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crazycanuck

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    Device for Cardiac Arrest Patients

    in Equiqment and Apparatus

    Posted

    Nice post Kelly. I have heard of the ResQPOD before but haven't done much reading on it.

    Here are some references:

    Community Consultation for the Proposed Cardiac Arrest Study

    powerpoint slides

    http://www.mcw.edu/display/router.asp?docid=11740

    http://www.zoll.com/product.aspx?id=377

    Big list of related publications:

    http://www.advancedcirculatory.com/CET/articles.htm

    *from manufacturer site but articles are in reputable journals*

    Case Study: Sepsis and Tachycardia (with EKGs)

    in Patient Care

    Posted

    AnthonyM83:

    Could we throw in a little education for the BLS providers? Smile

    I was under the impression, both from class and seeing it used in the field, that while adeonsine had a short half-life, its effects lasted more than the half-life. We just want to get the drug to heart quickly, then its effects EVEN THOUGH TRANSIENT last more than a few seconds.

    I was also taught SVT was rate over 150 coming from above the ventricles (aka not a wide NR? Was I given an oversimplified definition?

    Here's a few references for adenosine:

    http://www.drugs.com/pro/adenosine.html

    anesthesia.slu.edu/pdf/keywords/ADENOSINE%20PHARMACOLOGY.pdf

    (cut and paste, I dont know how to make it clicky)

    Everyone is going to have a different definition for SVT, some will cite it as any atrial rhythm >100bpm if there is no reason for sinus tachycardia such as illness, stress, exercise, compensatory response. For most patients, it will not become hemodynamically unstable until it reaches a much higher rate so it really isn't so much the semantics of what you will define SVT as, but more so about when it becomes a rate that you want to treat as symptomatic.

    As for the rapid push to get it in as quickly as possible, this is debatable too and I'll leave that for someone else...I'm not sure of the longterm effects of the drug, I believe the half life and mechanism of action are short. Half life less than 10sec, and action on the AV node is short too, the specific amount of time I do not have the answer....

    Cardiac Save Guidelines??

    in General EMS Discussion

    Posted

    AnthonyM83

    PostPosted: Wed Jul 11, 2007 7:29 pm Post subject:

    I couldn't find any studies on this, but I was told today that Washington requires CPR certification in order to obtain one's driver's license and also has a higher survival rate for cardiac arrests. Can someone support or refute this? If true, it would be a testament to how government can have an impact of civilian awareness.

    Do you mean DC or WA? I looked up requirements for both and do not see CPR listed as a requirement for licensing, but that would be a pretty dang good requirement!

    http://dmv.dc.gov/serv/dlicense/get_DL.shtm

    http://www.dol.wa.gov/driverslicense/18over.html

    And as far as literature you can search by geographical data, but outcomes would be difficult to compare between cities due to extraneous variable unless you are looking at a multi-site outcome studies with the same reporting parameters.

    Here is another excellent resource and interesting site:

    http://www.nrcpr.org/research_publications.html

    Cardiac Save Guidelines??

    in General EMS Discussion

    Posted

    http://www.pubmedcentral.nih.gov/articlere...i?artid=1336161

    Cardiac arrest in Ontario: circumstances, community response, role of prehospital defibrillation and predictors of survival.

    R J Brison, J R Davidson, J F Dreyer, G Jones, J Maloney, D P Munkley, H M O'Connor, and B H Rowe

    " from article linked above:

    CONCLUSIONS: The survival rate was lower than expected. The availability of prehospital defibrillation did not affect survival. To improve survival rates after cardiac arrest ambulance response times must be reduced and the frequency of bystander-initiated CPR increased. Once these changes are in place a beneficial effect from advanced manoeuvres such as prehospital defibrillation may be seen."

    http://www.aemj.org/cgi/content/abstract/8/5/424

    The Relationship between Out-of-hospital Cardiac Arrest Survival and Community Bystander CPR Rates

    Valerie J De Maio, Ian G Stiell, George A Wells, Michael T Martin, Daniel W Spaite, Graham Nichol, David Brisson, Donna Cousineau, Jeremy Doherty, Marion B Lyver, Brian J Field, Douglas P Munkley and , the OPALS Study Group

    from above article:

    "Conclusion: Improved community bystander CPR rates are associated with dramatically increased out-of-hospital arrest survival in a predictable fashion. EMS and public health directors should focus significant efforts towards improving their community bystander CPR rate."

