New ACLS????
- Thread starter Wildcard
- Start date
Please register or login
Welcome to ScubaBoard, the world's largest scuba diving community. Registration is not required to read the forums, but we encourage you to join. Joining has its benefits and enables you to participate in the discussions.
Benefits of registering include
- Ability to post and comment on topics and discussions.
- A Free photo gallery to share your dive photos with the world.
- You can make this box go away
- Messages
- 63,269
- Reaction score
- 16,548
the intubation issues for children, in the field, were definetly driven by litigation worries.
I agree with you. As an RN
As a mother of a child "football" they sometimes are called in the SoCal ER's, I can say that even when my baby stopped breathing, I had some concerns about the thrash his intubation became in the ambulance.
Ah...I remember the good old days when Emergency transport involved taking people from bad places (freeway carnage, arrests at home...etc) to a "better" place, a level one trauma center. Boy, did managed care change that picture!
The unchartered waters I encountered when, I had to suddenly take "pseudo-stabilized" people OUT of a trauma center equipped to save their lives in an operating room, across town to a hospital (usually in rush hour LA traffic) that the insurance companies had contracted with....well....that got ugly and ethicly questionable on the road. Our mission had changed. The lawyers and hospital administrators were constantly in our face, telling us how to do our jobs. I was Nursing Director for one of the largest OC ambulance companies. I got out...the liability and frustration became too much. I still miss leaving a profession I loved. I know many top gun trauma nurses who have left the job because of the silly beauracracy and insurance realities.
Off- topic.
I agree with you. As an RN
As a mother of a child "football" they sometimes are called in the SoCal ER's, I can say that even when my baby stopped breathing, I had some concerns about the thrash his intubation became in the ambulance.
Ah...I remember the good old days when Emergency transport involved taking people from bad places (freeway carnage, arrests at home...etc) to a "better" place, a level one trauma center. Boy, did managed care change that picture!
The unchartered waters I encountered when, I had to suddenly take "pseudo-stabilized" people OUT of a trauma center equipped to save their lives in an operating room, across town to a hospital (usually in rush hour LA traffic) that the insurance companies had contracted with....well....that got ugly and ethicly questionable on the road. Our mission had changed. The lawyers and hospital administrators were constantly in our face, telling us how to do our jobs. I was Nursing Director for one of the largest OC ambulance companies. I got out...the liability and frustration became too much. I still miss leaving a profession I loved. I know many top gun trauma nurses who have left the job because of the silly beauracracy and insurance realities.
Off- topic.
erparamedic
Vampire Girl......er Dork
Dive-aholic:
You are correct.... I was just stating the rationale that I was given by the Cardiologists in the ACLS recert class. I'm in the same boat with the rest of you.... I don't think that the new ACLS protocols are going to make any difference in improving the outcomes of a cardiac arrest patient.
Wildcard:
Not me. I get in a lot of trouble.
catherine96821:
That's why I won't take a core staff position anywhere. All I've done for the past 5+ years is agency/registry and travel nursing.
erparamedic:
I knew you were just repeating their words. Didn't figure you believed them too much either.
Just a few thoughts . . . First off, the statistics on codes are pretty awful. If I remember correctly, the only situation where you are REALLY likely to make it, and with a good neurologic outcome, is when the problem is an arrhythmia and you convert with the first sequence of shocks. After that, everything's pretty dismal. There is the rare person you bring back after ten or fifteen minutes of work, but few of those leave the hospital.
Second, research on codes is really hard to do. Animals don't have chest anatomy like ours, so studying CPR effectiveness can't really be done very well in a lab. Most of the studies consist of gathering retrospective data and looking at outcomes, and we all know how many variables go into each incident.
The fact is that somebody put the original protocols together mostly with an idea of what might work. Many of the medications we learned to use have subsequently been shown to be of limited, if any, efficacy (lidocaine comes to mind). And the big problem is that, because there is a huge, organized system for TEACHING us to do these marginally useful things, you have to take the classes, and you have to follow the protocols, because to do otherwise is against the "standard of care".
I have to admit, the longer I practice, the lower my threshhold has become for calling codes.
Second, research on codes is really hard to do. Animals don't have chest anatomy like ours, so studying CPR effectiveness can't really be done very well in a lab. Most of the studies consist of gathering retrospective data and looking at outcomes, and we all know how many variables go into each incident.
The fact is that somebody put the original protocols together mostly with an idea of what might work. Many of the medications we learned to use have subsequently been shown to be of limited, if any, efficacy (lidocaine comes to mind). And the big problem is that, because there is a huge, organized system for TEACHING us to do these marginally useful things, you have to take the classes, and you have to follow the protocols, because to do otherwise is against the "standard of care".
I have to admit, the longer I practice, the lower my threshhold has become for calling codes.
- Messages
- 3,138
- Reaction score
- 4
I don’t know how many lawyers were involved but…
… the new 2005 guideline changes from the AHA published in the Nov. 28 Rapid Access issue of Circulation is the most extensive evidence based review of CPR to date and represents the work of 6 task force committees composed of 281 international experts in resuscitation conducted over a 3 year period.
Experimental and clinical evidence was presented that shows major inadequacies in current CPR administered by professionals in both the pre-hospital and hospital setting. Long pauses in compression (especially during defibrillation), ineffective rate and depth and excessive hyperventilation all contribute to inadequate blood flow during CPR. Many of the changes recommended are aimed at improving this deficiency.
Also, new studies reviewing the use of AEDs suggest that in certain cases, establishing blood flow with CPR prior to defibrillation can improve defibrillation success and patient survival and that delay during rhythm analysis increases excessive “no-flow” time. Clinical studies suggest that patient outcome can be improved when 90 to 120 seconds of CPR is performed prior to defibrillation when the time between patient collapse and rescuer arrival exceeds 5 minutes.
