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We are involved in a prehospital study, so the protocols may seem a little weird. To be very honest it is frustrating because several departments are using the old AHA protocols, some using new protocols and some are involved with this study. Because of the system several agencies often work together and there can cause confusion. I will look into wether we were wrong to bag before intubation. I don't believe we were. Thanks for the feedback.

You misunderstand...

I didn't imply that ventilating prior to intubation was somehow wrong. It is in fact necessary. The way in which you described seems ineffective and potentially offers risks. Please correct me if I'm wrong.

I took a look at the ROC study (one of the biggest currently in NA). As far as I know that method is not part of the ROC study.

http://www.ohri.ca/emerg/roc.html#Introduction

It doesn't appear that AZ is on the list of participating areas.

Up front CPR (or variations based on time, etc...) is part of the 2005 ACLS and many services have been using this for quite some time. It is just the way that you described that seems unusual.

When you can find out, please link/outline the study. I'd be interested...

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Etfink,

It sounds like you guys did a fantastic job!!! Pt survival is what it is all about (hopefully with minimal deficits) and you achieved that end.

Just to clarify the new guidelines as there seems to be some confusion....(surprise, surprise!!! the new guidelines are confusing.) :shock:

For an unwitnessed arrest (generally VF) it is recommended to do 5 cycles of compressions/ventilations with a ratio of 30:2 (which is about 2 minutes with compressions at a rate of 100/min) before defibrillating as was said to "prime the pump".

You are meant to pause for the breath but the compressions are of a higher priority and are meant to have as minimal interruptions as possible. The breath is given faster than previously taught with an inspiratory time of no longer than 1 second and just enough to see visible chest rise.

"To minimize the potential for gastric inflation and its complications, deliver each breath to patients with or without an advanced airway over 1 second and deliver a tidal volume that is sufficient to produce a visible chest rise. But do not deliver more volume or use more force than is needed to produce visible chest rise." (AHA guidelines)

If someone is requiring CPR they actually don't need as much oxygen and ventilation as is normally required and the emphasis is on not OVERVENTILATING as worse outcomes have been associated with that.

Once the person is intubated you give breaths at a rate of 8 - 10/min or about every 6-8 seconds without pauses in compressions.

Hope this helps with the confusion. If you want the full guidelines with the rationales behind it all check it out on the American Heart Association website.

Congrats and all the best for your medic school etfink :thumbright:

Aussie

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Probably part of the new cardiac, trauma study that about 20 hospitals are performing. Pep'e and several others have been performing. I posted a reference of this study last spring, and I believe that EMS DeFrance web site has more info. I know the The OPALS study, and ROC, which has not brought much attention or is hardly mentioned in the U.S.

I still believe that ACLS is one of those medical technologies, either it will work or won't. Unless resuscitation measures are started in a quick and in a timely manner and good CPR is performed, success rates is going to be dismissal no matter what and how it is performed.

R/r 911

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Do you know what caused the arrest? I don't want to rain on your parade but I suspect alot of the ROSC has to do with why he coded to begin with, obviously.

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Etfink,

It sounds like you guys did a fantastic job!!! Pt survival is what it is all about (hopefully with minimal deficits) and you achieved that end.

Just to clarify the new guidelines as there seems to be some confusion....(surprise, surprise!!! the new guidelines are confusing.) :shock:

For an unwitnessed arrest (generally VF) it is recommended to do 5 cycles of compressions/ventilations with a ratio of 30:2 (which is about 2 minutes with compressions at a rate of 100/min) before defibrillating as was said to "prime the pump".

You are meant to pause for the breath but the compressions are of a higher priority and are meant to have as minimal interruptions as possible. The breath is given faster than previously taught with an inspiratory time of no longer than 1 second and just enough to see visible chest rise.

"To minimize the potential for gastric inflation and its complications, deliver each breath to patients with or without an advanced airway over 1 second and deliver a tidal volume that is sufficient to produce a visible chest rise. But do not deliver more volume or use more force than is needed to produce visible chest rise." (AHA guidelines)

If someone is requiring CPR they actually don't need as much oxygen and ventilation as is normally required and the emphasis is on not OVERVENTILATING as worse outcomes have been associated with that.

Once the person is intubated you give breaths at a rate of 8 - 10/min or about every 6-8 seconds without pauses in compressions.

Hope this helps with the confusion. If you want the full guidelines with the rationales behind it all check it out on the American Heart Association website.

Congrats and all the best for your medic school etfink :thumbright:

Aussie

Yes, I am quite aware of the new 2005 ACLS guidelines.