    *edit for formt

    Cardiac Save Guidelines??

    in General EMS Discussion

    Posted

    white 72: We should spend out time educating the public on the importance of CPR and AED training. Educate them to understand they can be a significant help in increasing the survival rate in cardiac arrest patients.

    I could not agree more.

    As far as my attitude sucking, its not an attitude its reality. Yes my expectations have everything to do with the outcome of arrest patients, give me a break. Maybe I should say a little prayer for them too, or work the arrest with my fingers crossed. That might help.

    We know what saves arrest pts. I explained it above.

    Thank you for expanding upon your points and thoughts. My post was not to pick at you or criticize your education or abilities. I misunderstood you to be saying there's not a hope in hell so why try, which is not really what you are saying I think.

    Your point right here is of the utmost importance:

    So if we are not going to put an ambulance on every corner, or educate the public, you will never see your arrest survival percentages rise.

    The latter of the two seems more reasonable, no?

    Outcome based measures and adapting treatment algorithms, protocols, and patient care are not the answer to saving everyone, and living in a rose-coloured glasses kind of world where people are saved by fairies and wishes is not going to help either.

    Education is going to be what makes the difference. Education of the public to be more effective bystanders and primary prevention of heart disease and illness need to be a bigger focus than our currently short-sighted model of damage control....but that's a whole other discussion :D

    Thanks for your comments whit. :wink:

    Cardiac Save Guidelines??

    in General EMS Discussion

    Posted

    whit72 Posted: Sun Jul 08, 2007 10:57 pm Post subject:

    --------------------------------------------------------------------------------

    I looked around a little I couldnt find any statistical data on save rates.

    This is going to vary dependent on the study parameters and so many factors. You will find a pretty wide range of numbers depending on the operational definitions used....

    AnthonyM83 Posted: Mon Jul 09, 2007 3:32 am Post subject:

    whit72 wrote:

    You cant find any info, because the minuscule percentage of survival to discharge without sever disability is about 0%. Give or take 0%

    Where are you getting these stats from?

    Did you not know that 98.376% of statistics are made up. :D

    This percetage survival to discharge of 0% is false. Though the OHCA survival rate is poor, it is more constructive to do as Medic26 is here, to educate oneself on the definitions, process, and outcomes in attempt to improve it.

    This attitude sucks. Plain and simple. If you expect 0% guess what you will get???....0%

    Here's a few references for OHCA survival figures.

    1) High Discharge Survival Rate After Out-of-Hospital Ventricular Fibrillation With Rapid Defibrillation by Police and Paramedics.

    Annals of Emergency Medicine, Volume 28, Issue 5, Pages 480-485

    R. White, B. Asplin, T. Bugliosi, D. Hankins

    http://linkinghub.elsevier.com/retrieve/pi...196064496701099

    2) Predicting survival from out-of-hospital cardiac arrest: A graphic model.

    Annals of Emergency Medicine, Volume 22, Issue 11, Pages 1652-1658

    M. Larsen, M. Eisenberg, R. Cummins, A. Hallstrom

    http://linkinghub.elsevier.com/retrieve/pi...0644(05)81302-2

    3) Cardiac arrest and resuscitation: A tale of 29 cities.

    Annals of Emergency Medicine, Volume 19, Issue 2, Pages 179-186

    M. Eisenberg, B. Horwood, R. Cummins, R. Reynolds-Haertle, T. Hearne

    http://linkinghub.elsevier.com/retrieve/pi...0644(05)81805-0

    4) Outcome of out-of-hospital cardiac arrest in New York City. The Pre-Hospital Arrest Survival Evaluation (PHASE) Study

    http://jama.ama-assn.org/cgi/content/abstract/271/9/678

    5) Improved Out-of-Hospital Cardiac Arrest Survival Through the Inexpensive Optimization of an Existing Defibrillation Program

    OPALS Study Phase II

    http://jama.highwire.org/cgi/content/abstract/281/13/1175

    6) Incidence of cardiac arrest: A neglected factor in evaluating survival rates.

