Transcript
It's a pleasure to have.
Steve Hilton here this morning on the second on the 3rd session we have.
Steve, then we'll go ahead and get you started up.
Hope you're doing good this morning.
Good morning.
Great.
Same here.
Glad to have you here.
It's a great I know you're you get a great topic coming in on ACLS.
So let me I'm gonna give you the the lead on this, the screen share, and make you the host.
There we go.
And you can go ahead and pull your PowerPoint up or presentation up, get it up on screen, and we'll get started here.
Everybody can see that.
Everybody if you can give a quick thumbs up, So if you're hearing Steve seems to do a test on this real quick.
Sure.
Good morning, everyone.
Good.
Everyone get me okay.
I'm seeing thumbs.
Hi, Doctor Heath.
Good good
morning, sir.
Got a good thumbs up here.
Good.
So everybody's we're hearing and everything we're good to go.
Nice.
Alright.
Great.
So so I'm a do a quick introduction.
Does everybody remember we'll go in we'll start this session We'll fit a 45 minute session with Steve, and then we come back in our last session.
We'll run into that one.
And at 11:30 CST, 12:30 EST, and we'll get started.
So it's a pleasure to have Steve Hilton here this morning with us on the Sports And Merchandise Care symposium, and the topic today is Advance Cardiac Life Support A little bit of background about Mister Hilton.
He is a firefighter engineer, also paramedic for the city of Cambridge, Ohio.
Since 2003.
He's a former EMS instructor and currently serves as EMS coordinator for his department.
He is an American Heart Association of Basic Life Support ACLS and p PALS instructor.
He also serves a tactical medic with the Cambridge Police Department SWAT team since 2011.
And he also he is he owns or operates a small training company providing CPR AED and 1st aid training for business industry since 2010.
And with that, Steve, great to have you here this morning.
I know I enjoyed talking with you, you know, with spoken periodically, but, you know, talking last week about your background experience and This is an area that I know that you have a tremendous amount of experience in and look forward to sharing your passion about it.
And as as we are too, and I'm just excited to have you here to give an overview of ACLS and really about what the importance is of the the for any provider before ACLS arrives is at the importance of what they do in the first couple of minutes.
To assist in in the survivability and and things that even doctor Heath and doctor man, and Doctor Slade had talked about this earlier, and I'm a I'm a give it overview.
So thanks again for being here, and the floor is all yours.
Well, I appreciate it.
Yeah.
Feel free to interject throughout.
That might help me out as well.
This is my first tough big webinar event, I guess.
So I I've I've been been involved in several before, but not as an instructor.
So I appreciate the opportunity and and your confidence in me.
You guys just to touch on some couple things real quick.
As I got caught the tail end of the of the last presentation, was the dual sequential defibrillation.
And that's something that I I I attended an AJ webinar on a long ago, and essentially, it was a cardiologist who had been having success with that in a cath lab setting.
And it was specifically for patients that were refractory V fib, meaning they had been shocked three times without success.
So then they were moving to this dual sequential defibrillation.
And in the absence of having a second monitor, they were doing something called a vector chain, which is essentially moving the position of the pads so that they could maybe capture the heart at a different angle as Doctor Heath was speaking up and and have success that way.
So I've never done that in the field, but it is an interesting topic, and I don't know if it's ever gonna come out as a guideline or not, but definitely is something to consider.
The other thing we're talking about, AEDs, for years, I've thought, we can do so much with technology and they were talking about AEDs being able to cardiovert.
I thought, wouldn't it be nice if we could have an app on our phone that could detect ventricular fibrillation and shock it.
And what would that look like?
So some guys here at work, we were discussing about, well, how would the phone have enough battery to do that?
And what would that be like in somebody suggested, well, how about we put the batteries and the pads?
So you can buy the pads that plug into the port on your phone, and then you could shock someone with your cell phone.
And so I got to look in, and I believe that someone already has the patents on that.
So maybe in the near future, the next 5 or 10 years, you'll see a cell phone defibrillator.
And I apologize if you can hear our tones going off because I'm at work today.
Alright.
So here's my disclosure statement.
Everybody can see my little meme down there.
I kinda found that, and I thought it was funny.
Because I really don't know what athletic trainers do either.
I know you guys dress really nice, and you always look look really nice.
But, young man, I don't know exactly what all you do or what you're keeping abilities are.
So I'm kinda learning as I go here.
So I just don't have any conflicts adventures through disclosures to to report to you guys.
So
Alright.
So
some of our objectives today, look at the different cardiac rhythms, kinda figure out what those are.
And unless you have a monitor, you're not gonna know what they are unless you have a one that you can see the screen on.
I know some AEDs will have a monitor window on them, a screen that you can see what the actual rhythm is.
So that may be an option for you as well.
Discuss the appropriate assessment, management, cardiac arrest for different age groups.
Identify assessment and management techniques for post cardiac arrest care.
And I'll tell you, that's not something I have a lot of experience in because once we get on back, we drop off the doctor Heath, and then they take care of him.
So so but we will touch on that, kinda see how all this ties together.
