Question: Hello, When a crew arrives on scene and finds a patient VSA, the ALS and BLS Standards require CPR per the HSFO guidelines at 30:2. When considering that there is strong evidence showing high quality CPR is the most important care to impact patient survival, my question revolves around what care or priorities should be considered when there are just the 2 paramedics on scene awaiting additional crews or resources.

The questions specifically are:

1) While Early defib, high-quality CPR and BVM ventilation's are a must, should an IV and medications be attempted with such limited resources? In attempting to do so, there is strong likelihood of compromising the quality of CPR because the compressor is doing about 2 compressions a second, and the 2nd medic is ventilating about every 15 seconds, thus making it next to impossible to perform any other tasks without diluting the CPR quality. This should the early defib, High-quality CPR and BVM ventilation's be the only focus until more resources show up, or should the IV and medication process be attempted to satisfy the requirements of the directive, even if doing so will compromise the CPR quality?

2) In regard to #1 above, when working in a rural setting, in which allied resources can sometimes take upwards of 20 minutes to arrive on scene, how does this play into the care?

3) As a given, I would love to be able to meet all the requirements of the ACP Cardiac arrest directive effectively, but with only 2 paramedics on scene the problem is there is just so much to do, and with quality of CPR and ventilation's/ETCO2 being able to be monitored and recorded, you can either violate the directive to maintain high-quality CPR, or risk having this data show your CPR quality was not great but got "everything done". Which is the preferred method of care?

4) While there is evidence supporting that CPR saves lives, is there any strong evidence supporting that the IV/Meds and the Advanced airways lead to better patient survival?

Thanks for your questions. Firstly, you should know that we recognize the fact that you can find yourself working in suboptimal environments with limited resources available to you, while at the same time are expected to meet certain performance metrics (particularly with cardiac arrest patients) that can be difficult to achieve given the working conditions.

That being said, this response is geared to attempt to answer all of your questions above, since the theme of all four questions is essentially the same. Also important to note is that every patient encounter provides its own unique and dynamic set of challenges, and that what might be appropriate and best management for one patient may not hold true for another.

The easiest answer to give is that at the end of the day, you have to do the best that you can with the resources available to you in the best interest of the patient. It is difficult to be very prescriptive and provide an exact step-by-step treatment plan for cardiac arrest since each situation is different, the resources available to you change, and the needs of the patient change. Our auditing team attempts to take all these factors into consideration and this is where optimal charting can be a valuable asset.

You are correct in identifying that high quality CPR is an evidenced based life-saving intervention you can provide for a patient (particularly true for those with shockable rhythms). There is, however, some evidence to support the administration of medications for cardiac arrest, as summarized by the American Heart Associations Guidelines on CPR and cardiac arrest (http://circ.ahajournals.org/content/132/18_suppl_2/S444) as well as summarized in a Webinar that was presented on June 9 2016. Generally, for non-shockable rhythms there is some evidence that early administration of epinephrine is associated with higher rates of ROSC, survival to hospital admission, and survival to discharge. For shockable rhythms administration of medications is withheld until after the 2nd defibrillation, to account for the survival advantages that high quality CPR and early defibrillation provide. Additionally, for those presenting in PEA who have a potentially treatable reversible cause (for example renal failure and hyperkalemia), then establishing vascular access and treating the hyperkalemia can be paramount for patient outcome.

If there is a concern regarding the amount of time that establishing an IV would take, and that doing so would detract from the provision of high quality CPR and early defibrillation, then dont forget that it takes only seconds to establish an IO, and that IO drug delivery has been shown to be comparable to that of IV drug delivery.

Again, we appreciate that there may only be two medics attending to a patient with very high resource needs, and that it can be difficult to achieve all of the points of treatment. When resources are limited, the expectation is that you attempt to provide both BLS and ALS care to the best of your ability as outlined in the medical directive.

Adult Intraosseous,Cardiac/Circulation,Intravenous and Fluid Therapy,Medical Cardiac Arrest,Pediatric Intraosseous

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