    Annals of Emergency Medicine, Volume 22, Issue 1, Pages 86-91

    L. Becker, D. Smith, K. Rhodes

    http://linkinghub.elsevier.com/retrieve/pi...0644(05)80257-4

    Cardiac Save Guidelines??

    in General EMS Discussion

    Posted

    Ventmedic linked up a thread with extensive discussion on what others consider "a save".

    I believe Medic26 is looking for some data and academic discussion of the definitions and guidelines if I read the request correctly.

    Personal definitions of survival are based on semantics and were discussed in the earlier thread. Survival outcomes and definitions will vary by study design. They will usually be as you mentioned based on time-line from intervention to time of death. Do you count it as a save if the patient has ROSC but no neuro function? Do you count it as a save if the patient goes on to discharge with previous level of function? This is the great debate, but here's what the literature says....

    Here's some of what I could dig up and I hope it is of assistance to you 26.

    1) http://circ.ahajournals.org/cgi/content/full/114/25/2760

    Increasing Use of Cardiopulmonary Resuscitation During Out-of-Hospital Ventricular Fibrillation Arrest

    **see the section outcomes for their definitions and descriptions of "survival" posted here as well

    "Outcomes

    The primary outcome was survival status at hospital discharge. We also assessed discharge destination (home versus nursing or rehabilitation facility) and neurological status at discharge based on hospital record review using Cerebral Performance Category. A Cerebral Performance Category score of 1 or 2 was classified as favorable neurological status.15,18 Using the electronic AED record, we assessed the timing of CPR between the first (stack of) shock(s) and the second (stack of) shock(s) to help determine whether the protocol changes influenced the timing and quantity of CPR. Specifically, we assessed the time interval between the first shock and the start of CPR (hands-off interval 1), the total time spent performing CPR between the first and second shock, the interval between the completion of CPR and the second (stack of) shock(s) (hands-off interval 2), and the total time between the first (stack of) shock(s) and the second (stack of) shock(s) (hands-off interval 1+CPR interval+hands-off interval 2).19 This review used both the real-time electronic ECG and the audio recording information to assess CPR timing. Prior study has indicated good interviewer reliability with regard to the timing of CPR with this approach.11"

    2) http://eurheartj.oxfordjournals.org/cgi/co...full/27/23/2840

    Predicting survival with good neurological recovery at hospital admission after successful resuscitation of out-of-hospital cardiac arrest: the OHCA score

    3) http://content.nejm.org/cgi/content/full/3...2473fbbdcdbfd38

    Long-Term Outcomes of Out-of-Hospital Cardiac Arrest after Successful Early Defibrillation

    **see the results section and it gives definitions for survival and outcomes

    4) http://content.onlinejacc.org/cgi/content/abstract/7/4/752

    Factors influencing survival after out-of-hospital cardiac arrest

    *check out the references at the bottom of that link as well for more articles**

    New AHA CPR/FBAO Protocols

    in General EMS Discussion

    Posted

    Here are the "new guidelines" from 2005 :shock:

    Here is a link if you see right next to the white and red icon it links to the full content in Circulation:

    http://www.americanheart.org/presenter.jht...ntifier=3035517

    Here is said link with individual sections for your perusal:

    http://circ.ahajournals.org/content/vol112/24_suppl/

    Adult BLS:

    http://circ.ahajournals.org/cgi/content/fu.../24_suppl/IV-19

    For peds:

    http://pediatrics.aappublications.org/cgi/...full/117/5/e989

    Often you do not need a journal subscription to get these online. Sometimes google will do the trick, and if not try:

    www.scholar.google.com and this will bring up journals and academic literature.

    Also, one more thing cayer, don't take this the wrong way. Last I checked it was a duty and responsibility of a person within a profession to know and understand the scope of their practice and all of the guidelines under which they practice. It does not reflect well on any person to not have the materials they need for knowledge and education for the reason you gave of not wanting to pay for it. Go to the library they have services to print articles or at very least have access to fulltext.

    Better to ask here than not at all, but it is your professional responsibility to have the materials. Don't ever use the answer that you didn't want to buy the book/paper/materials, it looks bad on you and you represent others.

