Question: You have a patient who you obtain ROSC and return of spontaneous respiration on scene who was in a VF (post rosc 12lead shows STEMI). They arrest on route into a VF, we pull over, defibrillate. You resume transport and reassess after each cycle of CPR. If you obtain ROSC again during transport, and the patient rearrests for a second time, is it prudent to pause transport quickly again for defibrillation. The treatment for VF is defibrillation. If there is still prolonged transport the pt will likely deteriorate to asystole if not defibrillated, correct? I appreciate we do not want to delay definitive care, would it be helpful or harmful to continue defibrillation in this setting.

 You are right that you are stuck between a rock and a hard place:  Knowing that definitive treatment for a STEMI is to relieve the coronary obstruction and that without defibrillation, they will deteriorate, as you state.  In this tough scenario, and according to the ALS-PCS companion document:

In the event a ROSC is achieved and the patient re-arrests en route, Paramedics will adhere to the following sequence:

1. Pull over
2. Initiate one immediate rhythm interpretation
3. Defibrillate as appropriate (1 shock max) AND
4. Continue with transportation to the receiving facility.

If in the opinion of the Paramedic(s) the patient would benefit from further analysis/defibrillation, a patch with a BHP would be indicated for direction.

References:

Auble TE, Menegazzi JJ, Paris PM. Effect of out-of-hospital defibrillation by basic life support providers on cardiac arrest mortality: a meta-analysis. Ann Emerg Med 1995 May;25(5):642-64

Berg et al. Precountershock Cardiopulmonary Resuscitation Improves Ventricular Fibrillation Median Frequency and Myocardial Readiness for Successful Defibrillation from Prolonged VentricularFibrillation:A ...Annals of Emerg Med.2002;40(6):563-570

Cheskes S, Schmicker RH, Verbeek PR et al. The impact of peri-shock pause on survival from out-of-hospital shockable cardiac arrest during the Resuscitation Outcomes Consortium PRIMED trial.  Resuscitation 2014 Mar;85(3):336-42

Kensch M, Stendell M, Berkell et al. Early prediction of prognosis in out-of-hospital cardiac arrest.  Intensive Care Med. 1990 Sep;16(6):378-383

Nolan JP, Soar J (2009). Defibrillation in clinical practice. Curr Opinion Crit Care 15; 1070

Roth R, Stewart RD, Rogers K et al. Out-of-hospital cardiac arrest: factors associated with survival.  Ann Emerg Med 1984 13:237-243

Uncategorized

Return of Spontaneous Circulation (ROSC), ST Segment Elevation Myocardial Infarction (STEMI)

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