And what you do before they get to the hospital makes all the differences into their recovery.
So and then make decisions regarding cardiac arrest scenario, what that's gonna look like for us.
So first of all, we have v fit, most common rhythm than cardiac arrest.
Starts in the ventricles as the name applies.
It's that fluttering action, which I'm gonna play the little video down there and let you guys kinda see what that looks like if you've never seen it that way.
Early defibrillation is 100% the key This is what is going to make or break us essentially.
So high quality CPR, we know, has shown to sustain that ventricular fibrillation for a period of time, not indefinitely, but for a period of time.
Something that you might see in an initial stages of a cardiac arrest to see here like activity.
Early on in my career, we used to get called all the time.
For someone having a seizure, and we would get there and that patient will be in complete arrest.
And I could never figure out for the life of me I was like, why are they calling this as in as a seizure when I get there?
And clearly, the person is is dead, right, during cardiac arrest.
Fast forward a few years.
I'm on a call with a guy having chest pain, shortness of breath.
He's got all the symptoms.
Right?
It's about 5 o'clock in the morning.
The guy's only, like, thirty nine years old.
So I'm not believing that he's having heart attack.
This was pre 12 lead days.
So I hadn't hooked up to the monitor, have to be in place.
I've given him aspirin at Nitro and all those things.
He's on oxygen.
And as I'm on the radio actually talking to the emergency room, if the guy reaches up to me buddy, I don't feel good.
And as he does that, he stiffens up on the cot, how's what appears to be a grandma seizure and goes into cardiac arrest.
And he literally went into V fib when you see her on the screen.
So I shocked the guy one time, and he immediately woke up.
And his response to me was, so that's what it feels like to have a heart attack.
And my response back to him was because I was so shocked.
I said, so that's what it's I said, so you were dead, like, 30 seconds ago.
So It was it was interesting.
And so right then, from that moment on, you know, I kinda I knew that this works.
So let me play this if I hit this thing to play it out here for you guys.
Oops.
There we go.
So as you can see there, the ventricles are quirk.
Got your age you're contracting, but the ventricles are doing that quivering motion.
And I know that that's not a great video, but that's kind of the best one I can find.
So did you guys Doctor.
Castle, do you guys discuss Agonal respirations in your in the previous presentations?
There's been some brief discussions about it, but definitely go ahead and review go ahead and throw into that that or or add and, you know, to expand on that a little bit.
What that would look like, especially in in the context of cardiac events.
Right.
So and and for someone, if you don't have a lot of experience doing this, I always tell when I teach We talk about this.
And AHA actually shows a video of a guy who's lying on the floor and he has these gasping type respirations.
Because normal respirations are are effortless.
Right?
We don't even realize that we're breathing.
Someone who has agonal gasping respirations though, it'll be that big gas If you were to count, he's probably, you know, maybe agree to it four times a minute, something like that.
But you couple that with skin color and level of consciousness, and I repeat that all the time when I teach, because a lot of times I'm teaching late rescue, somebody's never seen me on a cardiac arrest before.
And I say, when you use a couple skin color, if they're blue, cyanotic, pale, or gray, and they're unresponsive and not breathing or have these gasping respirations, that person needs CPR.
Every person I've ever had with Agamental or gasket respirations.
They've all been in cardiac arrest.
They've all needed CPR, and they've all needed to fibrillated.
And what that tells me is that's a very early sign at an arrest.
Right?
So this guy's been down a minute or 2.
This is certainly someone that we can we can save.
So just keep that in mind going forward.
Again, it's about skin color.
The video that AJ shows, the guy is unresponsive, but this color is really good because even a live guy pretend for the camera that he's in in cardiac arrest.
So just keep that in mind.
Logistics and benchmarks.
And there's a lot going on this slide, and I will just kinda walk through it here.
But This is probably the most important part when it comes to to ACLS, in my opinion.
NBLS and all of this is reaching these benchmarks and you you know, managing the logistics of the code so that we can do that effectively.
Right?
So early high quality CPR coronergic perfusion pressure.
That's what we're trying to build up as we as we start compressions.
And this little box over here is basically This is our compressions, and I don't know if you could see that because I've got videos on my screen here.
But over here, the compressions drop off because we've stopped.
It could get rest.
That same thing may happen if we stop to defibrillate.
It may happen if we stop to intubate.
It may stop to happen if we start to stop to start an IV.
Or call for help or get equipment or move the victim.
So but what we have to realize is every time that perfusion pressure drops, that reduces our chest compression fraction, which is the next thing on the list there.
American Heart Association says they want at least 60%, preferably 80% in order for to have survivability of your victim.
Meaning, say in a 10 minute code, we wanna be on the chest at least 8 minutes out of that 10 minute total time.
Now in hospital setting, that's certainly achievable, because everything's right there.
We're not moving the victim.
There's no stairs, there's no weather, there's no other stains that that come into play and then out of possible rest.
So for chest compression fraction, The only way that we can achieve that is what Mister Shleben spoke of earlier is that we don't move the victim until we've got everything done for the most part.