    I hope you see the point without being completely offended. And if you are offended you'll get over it soon :wink:

    pacemaker rate

    in General EMS Discussion

    Posted

    Intervention set point is going to be different according to the patient but you are correct that most times this minimum rate is usually set around 50-80bpm.

    There are a few possibilities that come to mind here.

    1) It is possible this is a pacemaker-mediated tachycardia (PMT). This can easily be tested by placing a magnet over the pacemaker which will set it into an asynchronous pacing mode (each device has a set rate, somewhere usually around 85bpm). This mode will cease the re-entry circuit that is needed for pacemaker mediated tachycardia to occur. (**I would not suggest placing a magnet over an implanted defibrillator without appropriate defibrillation backup as usually this will place the ICD into a non-sensing mode and will not deliver cardioversion. The magnet is often used in the case of "electrical storms" or multiple possibly inappropriate shocks from a device)

    http://www.emedicine.com/med/topic2918.htm

    2) The intervention rate is sometimes set to 100bpm or a hysteresis rate to prevent rapid rate drops. This newer algorithm called rate drop response (RDR) is often used in patients with severe debilitating vasovagal syncope or cardioinhibitory syncope. Though this may not be the reason for your patient being paced at this rate, it is out there. This intervention pacing is set to detect a specified drop of x bpm then set to intervene and pace at x bpm for x minutes. For eg. If there is a drop of 25bpm in 30 sec, then the pacemaker is set to pace at 100bpm for 2 minutes. One current model of pacemaker with this is the Medtronic EnPulse RDR.

    http://europace.oxfordjournals.org/cgi/con...bstract/2/3/245

    3) It is possible the rate responsiveness on the device has gone out of whack. Devices will vary but often on most newer ones a rate responsive feature can be programmed and activated. The purpose of this is to allow the patient to attain a rate appropriate to their activity level. Older pacemakers were set rates and the patient could be stuck at 60bpm regardless of if they were sleeping or running. With developments many attempts at designing sensors based on minute ventilation or peizo-electric crystals were designed to sense either body movement or activity level and then a program would tell the pacemaker to pace higher because the person is exercising or being active. The problem here sometimes is that this can be triggered by vibrations or electromagnetic interference (now uncommon with shielding of devices).

    www.ipej.org/0403/greco.pdf

    4) Another possibility though unlikely is a pacemaker lead malfunction. This is fairly uncommon and I think would be more likely to result in under-sensing or failure to capture than an inappropriate intervention rate. This problem can be more troublesome in ICDs as it can lead to inappropriate therapy.

    www.ipej.org/0304/toquero.pdf

    Pacemakers and cardiac implants have come a very long way. There is a lot that can be customized in programming and though I can't answer why this patient had what appeared to be an inappropriate intervention rate, it is very likely that a device rep would be called to come and interrogate the pacemaker. Th read out would include all of the specific details and likely reprogramming would solve it if it is a problem.

    A couple of questions: was this patient paced only in the atrium? Could you just see pacer spikes in the p-wave area? Or did this look like a slow wide rhythm? Patients who are A-V paced sequentially can appear to have a very wide complex and it can even be mistaken for a slow VT, especially if it is one of those higher intervention rates or with the case of PMT.

    You said his paced rate was >100bpm then later went down to 70bpm. When he was at 100bpm was anything going on? Had he just been moving around or was there anything to suggest that vibrations could have activated the rate responsive setting?

    If the patient has one of those RDR algorithms, this usually only lasts for a minute or two but can happen repeatedly if they satisfy the criteria for pacing intervention.

    From the information and in retrospect I don't know the answer but those are some of the possibilities.

    Do you have any follow-up? Was this related to the patient complaint or an incidental finding on exam?

    Oh and one more thing....you mentioned you thought it would not pace above a set point. Most newer devices have a much higher tracking and pacing rate available than the older fixed ones. Now a patient who wants rate responsiveness can be set at a very high or sensitive activity level and is able to be paced quite fast when needed some up to 150-160bpm. Many will have tracking rates up to 180bpm.

    The Golden Hour - is it a real a principal for EMS?

    in General EMS Discussion

    Posted

    As mentioned in the link Phil posted, the concept of the Golden Hour goes back to R. Adams Cowley, founder of Shock Trauma in Baltimore. Cowley was a 1st Lieutenant of the Medical Corps of the US Army.

