Everyone is still abuzz about the 2010 American Heart Association Guidelines release at this year's Emergency Cardiovascular Care Update (ECCU) conference in San Diego, Calif. Thus far, we've celebrated cardiac arrest survivors, awarded three pioneers of external cardiac massage and of course, discussed the hottest cardiovascular topics.
So what are those topics?
One of the most interesting sessions I had the privilege of attending was the Eagles'—an impressive group of medical directors from some of the nation's biggest cities. Or as Eagle Paul E. Pepe, MD, MPH, jokingly refers to the group, "the FDMs," or final decision makers.
One question they posed is, "What happens if you've done everything on the list and your patient is still in VF?"
Well, if you read the July JEMS, you may already know the answer: double sequential external defibrillation (DSED). This what Wake County (N.C.) EMS Medical Director Brent Myers, MD, is trying with patients who have persistent ventricular fibrillation (v-fib) rhythms.
Myers began trying the idea of hooking up a patient to two boxes when his EMS providers had already run the gamut of their ACLS care and had patients still in v-fib. He says that now, after the fifth shock, the providers take a peak to check the rhythm to see if it broke or if they have a pulse.
Myers can report that 66 of 99 patients cardioverted with the DSED method, but they currently hadn't had any neurologically intact survivors. But in New Orleans, they're trying the same method after the fourth shock, and they have two neurologically intact survivors. Although Myers was careful to say they don’t have much data to share and that this approach may not be right for everyone, we're certainly excited to see what happens next.
Acutely Agitated Patients
What do you use? Droperidol? Midazolam? Haloperidol? Well, Denver uses Droperidol, and they're not afraid to tell you why.
Despite the FDA's "black box" warning in 2001, Christopher Colwell, MD, of the Denver Paramedic Division and Denver Fire Department, couldn't ignore the drug's positive effects for acutely agitated patients in Denver. He surveyed the Eagles about which drug they use. Twenty six of 34 cities use Midazolam, but in all the research Colwell did, he didn't find enough evidence to rule out Droperidol. So he gave it a try.
In January 2009, they used the drug 779 times, 50% of the time for alcoholic related agitation, 25% of the time for psychiatric-related agitation and 25% of the time for an undifferentiated group. Out of all the cases, there were no torsades de pointes instances and only one complication.
Each patient received a 12-lead ECG, and all cases were followed through to the emergency department and discharge. Denver found that Droperidol patients had better sedation (2 point higher). This drug might not be right for your system, but maybe it's time to take a closer look.
Better Training, Better CPR
Pete Walka, NREMT-P, the battalion chief of Guardian Medical Transport in Flagstaff, Ariz., knows the importance of quality CPR training because he's seen its' affect firsthand.
Walka approaches CPR training like a Nascar pit crew: Every provider has a designated task. And teams meet to debrief after every code. How long were the pauses between compressions? How deep were the compressions? These are questions every provider has to answer, and it's created an environment where everyone is accountable.
Mark Venuti, NREMT-P, director of Guardian Medical Transport, reported that since their new training, every measurable area of CPR quality has improved. And survival to discharge from V-fib has increased almost 30%.
Ben Bobrow, MD, medical director for the Bureau of EMS & Trauma System Arizona Department of Health Services, says it's all about changing the mindset of their EMS providers.
"VF is a survivable rhythm, and we should save those patients," he says. And it seems the new mindset is working.
The ECCU conference concludes Saturday, Dec. 11, 2010. Check back on JEMS Connect for more exclusive coverage from the JEMS team.