Now if we can achieve all these benchmarks in a 10 minute window or so, if I've got an ID in place and all these things are gonna talk about here, I've got good high quality CPR.
I've got a breathing tube in place.
I've got waveform capography.
I've got drugs in place.
I've got fluids on board.
If I can do all that, in a window in the residence.
Well, then we'll move on.
But we need to establish all of these things before we do that because really their best chance of survival is gonna be that 10 minute window.
Early defibrillation, you're gonna hear that all day.
You've probably heard it all day already.
Early defibrillation is is the key.
Early IV or IO placement.
A lot of our guys in the field, prehospitality, they like to start IOs right away.
But in our protocol and AHA's guidelines, still the preferred method for an IV is a peripheral IV and not an IO.
And it's about delivery of medications to the heart and the time it takes to do that.
So We still work for peripheral IVs, but I o's, and you could see here if this is our I o drill.
If you're not familiar with that, it's got a few different size and heels.
It is really easy to use.
The most people like to use the tibial plateau for their IO placement down just below the knee.
But the preferred site if you're gonna do an IO is actually at humeral head.
That's the preferred site and, again, it's about the degree of the drug to to the heart.
So advanced airway with capnography.
Capnography is kind of a
a a a
a thing that's been around for for 10 years or so, but in the state of Ohio, if we put an advanced airway in anyone, we have to attach capnography.
And capnography can do a few things.
It's kind of an indirect number or indication of our cardiac output, and that cardiac output is an indication, a direct indication of the high quality CPR that we're giving.
So if your capnography numbers are low, that may tell us a couple of things.
It may tell us that the tube is just launched or that our CPR needs to be improved, and we're not doing really good.
High quality compressions.
And you'll hear that as well throughout this as high quality compressions that can't be overstable.
Planning ones and logistics when we're moving the patient.
A lot of our victims are upstairs.
They could be I mean, we've had cardiac arrest on rooftops.
I mean, you you name it.
People die in the strangest places.
So And even if you're at for for your for your case, if you're at a sporting event and they're up in the stands, what does that gonna look like?
Trying to get that person down in the stairs and And I would give you an example many years ago early on in my career.
I was working a code and a and a residence, and they the the victim was in a back room of of a house.
Right?
Down the hallway.
And the hallway was narrow.
I didn't really pay attention to how narrow it was.
We go back there.
We're working the guy.
We get him onto a back.
Board.
And when we go to leave the room with him to get him down the hall, the backboard wouldn't make the turn because it was so narrow.
So I couldn't get him out of the room on the board.
The family is in the living room watching this whole p s.
Go go on.
And so we had to take him back into the bedroom, take him off the board, physically drag him down the hallway and then put it back on the board literally to do all that.
And I swore that time that would never happen to be again.
So looking ahead, planning and logistics, having someone figured out, how we what's the best way to do that?
Right?
So and, again, that's another reason why we don't necessarily get in a hurry to move anyone got all our things in place.
So the mechanical CPR devices.
A lot of people have those, and and I think they have their place for sure.
They're especially good for if we have to move them up or down move the victim up or down a set of stairs.
Anytime that we can't perform high quality CPR, if we have one losing place, that's a benefit to the patient.
However, they do have their their limitations.
The person that's putting it on has to be versed in how that's gonna go on quickly we can do that.
And that takes practice.
You can't show up the first day with the device and then try and bubble through that because that's off the chest time.
That we have when we're trying to attach that thing.
So you really want someone who's trained on the device.
If you get 1, definitely wanna train on it regularly because that'll become an issue.
The other thing is is even though it says it's for anyone over the age of twelve, I believe, or most of the the manufacturer recommendation, it doesn't always is the case.
I know last year I had a a cardiac arrest and a fourteen year old boy who was he was actually a cross country runner at up by a tree during an event.
Yeah.
Crazy crazy thing that happened.
And I got there, and, of course, we started CPR on him.
And, of course, this was a trauma arrest, so But the volunteer department that showed up to assist us had their CPR device, and that's the first thing they they want to put on.
And I was okay with it just given the the the way we had to move him and get him out of there because we were clear back in the woods and everything else.
But the problem was when he put the device on, he met the age requirement.
But because he's a little cross country guy, He wasn't very big.
He literally probably had the body mass of a ten year old.
And what we found was that CPR device kept moving around on his chest, and we kept have and so I I moved it once after the second time, I said, let's let's just take this off to really better just to do manual CPR and have got better results with that.
Having sufficient personnel signing roles and and having a recorder because time management is crucial, and we'll talk about that.
We talk about drugs in that coming up.
Time management.
Time can get away from me in a coat.
This is a high stress event.
It's oftentimes what I refer to as a low frequency high risk event for most people.
So having enough people there, enough people to to complete all the roles and things that we need.
AHA came out years ago with something they called like a NASCAR team.
So everybody has a role and you're working as quickly as possible in that role, and you're very proficient in that role so that we have the best outcome for the patient.
And having a recorder is important.
Most of our newer heart monitors Your AEDs will reanalyze every 2 minutes.
