Digest

This episode delves into a complex EMS case where a patient presenting with chest pain rapidly deteriorates into cardiac arrest. The discussion covers the initial BLS response, advanced interventions like synchronized cardioversion, and the critical event of conversion to VF arrest following an unsynchronized shock. Experts analyze the challenges of sedation prior to cardioversion, the importance of scene management and delegation, and the potential for equipment malfunction. The conversation also explores system-level problems, including cognitive overload, the benefits of a just and coaching culture, and the nuances of airway management and advanced treatments like epinephrine drips. The case ultimately resolves with a return of spontaneous circulation during transport, underscoring the critical thinking and rapid decision-making required in pre-hospital care.

Outlines

00:00:00

Introduction, Conference Promotion, and Podcast Overview

The episode begins with a welcome and introduction of Dr. Mike Lauria. Hosts Chris and Spencer, experienced paramedics, discuss the upcoming Fast 26 conference in Austin, Texas, co-located with EMS World, and promote the EMS 2020 continuing education platform where listeners can earn CE credits.

00:07:03

Case Presentation: Chest Pain to Cardiac Arrest and Initial Assessment

A BLS fire crew is dispatched to a non-emergent medical aid for chest pain, which quickly escalates to cardiac arrest. Upon arrival, the patient is conscious but in severe respiratory distress and hypotensive, with SVT at 232 bpm on the monitor. The initial plan is to sedate and cardiovert.

00:20:13

Sedation, Cardioversion Challenges, and VF Arrest

Concerns are raised about administering Versed and Fentanyl together to a hypotensive patient. After an initial synchronized cardioversion proves ineffective and painful, a second shock, potentially unsynchronized, converts the patient to VF arrest. The R-on-T phenomenon is discussed as a potential cause.

00:34:07

Resuscitation Efforts, Airway Management, and Advanced Interventions

CPR is initiated, and the patient is defibrillated. An i-gel is placed, and end-tidal CO2 is confirmed. The crew begins ventilations, and the discussion touches on advanced interventions like epinephrine drips and lidocaine, with the patient's scene time being approximately 15-20 minutes.

00:49:04

Return of Spontaneous Circulation and Hospital Arrival

During transport, the patient experiences a return of spontaneous circulation after another lidocaine push and defibrillation, converting to a sinus rhythm. Upon arrival at the cardiac center, the patient is conscious and able to provide history, though ED doctors question pre-hospital sedation.

00:54:25

System Problems: Equipment, Delegation, and Cognitive Overload

Potential system issues are identified, including monitor functionality and a critical lack of delegation and scene management, leading to cognitive overload for the primary medic. The absence of a designated Person In Charge (PIC) is highlighted as a significant problem.

00:59:49

Expert Perspectives on Field Interventions and Culture

Dr. Lauria advises caution with sedation before cardioversion in emergent settings. The discussion emphasizes the importance of a coaching and just culture in EMS, promoting polite corrections and understanding the reasoning behind decisions.

01:21:09

Decision-Making: PIC, Cardioversion, and Bias Against Intervention

The importance of establishing a PIC is reiterated. The decision-making process for cardioversion, including when to proceed without a 12-lead ECG for unstable patients, is explored. The conversation delves into common "errors of omission" and biases that hinder intervention.

01:26:07

Managing Family Expectations and Advanced Treatment Protocols

This section highlights the importance of communication with families during procedures and discusses the experimental "Lighthouse Project" exploring epinephrine drips versus boluses, noting the lack of definitive data on epinephrine's effectiveness.

01:30:45

Epinephrine Use, Study Data, and ECMO Candidacy

The use of epinephrine in cardiac arrest is examined, including the paramedic-to-trial study and the challenges of identifying ECMO candidates by defining downtime accurately.

01:37:59

Airway Management Debates and Pre-hospital Extubation

A debate on I-gel versus OPA airway management is presented, considering when to remove an advanced airway. The controversial topic of purposeful pre-hospital extubation is also raised.

01:43:47

Historical Techniques and Patient Follow-up

The discussion revisits the pre-cordial thump, a technique now rarely seen, and provides a brief patient follow-up indicating discharge from the hospital.

Keywords

Q&A

• What is the Fast 26 conference and why is it being promoted?

  Fast 26 is an upcoming conference in Austin, Texas, co-located with EMS World. It's being promoted to encourage attendance, offering professionals a platform for learning and networking in the emergency medical services field.

• What are the potential risks of administering Versed and Fentanyl together to an unstable patient?

  Administering Versed and Fentanyl simultaneously to an unstable, hypotensive patient can lead to unpredictable respiratory depression and hemodynamic instability. It's generally advised to use single agents cautiously or avoid combining them in such critical situations.

• What is the R-on-T phenomenon and how does it relate to the case?

  The R-on-T phenomenon occurs when a premature ventricular contraction falls on the T wave, potentially triggering ventricular fibrillation. In this case, an unsynchronized shock during cardioversion may have induced this phenomenon, leading to VF arrest.

• Why is having a designated Person In Charge (PIC) important in emergency medical responses?

  A PIC ensures clear leadership, effective communication, and task delegation during complex emergencies. This prevents cognitive overload, improves scene management, and allows for better decision-making, especially in multi-agency scenarios.

• What are the benefits of a "Just Culture" and "Coaching Culture" in EMS?

  A Just Culture encourages reporting errors for learning without fear of blame, while a Coaching Culture focuses on development through feedback. Together, they improve clinical outcomes, employee retention, and overall system safety by fostering open communication and continuous improvement.

• When is it appropriate to proceed with cardioversion without a 12-lead ECG?

  For unstable patients with a low mean arterial pressure (MAP), cardioversion is often the correct immediate action. While a 12-lead ECG is ideal, the patient's instability may necessitate immediate intervention to restore a stable rhythm.

• What are the common biases that prevent medical professionals from intervening in critical situations?

  Common biases include "errors of omission," where clinicians hesitate to act due to fear of repercussions, the invasive nature of procedures, or a culture that questions interventions rather than supporting them.

• What is the current understanding of epinephrine's effectiveness in cardiac arrest?

  There is limited strong data supporting epinephrine's effectiveness in improving neurological outcomes in cardiac arrest. Some studies suggest it may even worsen outcomes, while others show more patients discharged, raising questions about the quality of survival.

• What are the considerations when deciding between an I-gel and an OPA for airway management?

  The decision depends on the patient's condition. If an I-gel is causing snoring or is ineffective, and the patient shows signs of waking or improving, removing it for an OPA might be considered. However, if the patient remains apneic, more aggressive airway management is needed.

• Why has the pre-cordial thump fallen out of favor?

  The pre-cordial thump was once included in protocols but is now rarely used or seen in current guidelines. While it was intended to convert certain arrhythmias, its effectiveness and indications have diminished over time.

Show Notes