    Ask Croaker if you're interested in this bit of history or check out the classic book Shock Trauma by R. Adams Cowley. It is a piece of EMS history and he was one of the "founding fathers" in the emergency medicine field. He devoted his life to the development of trauma protocols and the intensive study of the effect of shock on the body and outcomes.

    Opinions aside I will leave the discussion to people here with more direct input but here are some references for your perusal. This is just on the general concept of the golden hour, though this can be applied to specific problems such as outcomes for intervention of CVA or penetrating trauma.

    Reference #1 below was cited as the article of scientific review of cowley's principles that did not support the golden hour theory.

    1) Lerner, EB; Moscati (2001). "The Golden Hour: Scientific Fact or Medical "Urban Legend?"". Academic Emergency Medicine 8 (7): 758-760.

    http://www.aemj.org/cgi/content/full/8/7/758

    2) Bledsoe, Bryan E (2002). "The Golden Hour: Fact or Fiction". Emergency Medical Services 6 (31): 105.

    3) DJ Lockey - Resuscitation. 2001 Jan;48(1):5-15.

    http://www.skyaid.org/Skyaid%20Org/Medical...al%20trauma.pdf

    Device may prevent most heart attacks

    in General EMS Discussion

    Posted

    Terri this is an interesting link and brings up a few thoughts.

    Implanted cardiac technology has come a long way and now it is possible to use these devices in a wide population. Possible but perhaps not indicated. This device is somewhat similar to the Reveal implanted loop recorder. http://wwwp.medtronic.com/Newsroom/LinkedI...&lang=en_US

    There are specific guidelines in place for indications of implanting devices and I'm sure that ACC/AHA/NASPE would come up with clear indications for this and eventually allow physicians to bill insurance for it. I'm not sure insurance is going to go for a "heart attack warning" implant and I'm sure there will be issues with justifying implantation procedures and possible misuse of these as well but that's a whole separate issue. It seems like if the person has a high enough risk for sudden death that either treatment of the blocked vessels or underlying cause of the problem would be the proper way to go. It can be difficult enough to obtain approval for cardiac devices when there is a clear indication for them. Due to cost of procedure and the number of people who are candidates, insurance companies may often reject the initial request for coverage of these procedures. It will be interesting to see how they come up with the guidelines and justifications for implantation and what tests will be used to quantify risk and what the criterion for implant approval will be.

    It seems like this device would be targeted toward the middle age patient with not enough risk factors to indicate any other device or intervention, but rather as a CYA policy that may be too often relied on instead of focusing on health and well being in the form of prevention and regular check ups. Furthermore, if this device is aimed at the patient who may not recognize their symptoms or ignores them, then what is the likelihood of that target patient seeing a physician about this device or following through with an implant procedure?

    I think that as AZ said, if the medical system would focus on prevention we would not have so many people with coronary artery disease and we would not be focusing on damage control.

    Please understand, I'm all for these device developments and really these types of things can be a blessing to people. I do think too that we need to remove ourselves from the age of invinsibility where we think we can continue to abuse our bodies and our health and that modern medicine will have a quick fix readily available for us.

    References:

    Gregoratos, G, Abrams, J, Epstein, AE, et al. ACC/AHA/NASPE 2002 Guideline update for implantation of cardiac pacemakers and antiarrhythmia devices: summary article. A report of the American College of Cardiology/American Heart Association task force on practice guidelines (ACC/AHA/NASPE committee to update the 1998 pacemaker guidelines). Circulation 2002; 106:2145.

    Pacemakers and FBAO

    in General EMS Discussion

    Posted

    Hi Skibum,

    I have never heard of this, though let's wait to see what everybody else has to say.

    My suspicion is maybe this is her old school perception-- back in the day pacer and ICD pulse generators were large and implanted abdominally. Now this is not frequently the case, unless it's a ped patient who is too small for traditional implant or someone with erosion problems or other anatomical anomalies.

    Perhaps back in the dark ages when we had much larger pulse generators implanted in the abdomen she was told not to perform abdominal thrusts due to risk of lead dislodgement. Even then, is she going to let someone choke so she doesn't "hurt their pacemaker"?!??!?!

    Just my 0.02.

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