So you know it's been 2 minutes, but most of your manual heart monitors will not announce when it's been 2 minutes when you're working a code.
That's something I'd like to see change in those for sure.
So alright.
And there's your you've never seen wave cap waveform cap andography.
I want to show you that.
Basically, all it is is this, it attaches to the tube, and this orange piece attaches to a sampling device you're under or under reportable device.
So alright.
Here's your ventricular tachycardia.
Another common rule that we see in cardiac arrest Now the problem with this rhythm is that you can have a pulse with this rhythm.
Ultimately, though, again, skin color, level of consciousness.
If they're unresponsive, turning blue and not breathing, it don't have a pulse, it doesn't matter if he's in this rhythm.
That's a shockable rhythm, and that means he's in cardiac arrest.
Right?
So let me play this for you.
Very looks very similar to the to the ventricular fibrillation.
It's just a wide complex tachycardia, but you can certainly have this rhythm here and have the patient sitting up and and looking at.
Right?
This is how well they're compensating if they have that.
So but in terms of arrest, it can look like any of these as well.
The trickler tactic party have many forms.
These are all what I would call unifocal ventricle tachycardia.
This will be a multifocal ventricular tachycardia.
Alright.
Trying to advance my slide here.
There we go.
Alright.
So how are we gonna treat this?
Now you can see, like, yeah, a lot going on with this slide, but this card number here, if you're not familiar, this is an ACLS algorithm for cardiac arrest.
And so what I've done is I've divided it with this yellow line.
So this would be our ventricular fibrillation or ventricular tachycardia outward.
So this is kinda what we follow in the field, and you can see there's lots of information over here about what we do.
So there's a lidocaine.
If you've never seen one of those, area to run, and this is their backbone mass.
Just trying to put some tools in the trade in there for you.
So what are we gonna do?
Early CPR.
Again, number one thing that we do, immediate defibrillation.
Establish an IV or IO.
And I'm literally I prefer 2 IVs as quickly as possible, certainly in the field, I can't tell you how many times we've started an IV, and immediately someone stepped on the line and it got pulled out or got misplaced or the line blew.
And then we don't have any way to administer the drugs.
And we know that it's not very effective putting drugs down into tracheal tube.
So We definitely wanna have an IV and 2 IVs in place if at all possible.
We give this epinephrine give epinephrine every 4 minutes, which is basically every other rhythm check.
And we have to give it at the beginning of the chest compression cycle.
So we get off the chest.
We're gonna check the rhythm We're gonna defibrillate or whatever needs done.
As soon as we get back on the chest, we wanna have that medication drawn up and ready to give because of the amount of time it takes to circulate.
So about a minute a half, maybe 2 minutes to get that circulated, then we have to remember the half life of epi isn't very long.
Right?
And that's why we repeated every 4 minutes.
So The antiarrhythmics that we get, amiodarone or lidocate.
I think that the new guidelines are that One isn't preferred over the other, so it's whatever your system carries.
Most everyone is using Amiodarone these days.
So it's 300 milligrams of Amiodarone that we that we draw off and give.
And I think there's only a 150 in this.
You have to draw up 2 of those.
So, again, if you're gonna give early medication administration, you have to have that drawn up ahead of time.
Again, logistics.
Who's doing that?
Who's our med person?
Who can draw that up?
If you can get that taken care of?
And literally, they want us to defibrillate within 5 seconds of the last compression.
And they want us back on the chest within 5 seconds of that defibrillation.
So, again, that takes time.
Right?
No.
PEA, about 20% of cardiac arrest outside of the hospital have PEA as their initial rhythm.
Most common causes are hypoglycemia and hypoxia.
Well, there's happened to be a couple of things that we can fix or at least attempt to fix in the field.
Trauma is the leading cause of PEA, and I can attest to that.
A lot of trauma arrest we've had over the years.
That's the initial rhythm that we see.
They say women are more likely to develop that than men.
And then we're gonna talk about the agents and teams.
A few months back, I had a cardiac arrest not far from the station, so we got there pretty quick, and I and we arrived on scene.
She was in cardiac arrest.
We started CPR, hooked her up to heart, honored, and this is the initial rhythm that we had.
We never had a shock of a rhythm on her.
This is what we had.
So we gave fluid boluses.
We started 2 IVs.
Gave her in airways.
We accomplished our hypoglycan or hypoxia scenario, and we had her back before we got her out of the house.
Never did hear what happened to her fast forward about 2 months.
I'm in a in a rehab facility looking for a faulty smoke detector on a fire call.
And I walk into this room of a patient to to find it to look at her detector, and it's the lady that I had in cardiac arrest too much prior.
To sit their way without me to chair.
So we don't give up on these rhythms whenever we see this.
We give every patient a 100% and we go through this checklist, and that's why this is a algorithmic systematic approach for every patient that we have.
Asystole Obviously, everybody knows what asystole is.
That's the rhythm that they shock on TV all the time.
Right?
So we don't shock asystole, obviously.
Usually, it's the end result of an untreated ventricular rip.
So what does that mean?
