med. 2010;56:348-57).

"Load-and-go is not the appropriate approach; resuscitation is a prehospital exercise," Dr. Myers said. "In the vast majority of cases, if we interrupt compressions to move patients" – which is unavoidable with even the most careful transport – "we have sealed their fate."

An ever-increasing number of emergency medicine experts agree, but some EMS systems still have forced moves at, for example, 20 minutes. That standard probably accounts for much of the considerable regional variations in survival of cardiac arrest patients. "The variability, in large portion, can be explained simply by who’s on the chest and who’s not. As you stay on the chest above 80% of the time, your odds of survival triple," he said (for example, Circulation 2010;122:S685-705; JAMA 2008;300:1423-31).

"How long we should stay on the scene still needs further research, [but] the old rule that says you shouldn’t go beyond 30 minutes is clearly not true. We just don’t know what the new time is; it’s somewhere north of 30 minutes," he said.

In general, Wake County crews keep at resuscitation until asystole or disorganized pulseless electrical activity (PEA). "We don’t ever terminate [a patient with ventricular fibrillation] or good-looking PEA, which has resulted in prolonged resuscitation times" of sometimes 50 minutes or more. "They are very unlikely to survive after 40 minutes; but if they do, they are just as likely to be neurologically intact. We are not creating persistently vegetative states," Dr. Myers said.

In-home termination – which happens in almost half of Wake County cases – goes hand in hand with the approach. "The systems with the highest resuscitation rates also have the highest field termination rates. I don’t think that’s an accident; it’s a marker that [they] are focusing resuscitations on the scene," he said.

"You have to have the capacity to terminate, [and] be ready to [help] families" with grief. "Every published paper indicates that family members want to be present for the resuscitation." Among the most important things for them are knowing their loved one is not in pain and being able to touch the body; the cleanliness of the body is also important (Ann. Emerg. Med. 2002;40:521-3).

There may be a small number of patients who benefit from intra-arrest transport, but "we do not have sufficient data" to identify them. One group might be young, otherwise-healthy people in VF who can be whisked straight into a cath lab. "It sounds good, but we haven’t proven it yet," Dr. Myers said.

Rearrest is most likely within 10 minutes of a successful resuscitation, so, just in case, Dr. Myers’ crews stay put with patients for 10 minutes after they come around, before transport. If they re-arrest en route to the ED, in most cases crews "pull over and work the arrest right there in the ambulance," he said.

Dr. Myers reported having no disclosures.

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