The recommendation to no longer use “stacked shocks” is based on the observation that consecutive defibrillation attempts prolong the period of no blood flow. It had been previously noted that in the treatment of VF chest compressions were being delivered for less than half of the total resuscitation time. Again, the new guidelines seek to decrease the amount of time the patient is in this no-flow state by limiting the number of shocks. In addition to this, new technology has improved defibrillation success. Biphasic defibrillators have a 90% first shock efficacy.
The suggestion to resume CPR immediately after defibrillation without rhythm analysis or pulse checks is in response to the evidence that suggests that there is inadequate blood flow immediately after conversion to a “perfusing” rhythm. It is thought that the heart is temporarily "stunned" by defibrillation and that coronary blood flow is improved by continued chest compressions.
The 2005 AHA guidline changes are an attempt to streamline and simplifying the resuscitation and puts the focus on improved technique in an effort to maintain adequate blood flow and decrease the amount of no-flow time. Sounds kinda Hogarthian to me...
… the new 2005 guideline changes from the AHA published in the Nov. 28 Rapid Access issue of Circulation is the most extensive evidence based review of CPR to date and represents the work of 6 task force committees composed of 281 international experts in resuscitation conducted over a 3 year period.
Experimental and clinical evidence was presented that shows major inadequacies in current CPR administered by professionals in both the pre-hospital and hospital setting. Long pauses in compression (especially during defibrillation), ineffective rate and depth and excessive hyperventilation all contribute to inadequate blood flow during CPR. Many of the changes recommended are aimed at improving this deficiency.
Also, new studies reviewing the use of AEDs suggest that in certain cases, establishing blood flow with CPR prior to defibrillation can improve defibrillation success and patient survival and that delay during rhythm analysis increases excessive “no-flow” time. Clinical studies suggest that patient outcome can be improved when 90 to 120 seconds of CPR is performed prior to defibrillation when the time between patient collapse and rescuer arrival exceeds 5 minutes.
The recommendation to no longer use “stacked shocks” is based on the observation that consecutive defibrillation attempts prolong the period of no blood flow. It had been previously noted that in the treatment of VF chest compressions were being delivered for less than half of the total resuscitation time. Again, the new guidelines seek to decrease the amount of time the patient is in this no-flow state by limiting the number of shocks. In addition to this, new technology has improved defibrillation success. Biphasic defibrillators have a 90% first shock efficacy.
The suggestion to resume CPR immediately after defibrillation without rhythm analysis or pulse checks is in response to the evidence that suggests that there is inadequate blood flow immediately after conversion to a “perfusing” rhythm. It is thought that the heart is temporarily "stunned" by defibrillation and that coronary blood flow is improved by continued chest compressions.
The 2005 AHA guidline changes are an attempt to streamline and simplifying the resuscitation and puts the focus on improved technique in an effort to maintain adequate blood flow and decrease the amount of no-flow time. Sounds kinda Hogarthian to me...
erparamedic
Vampire Girl......er Dork
I just worked another code today. The patient was 90 something years old, with end stage liver cancer. Of course, she died. The family wanted her to be "worked" even though she had terrible, painful, and terminal disease process. It still never ceases to amaze me that family members want someone in that situation resuscitated. I guess, in this field, we tend to look at the whole picture and have a different "view" of death. It's not always a "bad" thing. In this case, the patient's body/soul was finally at "peace".
Stephen, I know that the changes are "evidence-based", but I still think we are desperately trying to refine a very blunt and ineffective instrument, and really good studies are hard to do. It is certainly true that it's easy to spend WAY too much time "holding CPR" to check pulses, and it's a good thought to keep a close eye on the total amount of time that perfusion is being supplied. And my guess is there is probably some fairly good data on the efficacy of stacked shock -- that's not that hard to do.
I guess, having seen the changes in protocols over time, and having read some of the literature about the relative lack of efficacy of many of our antiarrhythmics, and the poor outcome from the use of pressors, I had the outlook that rapid and effective shock and good CPR were the foundation of good resuscitation a long time ago, as well as the feeling that a long code is rarely, in the end, a success for much of anybody.
I guess, having seen the changes in protocols over time, and having read some of the literature about the relative lack of efficacy of many of our antiarrhythmics, and the poor outcome from the use of pressors, I had the outlook that rapid and effective shock and good CPR were the foundation of good resuscitation a long time ago, as well as the feeling that a long code is rarely, in the end, a success for much of anybody.
- Messages
- 63,269
- Reaction score
- 16,548
practice? I know what you mean....we would have inexperienced health care people get some experience those last ten minutes or so when there was not much at stake. The guy doing the third or fourth shock might be up to bat first next time...etc, etc.
Stephan Ash, thanks for that....makes sense. I had not heard it summarized that way, makes it a bit more palatable.
- Messages
- 3,138
- Reaction score
- 4
TSandM:
I certainly agree.
I was only trying to give some of the rational for the recommendations that came out of the 2005 conference. The evidence evaluation process of the ILCOR task force teams was probably the most thorough review of resuscitation to date. Simply put, this is the best we have right now.
...
Another reason for the recommendation to no longer do stacked shocks is that termination of VF most often is followed by a nonperfusing rhythm such as PEA or asystole. As we all know, the appropriate treatment for such rhythms is CPR. Yet, the rhythm analysis of a stacked shock sequence of most modern AEDS results in a 30 to 40 second delay in the resumption of compressions. This guideline change is based on the assumption that the patient is better served by resumption of CPR than "no-flow" delay inherent in the analysis a rhythm... a rhythm that most likely can not be treated successfully with defibrillation.
Similar threads