Well, it could mean that someone collapsed on the floor and either no one found them, and they've been there for 5, 10 minutes, or that we're standing around on a group.
And everybody has decided if this guy needs CPR or not or what should we do.
Right?
So we see that.
I've seen that many times in my career kind of as as as a people, as a human race, we will form a circle around a victim, and everybody's looking at each other.
But, boy, somebody better do something because that looks bad.
The moment that someone gets involved and takes charge and the circle gets real tight.
So my experience is if I pull up on a scene and there's a really tight circle around a victim, usually someone's doing something.
If there's a very wide circle, usually no one's doing anything and they're just looking at the gas.
So, again, Hs and Ts are what we're gonna cover on these on these non shock rhythms.
H's and t's, what are well, you can see there are potential reversible causes of arrest.
And, obviously, in the field setting, there's only a the limited amount of things that we can affect change on.
Right?
So hypovolemia would be 1, so give them a fluids, hypoxia would be another one.
So making sure have them oxygenated, that we have an airway in place.
This hydrogen ion, maybe they're acidized.
So sodium bicarb was often given at arrest, especially after we've been working them for a period of time.
Under your keys, a couple that we can fix right away is attention pneumothorax.
Attention pneumos, I I've typically seen that's where the the lungs get collapsed if you're not familiar.
From air, it's coming in from the outside.
I have seen spontaneous pneumothoraxes and a cardiac arrest or not trauma related before that we've had to decompress.
But the majority of the pneumothoraxes that we've seen in a in a rest are typically trauma patients.
The toxins, we think about overdoses.
And overdoses are a real part of have become a real part of our cardiac arrest scenarios here, especially in the area that we live in.
We have lots of heroin, a heroin problem, lots of heroin overdoses.
So toxins aren't an issue.
So again, we just run down this checklist and we think, well, okay.
So what could it possibly be and what could we fix?
So for toxins, we might give Marcan prophylactically.
Of course, check their pupils.
You know, are they constricted all these things?
Look at the surrounding areas, get information, bystanders, and those kind of things.
When you're looking down at your thrombus's there's not a lot we can do about that in the field, but oftentimes we're suspecting this coronary thrombus here as a cause for, you know, it was a it was a and myocardial function that led to cardiac arrest.
So Right?
But, again, the goal is to fix the simple and fastest first.
Nonchocable rhythms.
So we're on the other side of the card now.
You notice there, it's a system PEA at the top.
So we're not shocking these guys.
Right?
We're given epi as early as possible.
K?
Starting our IVs.
And if we don't have IV or IO access, that's what we're doing times 2.
We're given epinephrine every 4 minutes.
And as soon as possible, again, it's beginning at the chest compression cycle, getting their airways in place, doing our capnography, and running over those h's and t's.
K?
So it works.
So every one of these people here is under the age of twenty four.
Some of them may recognize.
I've got all their names listed.
I don't know if we need to go through them, but they range it range anywhere from 13.
To 24.
Of course, everybody knows about Demar Hamlin that that raised the level of awareness on CPR and defibrillation and all those things.
When that happens.
So that was probably a really good thing that happened for cardiac arrest.
And over here, you have more recently Bronnie James that collapsed under arrest, that I don't know the details of these, but I I read somewhere that the trainers and and personnel that were on scene shocked them are handling twice on the field, and had him back in a in a perfusing rhythm before they ever got it loaded into the ambulance.
True or not.
True.
I don't know.
But that certainly makes sense because we've seen that time and time again.
Every one of these people on this on these pictures here, all of these people were safe.
So age considerates.
Wanted to talk about that some.
There really isn't a whole lot of difference other than the occurrence.
Right?
So Powell tells us that roughly 15% of pediatric cardiac arrest are cardiac related So, right?
They define a child versus an adult now.
It used to be 1 to 8.
Now what they're telling us is, it's signs of puberty.
So it's underarm here in boys and breast development in girls.
So that's kinda how you decide that.
I always say that if you encounter someone in cardiac arrest and it enters your brain that they might be an adult, they probably should be treated as an adult.
Right?
So possible cause of a rash to drive it.
I can tell you, in my career, I worked a lot of pediatric codes infant codes and all this.
And I've never had a child in cardiac arrest that was in a shockable rhythm by the time I got to them, not not in my whole career.
So doesn't mean they weren't at one time.
Just means in the amount of time it took us to get there, and also the the the percentages tell us that that's probably not the case.
So, however, if you have these kids collapsing in ball fields, in soccer fields, in in volleyball courts, in that, these witness sudden cardiac arrests are probably a cardiac event and can definitely benefit from use of an AED.
Again, early CPR and fibrillation is the key.
We're trying to create cardiac output.
It's the same as for the adult.
Right?
But as he showed you before, prevention is the first lane link in the chain of survival because my experience has been in the data shows that Once a child reaches a rest, it's really hard to get them back.
We've we've had some success getting them back as far as a pulse of a blood pressure.
Only to have them succumb 4 or 5 days later for organ failure, brain injury, and things like that.
So that's that's an issue for sure.
So post cardiac arrest care, what are we gonna do when we get them back?
