EMCrit 232 – SteelMan Debate – EMS Field Decisions in Cardiac Arrest with Howie Mell - a podcast by Scott D. Weingart, MD FCCM

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A few tweets sparked a debate (big surprise there) and suddenly there was a storm of opinions on whether OOH cardiac arrests should be transported or terminated in the field. Well, since I do not debate on twitter anymore, I needed a person to speak with on the topic--and there is no better than Howie Mell.



Howie Mell, MD, MPH, FACEP

Chair - ACEP Subcommittee on EMS Education

Reservist Emergency Physician - Vituity

Host of the So What 2.0 podcast

SMACCforcer

(@DrHowieMell)





Steel-Man Rules for this Debate



* Any time you want to contradict the other discussant, you must first restate the views they have just stated and confirm with them that you are understanding correctly. If you can bolster their point even more strongly before contradicting, this is even better.

* No ad-hominem attacks (i.e. attacks on the person, not their views. Feel free to politely destroy the views)

* Logical fallacies should be pointed out

* Try to state whether a viewpoint is based on evidence, and what quality or based on your clinical practice



Accepted as Given?



* We are dealing with Adults

* Asytole without signs of life should be run and terminated in the field

* There are EMS services and EDs where EMS does a better job running the arrest than the ED, in those venues EMS should run almost all codes to field termination

* There are some venues where nothing (nothing!) additional gets done in the ED beyond what EMS can do, in those venues EMS should run almost all codes to field termination



The Questions



* What is a public health view of EMS vs. a medical view?

* What is the best approach to <75 y/o vfib/vtach/PEA patient without end-stage comorbidity?

* Can we safely get these patients to the ED?



Cardiocerebral Resuscitation (CCR)



* Watch Ben Bobrow's vid

* Search for Pit Crew CPR to see amazing coordination and perfect, continuous hand cpr



Beam Me Up Scotty?

if we had teleporters…

Can We Safely Transport?

Take Out 1-2 Shocks from the Field Success Rates

and everything changes!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!

why is this cheaper?

Things I Can Do in the ED



* Ultrasound

* TEE

* Arterial Lines

* Esmolol

* DSD

* Multiple Antidysrhythmics for Electrical Storm

* Cath Lab

* ECMO

* Blood

* Pericardial Drainage

* Thrombolytics



 

3 Scenarios for when a Resus Center can make a difference

Vfib shocks to Sinus and then Regresses

these patients almost always have a coronary lesion and there is NOTHING the field management can offer these patients. Even if they don’t you don’t have the monitoring to keep these patients in sinus. multiple pressors/varied pressors

Electrical Storm

there is nothing the field is going to accomplish in these patients

PEA



* what you can fix—hypoxemia

* what you can’t accurately diagnose



* tension pneumo





* what you can’t



* bleeding

* pericardial tamponade

* PE

* SAH





* what you sort of can



* hyperk

* toxicology in most protocols







Please tell us what you think in the comments section below

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