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Cardiac Procedures in the Resuscitated Comatose Patient

With some of the latest literature, the recommendation has been to transfer patients with STEMI post resuscitation if they are responsive. This latest article from the Journal of the American College of Cardiology just published this gem that talks about what we do if they are still comatose!

This algorithm starts pre-hospitally. Return of circulation occurs and we transport to the nearest hospital. Within 10 minutes, the physician is to have a 12-lead ECG done and initiate mild therapeutic hypothermia (like the studies suggest, avoiding fever is the goal).

So, now we see the massive STEMI. As the previous literature suggests, we push these guys for emergent angiography and PCI should the patient not have unfavourable conditions. Nothing changes here.

What about those patients  that the physician finds that is non-STEMI?

They introduce the “ACT” abbreviation. Essentially, Assess for unfavourable resuscitation features. Consult with cardiology and intensive care.  Transport to cath lab once the decision has been made for angiography.

What is an unfavourable feature you might ask? Well, they include the following:

  • Unwitnessed arrest
  • Initial rhythm: Non-VF
  • No bystander CPR
  • >30 min to ROSC
  • Ongoing CPR
  • pH <7.2
  • Lactate >7
  • Age >85
  • End stage renal disease
  • Noncardiac causes (e.g.,traumatic arrest)

(Rab et al. 2015, p. 64)

With multiple unfavourable features, the patient should be considered for individualised care. Those who are deemed suitable should be sent for early angiogram and PCI.

We may start to see this coming into play within your local ED. What are your local policies and procedures involving this?

As practitioners, remember the value of your history. We can relay important information, such as down time, bystander CPR, initial rhythm and so on.

“Successfully resuscitated comatose patients represent a heterogeneous population with a baseline survival rate of only 25%. With hypothermia and PCI, survival improves to 60%, with favorable neurological outcomes achieved in 86% of survivors” (Rab et al. 2015, p. 63)

Rab, T., Kern, K., Tamis-Holland, J., Henry, T., McDaniel, M., & Dickert, N. et al. (2015). Cardiac Arrest. Journal Of The American College Of Cardiology, 66(1), 62-73. doi:10.1016/j.jacc.2015.05.009

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Should we be cooling kids?

Post arrest hypothermia study says no!

The debate has been happening for a while now! Do we actively cool or not? Well, many guidelines have us pushing our patients for that deep hypothermia to below 33 degrees. Nielson in 2013, found that patient outcomes did not change with the maintaining normothermia when compaired to hypothermia.

So fever is bad, and we ultimately need to avoid it.

While the debate continues with adults, there has been little evidence with pediatrics surrounding this.

Until now!

In an article published in the New England Journal of Medicine, Moler et al (2015) find that “in comatose children who survived out-of-hospital cardiac arrest, therapeutic hypothermia, as compared with therapeutic normothermia, did not confer a significant benefit in survival with a good functional outcome at 1 year”.

Here is a link to the abstract

This study showed there was a difference, however not significant. Perhaps a larger study would be required. Let me know your thoughts in the comment section!

References

Moler, Frank W. et al. ‘Therapeutic Hypothermia After Out-Of-Hospital Cardiac Arrest In Children’.New England Journal of Medicine 372.20 (2015): 1898-1908. Web. 17 June 201

Nielsen et al. Targeted Temperature Management at 33°C versus 36°C after Cardiac Arrest NEJM 2013;epub Nov 17, 2013

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Alberta Paramedic Association

I know what you are thinking! This site hasn’t had as many updates as I would like. The reason for this is due to my commitment to completing my EMT-P/ACP certification. Further to this I have been assisting with the set up of the Alberta Paramedic Association’s new website.

I am proud to say, that after much work, it is now released! With that, the General Membership has opened up to the public.

Check it out! These guys have their heads on straight (all starting with their low membership cost of $69.99!

I just added a new listing in the must have link list. I really need to refresh it, but if you haven’t checked it out yet, one of my good friends Roger the Rogie Tewson has reopened his blog. He shares his experiences with EMS and everything that effects us.

Rogie The Medic: http://rogiethemedic.dinstudio.com/

Meanwhile, take a look at the APA’s new website

 

 

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2014 AHA NSTEMI update

Another round of guidelines are now on the table. For practitioners across Canada this may lead to a possible change in practice. Fortunately it seems, that the changes will not be drastic.

Some interesting things to note:

  • In the absence of contraindications, it may be reasonable to administer morphine sulfate intravenously to patients with NSTE-ACS if there is continued ischemic chest pain despite treatment with maximally tolerated anti-ischemic medications (Class IIb LOE B)
  • Measure serial cardiac troponin I or T at presentation and 3-6 hours after symptom onset in all patients with ACS symptoms. Additional troponin levels should be obtained beyond 6 hours in patients with normal troponin levels on serial examination when ECG changes clinical presentation confer an intermediate or high suspicion for ACS. (Class I LOE A)
  • If the time of symptom onset is ambiguous, the time of presentation should be considered the time of onset for assessing troponin values (Class I LOE A).
    • Further reinforcing the need for a good history while on scene.
  • With contemporary troponin assays, CK-MB and myoglobin are not useful for diagnosis of ACS. (Class III LOE A)
  • A 12-lead ECG should be performed and interpreted within 10 minutes of the patient’s arrival at an emergency facility to assess for cardiac ischemia or injury
    • This protocol used to indicate an experienced physician to interpret the ECG. However that has been removed. This further reinforces the need for all practitioners to know their ECG’s!

Reference: Amsterdam A, et al. 2014 AHA/ACC Guideline for the Management of Patients With Non-ST-Elevation Acute Coronary Syndromes Circulation, epub September 23, 2014.

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Sprinters vs Marathoners – Basics of how muscles work

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