Right?
So return of spontaneous circulation or risk is something to turn it here a lot.
First thing we're gonna do is check for their vital signs.
Right?
I told you about the guy that I shot, and he literally woke up.
Right?
So that guy he he was immediately conscious, so it changed the game for us.
Right?
But there's lots of times that we bring them back and we get a pulse and a blood pressure.
Or if you're using an AED, it'll say no shop buys, or we have a heart monitor hooked up, and we see a a rhythm, and we check for a pulse, and they have one.
Well, oftentimes they're not breathing up around.
They don't regain consciousness.
Sometimes they do.
Sometimes they don't.
So your treatment is based on what we're seeing.
Right?
So vital signs supporting with volume expanders.
Again, the the vital signs will tell us what we need to do as far as volume expansion, blood pressure, and things like that.
Manage the airway and respiratory exam.
And again, most of this probably doesn't mean anything to to you as an athletic trainer.
But just know we can't get to this unless you've done what you need to do before they get there.
Right?
So that's our goal.
And again, I don't have a lot to do with this.
This is after we drop them off, and doctor Heath has to do all of these things here.
So but they're gonna of course, they're gonna do EKGs, 12 leads, and labs.
Maybe they're going off to the cath lab.
And one of the things they added in 2020 guidelines was now they're doing a CT of the brain.
The patient is still unresponsive after we get a bag They want you to elevate the head, and it's do a CAT scan of the brain.
They also do some serum and tests now to they call it neurologic prognostication.
Because, again, everything we're doing is about you can see at the bottom there is goal is to ensure organ perfusion and a functional recovery with a neurologically attacked patient.
Right?
That's that's the goal.
The goal is just to get them back.
The goal is to have them functional as they were before once we do.
Right?
So targeted temperature management or induced hypothermia, they say that's the only treatment post arrest that's shown to improve neurologic outcomes.
Our small hospital here locally doesn't really do that.
Most of our cardiac arrest patients get sent out to larger facilities.
So I've never seen that done.
But that is something that is that is a standard of care now for post cardiac arrest.
And then again, course your ages and teens as well.
Well, I went through that quick.
So there's our GAAP statement.
At the end, I had a couple of
notes on that.
You guys?
I guess, ultimately, you can't overemphasize the importance of the BLS care.
I say that to our basic EMTs all the time.
If you don't do proper BLS, none of the other we're not even gonna have the opportunity to do post arrest care or even do some of the things that we need to we get there.
So I always say, I've been on 100 of codes in my career.
I've been doing this for about 30 years, and the only people I ever stayed are people that received bystander CPR or something happened in front of us or very near to us.
And that's just a reality.
So that speaks to the importance of CPR for sure.
So let's see here.
Proficiency in distinguishing cardiac rhythms is fundamental in ACR.
And it definitely is.
I don't know if that's something that you guys get to do very often or even get to see, but understanding that if we don't have something to work with and we get there such as V fib or V TAC, then everything else probably is gonna be a tougher road to hoe trying to get people back when they're an asy sleep or PEA.
Certainly not impossible.
We're gonna give them a 100%, but that's something all those things are things that need to be considered.
So Right.
And and I you know, even in my career, I always say, I feel like our basic EMTs and every basic EMT should go through an ACLS class because because, you know, it I feel like that you're when you're better informed, you know, when you know better, you do better type of things.
And so kind of knowing that and knowing the the why of what we're doing something makes the how a little bit easier.
So in my opinion, I think that that that really helps everyone, especially when you're working as a team.
On a cardiac arrest.
And sometimes, you guys may not have the luxury of working with people that you've never worked with or that you've worked with all the time.
And that may be an issue as well.
So and and which brings I guess brings another point.
Anytime if at any time during any of this and this may have been touched on, If someone isn't doing good CPR, you need to tell them.
If someone's doing something that's gonna be not beneficial to your patient, you need to say something because literally someone's life depends on.
Right?
So and and that's important.
So now I've got a couple brief stories for you.
Maybe if you guys wanna hear that we'll hear about as we go forward.
But I'll see if anybody's got any questions because I'm not even sure where we're at on time, doc.
I apologize.
I
didn't look.
Hey.
Fantastic overview in in presentation.
We still got about 10 minutes.
Sure.
Doctor Kuzl comes in.
I just you know, one thing you brought and now I do have one question while we have you might have any questions.
Please put those in the q and a.
First off, you know, you mentioned you mentioned about the, you know, the hypovolemic or or hypoxant.
And you just you just alluded a minute ago the role of BLS units But BLS and I was like, my colleagues are Aflac Trainers, you have that ability to hand to address 50% of the problem a 100% of the time.
With that being and and, you know, just emphasize, we have it.
We can create a 50% survivability just by rapid CPR a d, perfusion, doing the things that you mentioned earlier, we might not be able to do the you know, depending on the setting, Like, some of the universities may have they may their physicians may be able to be there to have an ALS medications in with that.
But make sure the protocol you you alluded to protocols already, making sure those are in there in in your overall profiles based on based on practitioner level.