The OP said "Per new protocols for unwitnessed arrest began continuous chest compressions 100 per min for 2 min while bagging every 5 sec."

I then questioned his/their method of ventilating a non-intubated patient with CPR in progress.

The OP then responded, "sorry I was not clear. Our medical direction is to ventilate via BVM if a second rescuer is available. You do not stop compressions."

He then responded that "We are involved in a prehospital study, so the protocols may seem a little weird."

The OP inferred that they are doing 100 compressions/min CONTINUOUSLY and ventilating every 5 secs with a second person available WITHOUT stopping compressions.

This is "unusual" for the reasons I stated and does not jive with 2005 ACLS standards (or others) because:

- you aren't doing 30:2 every 5 secs

- you are giving at minimum 12 vents per min

- you are ventilating a non-intubated with active CPR CONTINUOUSLY in progress which to me wouldn't be terribly effective (for the reasons I stated)

The OP stated he was in a study, which is cool. Just interested in what study is doing this, that's all. What he is saying doesn't seem to be a misunderstanding of 2005 ACLS as you say.

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Do you know what caused the arrest? I don't want to rain on your parade but I suspect alot of the ROSC has to do with why he coded to begin with, obviously.

Unsure exactly what caused the arrest. He converted eventually into a Sinus First Degree Block rhythm. Hx of stroke and high blood pressure.

Don't worry about raining on my parade. While the end result was that the patient converted was at least admitted alive, we have to be willing to examine our actions ex post facto. I'm starting medic school in Jan and if I can't listen to critisim or critique given with good intentions than I'm in the wrong field. I post here and read here to learn and maybe at some point share something that other may learn from.

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I would have to agree that bagging while doing compressions would not be effective and would at best cause alot of Gastric Distention. So that is kind of odd to me. A couple other things in this scene don't make sense to me, maybe someone can help me understand or you could clarify.

He was in V-Fib, You shocked him at 360J? Right off the bat? And that converted him to PEA, but he had pulses? You should have gone through the 200J, 300J, 360J on a Monophasic Defibrillator or the 120J, 150J, 200J on a Biphasic Defibrillator. Maybe clarify for me because on the last post you said he converted to a First Degree Heart Block, which also isn't PEA. Thanks.

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Good Job on the save though. Whatever you did worked. Sometimes you can get caught up in the critique and forget to commend on a job well done. Sorry that I forgot to do that. Anytime you have a save it is a good job, even if you weren't responsible for it. I'll take a save anyday.

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I would have to agree that bagging while doing compressions would not be effective and would at best cause alot of Gastric Distention. So that is kind of odd to me. A couple other things in this scene don't make sense to me, maybe someone can help me understand or you could clarify.

He was in V-Fib, You shocked him at 360J? Right off the bat? And that converted him to PEA, but he had pulses? You should have gone through the 200J, 300J, 360J on a Monophasic Defibrillator or the 120J, 150J, 200J on a Biphasic Defibrillator. Maybe clarify for me because on the last post you said he converted to a First Degree Heart Block, which also isn't PEA. Thanks.

All right here we go:

Our electrical therapy was in accordance with the 2005 AHA ECC guidelines. Stacked shocks are out. Check the AHA website you can download the new algorithms if you don't have access to them.

In my post I said that he converted into PEA with a first degree heart block. PEA- Pulseless Electrical Activity, you do not need to show a perfect sinus rhythm with out ectopy to be in PEA. Our pt showed a first degree heart block with no pulses. That is PEA. He had a good rate on the monitor so we tried a fluid challenge before epi. It worked, after a challenge we had radial pulses.

I think we were wrong to bag while doing compressions. I've talked to my partner and called our prehospital coodorinator. We should have done 200 compressions with no ventilations. Once the pt is intubated, you don't stop for cycles. That was our confusion.

This is a good discussion. We had a save which is great however if we made mistakes I would like to find them so that we can do better with our next pt.

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I would have to agree that bagging while doing compressions would not be effective and would at best cause alot of Gastric Distention. So that is kind of odd to me. A couple other things in this scene don't make sense to me, maybe someone can help me understand or you could clarify.

He was in V-Fib, You shocked him at 360J? Right off the bat? And that converted him to PEA, but he had pulses? You should have gone through the 200J, 300J, 360J on a Monophasic Defibrillator or the 120J, 150J, 200J on a Biphasic Defibrillator. Maybe clarify for me because on the last post you said he converted to a First Degree Heart Block, which also isn't PEA. Thanks.

New guidelines are 360J monophasic (200J biphasic) on all shock deliveries. AEDs are being reprogramed.

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