Changing ACLS to reflect pre-hospital applications

[Guest Yankee medic]

Here is some food for thaught. Who would be opposed to ACLS being geared towards the pre-hospital setting. And if we (ems world) could who and how could we do this?

[ndpemt519 10]

Huh? ACLS is already done pre-hospital........

[Guest Yankee medic]

Huh? ACLS is already done pre-hospital........

If I'm not mistaken it is geared for in-hospital not pre-hospital. correct. If I were to take someone from Rt 55 and Beekman rd in cardiac arrest and do just opa and bvm what would the abd. look like when I get to Saint Francis. They don't want people tubed. That would not work in the pre-hospital setting. That's what I mean.

Edited March 25, 2009 by Yankee medic

[Tapout 42]

If I'm not mistaken it is geared for in-hospital not pre-hospital. correct. If I were to take someone from Rt 55 and Beekman rd in cardiac arrest and do just opa and bvm what would the abd. look like when I get to Saint Francis. They don't want people tubed. That would not work in the pre-hospital setting. That's what I mean.

Who's they (they don't want people tubed)? I don't understand your question- ACLS is geared for anyone providing 1st response care pre- OR in-hospital. Do you mean allowing ACLS treatments for BLS responders, like an EMT tubing the afore-mentioned arrest victim? Duck, then. I feel a poo storm coming over that proposal.

And, regarding the abdomen of the same victim after admin of OPA and PROPER BVM ventilations... it should not look any more pregnant than when you started.

[NWFDMedic 58]

If I'm not mistaken it is geared for in-hospital not pre-hospital. correct. If I were to take someone from Rt 55 and Beekman rd in cardiac arrest and do just opa and bvm what would the abd. look like when I get to Saint Francis. They don't want people tubed. That would not work in the pre-hospital setting. That's what I mean.

If you did effective BLS ventilation it would be fine.

[Guest alsfirefighter]

If I'm not mistaken it is geared for in-hospital not pre-hospital. correct. If I were to take someone from Rt 55 and Beekman rd in cardiac arrest and do just opa and bvm what would the abd. look like when I get to Saint Francis. They don't want people tubed. That would not work in the pre-hospital setting. That's what I mean.

As NWFD said, if you did effective and proper ventilation it generally isn't a problem. I'm also not sure why you would worry what the abdoman looked like to begin with if good cpr with good compliance with ventilation?

Second...I'm not sure I understand what you exactly mean that ACLS is geared for "in house" and not prehospital. In all actuality you are not following "ACLS" per say but your regional protocols for cardiac arrest which generally follow ACLS guidelines. This is why sometimes ACLS guidelines get updated but the regional protocols lag behind slighty in the change. I'm interested in knowing what it is that you feel would need to be changed as the medications are the same and most of the skills are also.

Thirdly, I don't understand your reasoning about having a cardiac arrest from Rt 55 and Beekman Rd. and your ACLS in house theory. Why as an ALS provider would you just do an OPA and BVM to begin with, and what makes you think that is all that would happen in a in facility cardiac arrest? Advanced airway is lectured and practiced in ACLS courses to begin with. The only thing that makes it a little more "in house" is that many of the questions on the test are geared towards being in a hospital setting. I tell all newer medics who take ACLS for the first time to just flip it in their mind and look at the patient..not where you are being told they are.

[ndpemt519 10]

If I'm not mistaken it is geared for in-hospital not pre-hospital. correct. If I were to take someone from Rt 55 and Beekman rd in cardiac arrest and do just opa and bvm what would the abd. look like when I get to Saint Francis. They don't want people tubed. That would not work in the pre-hospital setting. That's what I mean.

What do you mean "that would not work in the prehospital setting"? Are you saying intubating a patient and bringing them to the hospital wouldn't work? Hospitals in this area expect at minimum an IV and ET tube in place on a code. And intubation isn't a skill only limited to ACLS, it's an airway control procedure in any ALS protocol.

[Guest Yankee medic]

Alsfirefighter I agree with you. the rx are fine but the service I work for wants the iv and first rx given before getting the tube. Their reasoning is like you said if the opa and bvm work keep it. But we get overzealious first responder firefighters on scene first and the belly gets distended. Maybe it's just my service. But I still tube before the rx. I remember my ABC's.

[Guest Yankee medic]

What do you mean "that would not work in the prehospital setting"? Are you saying intubating a patient and bringing them to the hospital wouldn't work? Hospitals in this area expect at minimum an IV and ET tube in place on a code. And intubation isn't a skill only limited to ACLS, it's an airway control procedure in any ALS protocol.

Not intubating a pt wouldn't work in the field. If you only did bvm and opa there is a more chance of a distended abd. The hospitals in my area expect the same iv and tube/combi-tube. As well as the previous answers I agree with all. It's just my service that's a little backwards. But it is all in the way you document your pcr. Thanks for responses.

[ny10570 745]

I'm confused here, why delay drugs for a tube? So what if the belly is distended due to some over zealous ventilation. Get them doing ventilations the right way; one on the seal and one on the bag, squeeze until chest rise, once every 5, etc. If you're not shocking, administer first line drugs and then while you're waiting three minutes set up your ETT and during the switch/rythm check drop your tube. Yes, it will probably delay the second round of drugs for a minute or two but it gets everything moving a little bit faster over all. Especially if its a tough stick, or a tough tube. Once the tube is secured you can burp that over inflated stomach and take some of the pressure of the vena cava. If BVM is ineffective then absolutely, then airway is a priority and you grab the tube kit. All this being said, there's no reason to transport without an advanced airway in place (excluding extremely unusual circumstances). A while back I ran through just about the entire drug bag on an arrest, and finally got to intubating about 15 minutes in. Ventilations were great and I had the capnography strip to prove it. I'm either going to need a new partner or figure something else out once we get our Res Q Pods. Need a tube for those to work.