The question I have is around waveform catnography.
Mhmm.
And and maybe Doctor Heath as well, you're on here as well.
In in y'all's experience, what has been and this was a lot of conversation came out yesterday from Eric Fuchs, and he was talking about some of the critical care or clinical decision making with respiratory emergencies.
With waveform capnography, where have you seen over the years?
Like, you saw that, like, what improvement or how must it improve your ability to provide a better care in the field before or without having waveform capnography and then now that you have it or your other providers have it in place.
What does that what does that change in in the trajectory?
I guess when we started adding that into the infield care.
Sure.
Well, for us, I mean, it's just another tool to measure the effectiveness of what you're doing.
If I'm looking at my waveform capography and I'm less than 10, that tells me immediately something's wrong.
Something's wrong with the tube.
Or my compressions are not effective.
And so and and so that's the 2 immediate things that we're gonna chat.
So I I saw a story about a guy at and I'm not sure what hospital it was.
It's just a couple years back, and they were talking about the use of leafworm catography.
And during this arrest, they had this they had way for a cat, obviously, they had him innovated.
And their cabinography numbers were around 20.
And they were basing their their their working him this long based on their categories that we believe this guy still has a chance based on this based on the cardiac output, which is what this thing is indirectly measuring.
So they work they work the patient for an hour 45 minutes, which is unheard of.
Right?
Now it didn't say if they if he rested and rearrested, but it it basically said that they worked in for an hour 45 minutes, and the guy walked out the hospital neurologically intact.
And they were basing it on their waveform cataloging numbers.
So that's pretty significant, you know, in my opinion.
So Doctor Heath, what are you saying?
Yeah.
It actually changed the game.
I mean, now I can actually assess folks in respiratory distress, cardiac arrest, stop, just like we mentioned.
I mean, we're measuring their amount of carbon dioxide in their XL hair XL hair.
So it gives me more information on the breath to breath ventilation data.
Basically.
And it helps me kinda get a clue on what their respiratory effort is, like what the CO2 levels in their bloodstream is, so I can control ventilation.
So it it's it changed the game for me.
Okay.
Is there I know there there were some other questions about cost I know that the I know, obviously, with the ALS units, you have the built in wafold Catanarko unit built into the SIS in built looked into the defibrillator unit.
Are there other ones or portable ones that you've seen?
And if so, how much they how much the cost is?
And we got we had some questions yesterday and what what that may look like.
There's more of a for maybe there may be a limited budget.
Yeah.
I am not sure what the cost of the portable units are.
Most of your new monitors that will have the sampler in the in the heart monitor itself.
So and the devices that attach the tube, the actual device itself are not hardly expensive at all.
So Yeah.
The because that cost isn't it.
But it's worth it, though.
I think the other I think Oh, a 100%.
Yeah.
We can between the presentations yesterday, we talked about it was discussed.
And maybe the day you see there's a there's such a benefit to it.
It's just like having the AED.
You wanna have it's it's an expense but it's something you you don't wanna use, but you have it.
It's incredibly effective in determining clinical trajectory of where you're going to take that patient for the first 5, 10, it could be 30 minutes.
So, I mean, even if you'll just in with that running running a code, with that.
Along those lines, did from y'all's for y'all's protocols or y'all have the we're running a a a code.
Are are you treating in place through a certain time period and then trans or you can get a if you can get a rhythm then you move them, then you can transport or do y'all what is y'all's I've seen different practice guidelines for different EMS systems where they will treat in place I know that with, like, with the case, there was document with DeMar Hamlin.
I think they've had I'm not sure.
It came out specifically, but I know within Cincinnati, one of the EMS systems.
I've I've done a presentation related to EAP gaps and and looked at what One of the systems may have.
I don't know if that was the case, but their their recommendation is whenever possible, treat treat on-site until you get a a rhythm and then the then it's the load and go versus putting in a into a unit.
Right.
A lot of departments that were studies, I think, that were on Houston, maybe 1 in Seattle years ago, maybe 10 years ago now.
That that talk about that and the and the benefits of treating on scene, our protocol specifically doesn't give us a time frame or a rhythm, but understanding that we can spend as much time as we need to on scene to get to accomplish those benchmarks.
Because ultimately, if you can accomplish events parts moving them, I can tell you that I've seen many times in my career where the patient got their first happy 20 minutes into the code or 10, 15 minutes into the code because they were the providers will they were more worried about moving them from the area they were in than providing the treatment that they needed in that window.
Because once you get outside that tenant window, if you haven't done anything with CPR and millions, we're probably working we're way behind.
So Yep.
So that that's just that's been our opinion, and that's our that's our when we go out on calls, that's what we do.
We do the best we can for the patient right there where they're at.
And, again, the quicker I can accomplish all my goals and get the benchmarks met, then we can move them.
As long as we can continue high quality CPR when we do so.
You know?
For instance, if we have a really large patient in an upstairs setting, that's nearly impossible to continue the high quality CPR.
Now that's when that mechanical device comes into play.
We talked about that earlier.
They have their that's the place where you can definitely benefit from one of those devices.
