This week we had one of our #ResusFridays organised by @kirstinEM , @drgarethroberts & Katie Jones in Virchester. This concept was inspired by our friends in Edinburgh who have run them for some time1 with the aim of improving the perfomance of the multiprofessional team. Since plagiarism is the most sincere form of flattery we’ve done the same.
This week we looked at cardiac arrest management with the belief that the emergency department should be exemplary in our management. We obviously covered the basics of cardiac arrest management but also looked at cardiac arrest management beyond ALS.
We use a flipped classroom model for our #ResusFridays and unsurprisingly we use #FOAMed resources to do this. Here is the flyer that we used this time with embedded links from @emcrit , @litfl, REBEL_EM and others.
Key learning points from the day:
- Use of checklists to aid decision making during an arrest. Even a simple recollection of 4 H’s and 4 T’s is tough when trying to keep track of everything that is happening during an arrest. No-one should be too proud to get out an algorithm or checklist to help in the resuscitation.
- We can split off the running of the ALS protocol from the overall situational assessment. This should be done on competence and not tribes. There is every reason why a competent nurse can run the resus whilst others search for a reversible cause.
- Life support is just that. Support for life whilst we search hard for a treatable cause.
- Ultrasound is your friend in finding treatable causes.
- Precharging the defib when coming up to rhythm checks saves LOADS of time (Ed – I’ve spoken to Nat and we need another post on how to do this).
- Dual axis defibrillation in refractory VF/VT2
- Esmolol for refractory VF3.
- When to give thrombolysis4 as part of the resuscitation5 and how long to go on for.
- ROSC priorities6.
- We didn’t talk about ECMO as Virchester is ECNO at the moment, so we aimed at what was possible here.
Dual axis defibrillation caused quite a bit of interest. It’s something we’ve done in clinical practice for those patients who are 6 + shocks and cycles into the VF/VT algorithm and for whom we are jsut not getting them out of VF. I’ll draw a distinction here between patients who we can shock out of VF/VT, but who subsequently go back into VF/VT; they are a different group with different requirements (then I’m thinking about other antidysrthmics). I’m thinking about patients whom when you defib it looks as though you are just not getting them out of VF/VT at all. It’s as if the defib is not working. What to do then?
It’s nicely explained in the video below from the lovely EMRAP team.
Dual-Axis defibrillation has been proposed as a method to improve the proportion of myocardium defibrillated. Scott Weingart talks about the need to defibrillate >95% of the myocardium in order to achieve successful defibrillation, and if we don’t achieve that it will fail. So if we are not getting success maybe it’s because we are not defibrillating all the myocardium. We could increase the energy levels and I suppose there is some logic in this, particularly if our patients are ‘insulated’ (Ed – you know what we mean – aka urban padding), but it may be that we are just not getting flow through the whole heart. That’s where the idea of dual axis defibrillation comes from.
At this point it’s worth pointing out that this is an evidence light zone. There are no RCTs here, just case reports, but there are some pathophysiological arguments to support it (but we recommend you retain a healthy degree of scepticism whenever we lack real world patient data
Dual axis defibrillation uses two defibs at the same time to try and maximally defibrillate the heart. Typically one in the traditional antero-lateral configuration and one in the antero-posterior configuration. You basically charge them at the same time and then discharge them at the same time.
We practiced how to get the Posterior and Anterior pads on as quickly as possible whilst minimising disruption to CPR. For manual CPR that’s fairly easy, but if you’re using mech-CPR it may be a little more tricky (I’ve not tried).
Realistically they will not be perfectly timed, but the idea is that they are discharged as close as possible to each other.
So what about the evidence?
Well it’s scanty. It has certainly worked for me in a very limited number of cases, but sadly not with patient survival so you could argue that we’ve not achieved what @dralangrayson calls a Patient Orientated Outcome (POO). There are case reports in the literature7,8,9,1011,12 , but we should remain sceptical as this is not high quality evidence, though it may well be the best available at the moment. We should also be slightly cautious about adopting something that looks rather spectacular and a bit cool in the resus room. There is something about charging and discharging two defibs at the same time that feels like a scene from a sci-fi movie and we must be cautious about doing anything just because it looks great and feels as though we are doing ‘something’ rather than nothing.
On the other hand our current practice is to be trapped in the VF/VT algorithm until it degenerates into asystole and we know where that ends. Thus an alternative view is that our patients have little to lose. Will I be using it routinely? Probably not, but it’s yet another tool to put in the resuscitationist’s tool box for when you’ve reached the end of standard protocols. As ever, please let me know what you think?
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