[Goose 188]

Nothing a little cricoid pressure couldn't solve.

[Guest alsfirefighter]

I'm still not getting exactly what it is that your saying? If anything the new ACLS guidelines to me complement single medic systems with the unwitnessed arrest paradigm. The 2 minute cycle gives you a good amount of time to get your pads on, set up your intubation equipment, have any other available resources on scene spike a bag for you. I'm with NY and didn't say it in my first post but what's the big deal with a distended abdomen? They are in cardiac arrest and out of sight out of mind. If its that much of an issue you have a QA/QI problem in your area and communication and training for all parties are in order and would eventually help the situation. What did you do before the usage of secondary airway control devices and you had difficulty intubating a patient? You brought them in with solid BLS airway skills. I generally do not have an issue with overzealous ventilation volume...I generally find myself having to coach many BLS providers in ventilation rate. With the addition of end tidal CO2 monitoring this has helped as they can see the number and not just have to count.

And just for the record...ED's can expect a lot...it doesn't always mean its going to happen nor is feasible. Its very rare that any provider in my system would come in without both..but every once in a blue moon you get that train wreck that is just perfect for not having easily found veins , even an EJ and a difficult airway. You keep going until you get it. But I'll certainly not feel any ill will because a patient has gastric distension...the only main issue is in the event they aspirate, which is more critical in conscious sedation intubations...not cardiac arrest.

[ckroll 101]

What the original author may be getting at sounds like he has trouble with his/her back up. One medic alone is going to have a hard time on a code. When we practice 'mega' codes in ACLS there are 4 ALS trained people... and that ever happens when in the field?

We all need our BLS providers to know their skills and hopefully know how to interface with ALS. It sounds like that isn't happening, but it may be a filter down of education not a problem with ACLS per se. I know in my BLS corps the person in charge of 'training' outright refuses to let EMT's practice bagging with a tube in place because that's 'an ALS skill' and he has a bug up over anything ALS.

What might be useful to us all is an integration course that brought BLS up to date on how to contribute effectively to an ALS response.

[Guest alsfirefighter]

What the original author may be getting at sounds like he has trouble with his/her back up. One medic alone is going to have a hard time on a code. When we practice 'mega' codes in ACLS there are 4 ALS trained people... and that ever happens when in the field?

We all need our BLS providers to know their skills and hopefully know how to interface with ALS. It sounds like that isn't happening, but it may be a filter down of education not a problem with ACLS per se. I know in my BLS corps the person in charge of 'training' outright refuses to let EMT's practice bagging with a tube in place because that's 'an ALS skill' and he has a bug up over anything ALS.

What might be useful to us all is an integration course that brought BLS up to date on how to contribute effectively to an ALS response.

1. I think your right he does have a problem with his FR personnel but he does also get into how his agency wants codes handled, which I believe he is trying to flip onto the ACLS course.

2. In regard to the training at your BLS VAC...it sounds like the training officer is not qualified or had no background in providing training. Either that or they are completely inept. Personal opinion has a narrow scope in certain training topics and its pretty obvious they have a problem with that as bagging via an ETT is as BLS as it gets. I personally if I were in a management level position would remove him/her or ensure that the training was appropriate.

3. Been there done that...in fact in many ways every ALS call is a way to contribute on how to contribute. But I have done some CME lectures on "ALS for the BLS provider." Which didn't always get a great turnout unless I did it at specific agencies and the feedback was good and the fact that it was solid "preparatory" hours for recert.

[Goose 188]

You know, it's both sad and astonishing that in 2009 there are still individuals who are ultra-resistant to ALS. It's the standard of care. Period.

As far as the BLS/ALS integration - awesome idea. EMTs need to start growing a set and be able to hold their own. That may mean canceling the medic on a stubbed toe or being able to bag with a ET tube in place so the Medic can move on to something else.

It just sickens me that this sorta garbage continues today...and people wonder why EMS is the butt crack of the emergency services...

Edited March 26, 2009 by Goose

[Guest mediconpatrol]

In comparison of ACLS in hospital and out of hospital is very easy:

Even though I am ACLS, I still need a doctor to respond to a code in house and order the medications and procedures to be done.

Though, many will "back me up" if I begin administering that is because of the time I have had there and proven myself.

Out of hospital, I am covered by protocals.......

Therefore, I believe we are more talking about what preference of receiving hospitals or agency running the code.

No aspect of ACLS should be sacrificed for another...spending to much time on one aspect if there is an alternative is bad patient care....

Good BLS has been proven to sustain a patient until more definitive care can be provided.....

Remember: we are doing what is best for the patient ...not what is best for the receiving facility

[WAS967 97]

I'm of the mindset that BLS comes before ALS (duh) and that if bagging a code is working just fine, then don't mess with it (If it ain't broke don't fix it). If gastric distention becomes a problem and BLS procedures aren't cutting it, or if there is vomitting/etc, then I'll most definitely drop a tube. On codes it seems to be more effective to have good BLS and move on to dropping an IV and pushing a round of meds before trying for a tube. Like somone said previously, get the first round in, prep you tube stuff then give it a shot.

There has been a de-emphasizing of intubation lately in the ACLS and (especially) PALS classes due to the tendency for people to stop compressions while trying for the tube. If you have the opportunity, try tubing without stopping compressions. In many cases, it's really not that hard. I'm sure most of us involved in the above discussion are aware of the science behind "priming the pump" and minimizing time without compressions [if someone is not, and wants more info, feel free to ask and we shall provide].

Personally, I don't see a problem with holding off on the tube in favor of getting a line and a few rounds of meds in place first. Sure we want to get one eventually, but intubation has taken a get steps backwards recently on the priority meter.