If you're going down a set of stairs, it can take 10 minutes to get somebody down two flights of stairs.
If you're not doing any CPR during that time, then you might as well not Google it all because, you know, that's kind of our feeling.
And the same thing being in the unit, you need to have if you have two people in the in the 2 providers in the back of the unit, that's a very different but also the the advantage of having a mechanical unit is that you're being jolted around, you actually can that's the really the big advantage for the hits.
It's cost it.
But, you know, I think there's been I know we've seen that here in Louisiana where there's been a push to have the mechanical devices at set facilities.
I'm like, it's really if you're if you're there in place and you're doing CPR, it's nothing wrong with having that if you have the ability to have that because it's a it's a $20,30,000 device.
But the best doing hands on early CPR is gonna be your best advantage.
But when you get into a unit, that's a whole another that's a whole another bottle.
Especially
Well, that's where you see them that that's where you see them holding on to the bar on the ceiling and doing one hand CPR, which is not good quality CPR.
That's right.
Yep.
Yep.
That's it's trying to do what's most effective with there as well.
Any case, any other questions?
I so we have one question that popped in.
This is from Mandy.
And Mandy, if you would, just let us know where you're from.
As well.
I don't I didn't see it earlier.
So I'm gonna so she's from Ohio.
So this works so her question is, could you share any suggestions into experience of patients with pots syndrome.
I've had some athletes diagnosed with this recently, so I was curious on the diagnosis in what you have seen on treatment response in EMS for this?
Well, that would not be a question for me.
I'm gonna give that to doctor Heath because I have lunch familiar.
Alright.
No problem.
So pots so postural orthostatic tachycardia syndrome.
So I tell you what I have seen.
I have seen a number of individuals, but actually a a greater number, maybe 30% increase over the past 3 years, and the theory is because it gets COVID.
And the theory is that the COVID has basically invaded their nerves and is now causing their periphery to not quite clamp down like it should.
So it's causing posture or orthostasis, so they may pass out, but they may have persistent tachycardia.
So the good news and bad news with this I guess the good news first is you can treat it somewhat effectively with good compression stockings, but you have to wear them up to the groin.
Not like the cheap Amazon ones where you wear them up to the knees.
Okay?
So wear the the good quality ones.
And I guess the bad news is that it's probably gonna be there for the rest of your life.
They don't know yet.
That's one of the common things that we're seeing from COVID is this posture or static type cardio syndrome being more prolific now.
I used to not see it so often.
So that that's what I got.
Great question.
If I could
I'm sorry?
No.
I was just saying I was just commenting on Mandy's question.
Yeah.
I I I was just looking at my little side notes here and and something I wanted to bring up.
And I and I've thought this for many years as far as pediatric arrest goes and And my son just went through this yesterday actually for basketball.
For many years, you know, it's not very often that we have these kids in cardiac arrest on the ball field and on the basketball court.
But when it happens, you know, it's it's a very small percentage.
But if it's your child, then it's every percentage.
Right?
I've always been amazed how what we require physicals for children, for sports, that there's no EKG done or anything like basically, you go to your pediatrician who go to your whole life.
They go, yep, went pretty good.
Never had any problems.
The chances are they never had any KG.
You know, there's all a lot of those things that you're looking for.
So as I was doing research for this, back in 2021, the American Academy of Pediatrics made a suggestion that all primary providers when they're doing physical, so kids at least do an EKG and do a a a a history on them to see what their risk factor is.
For an arrest.
And and I'm surprised that all the parents of these children, no one's begged for legislation for that to occur.
Yeah.
I think you've seen some of it now with a 14 point cardiac exam, president of college, athletics requires that some some uni some at this high school level started to get that Fortive American College of Cardiology, a 14 point Mhmm.
Recommend date or examine or part of that of the physical exam being just that.
I think we're gonna continue to see more of that.
And I think the unfortunate side the fortunate but unfortunate side of it are cases like, you know, Demar Hamlin, or other cases that that occurred like the Matthew Magnini case.
It was unsuccessful in Kentucky with the CPR that they've that lawsuit.
Was settled back in January, I think, or February.
That would then be out in the training area and act activation, but it does go back to having, you know, getting more comprehensive exam you know, examination through well.
For all for all half links.
So I think we're we're unfortunately, we're out of time.
And before we've gotta move on, with Doctor Kuzl.
Steve, thank you so much.
Appreciate you so much.
Look forward to having you again in the future with with some other presentations.
And again, this is it's a fantastic presentation you provided.
This is a final note.
One comment came in to the panelists is there is a foundation of Ohio called the encore foundation that does free echoes at schools and scan of the school when sent to pediatric cardiologists and nationwide children's and the results are sent over to the athletes or PCP.
And they've done a lot of schools here in Ohio.
So That's that's fantastic.
Schools.
Yep.
Definitely reach out to those resources.
But thank you again, Steve.
Thank you.
Thank you so much, and look forward to working with you again in the future.
Thank you, guys.
Thank you.
Thanks, Doug.
Thank you, Steve.
Good job.
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