Load-Play-Go and “6 minutes approach” in Out of Hospital Cardiac Arrest . Is this just fool?

3 Ago

PROTOCOLLO ELS da plastificare_engI’m really surprised of the great debate that the previous post (Load-Play-Go in Out of Hospital Cardiac Arrest. The “6 minutes approach”) arouse around the “6 minutes approach”, and all the comments on the “load-play and go” way to manage the OHCA patients potentially candidate to Externa Life Support.

Most of the comments affirmed that 6 minutes to run a code is an utopia, and that stay and play is the right and only way to manage out of hospital cardiac arrest (OHCA).

“This is silly. 6 minutes to work a code into the back of your ambulance?….”, “I just wish I could convince more people that out-of-hospital cardiac arrest is a “stay and play” and not a “half ass cpr that provides nothing to the patient and rush to the hospital” kind of call……”, “There’s next to nothing that will be done in the hospital that you can’t do in the field (in most cases at least)…….” and many more….

So I want to add some considerations on this topic to clarify more on my thoughts about this argument.

The “6 minutes approach” is intended in patients who suffer a Cardiac Arrest from medical conditions (and in general the traumatic patient is not the right candidate for ECMO).

Traumatic cardiac arrest is another story (Mind of Resuscitation in Traumatic Cardiac Arrest).

The “6 minutes approach” is a way of thinking more than a realistic scenario (at least in the majority of the situations). It means that when you decided that the patient you are resuscitating on the field is the right candidate to External Life Support (and this depends on criteria that the institution where anyone works estabilsh), you don’t have to esitate and go straight to the ECMO center (even after more than 6 minutes!). It doesn’t mean you don’t have to perform all the meaningful (?) interventions that current guidelines indicates, but it means only that these interventions  (mechanical chest compression, ventilation, defibrillation, medications) can be performed on the way to ED, in the back of your ambulance, to allow the patient to arrive fast at his destination.

I know (from 20 years of out of hospital working experience) that real life is different from planning a situation on the paper. But the right mentality of professionals in these cases has to be determinated to a fast transport toward the closest ECMO capable center. 

To all the fans of “stay and play” in medical cardiac arrest (I myself am a fan of stay and play, but in traumatic cardiac arrest where manouvers performed on the field can be determinant if performed fast) just want to remember that the only “advanced” interventions that have probated evidences to improve mortality are chest compressions and defibrillation. The rest is usual and traditional but not evident. So I don’t ask to go against the (old) guidelines, but at least do it on the way, don’t loose time.

In cases when there is chance of good recovery (short no flow time, good pre-arrest conditions, young age) is right to give a real chance to the patient with a second level diagnosys, not available on the field, and in the meantime, with extracorporeal circulation now we can, mantaining the brain alive.

ECMO doesn’t cure anything, just give us time. Time to perform a clinical oriented diagnostic process and, when it’s possible, to find the cause of cardiac arrest, to treat it (PTCA for AMI, thrombectomy for pulmonary embolism, electrolyte EGA oriented replacement for electrolyte imbalance), and hopefully recovery the patient to a good quality of life.

I thought stay and play was the best option for patients in the past when ELS and mechanical chest compression devices where not available and the excellent experience of prehospital professionals made the difference in term of quality of interventions and resuscitation. Today, not for all patients, not for all conditions, the field is not the right place to run a code anymore. We have to abdicate a piece of our self-consideration to admit that ECMO opened new chance for OHCA patients, inside the hospital and this can make the difference for a selected group of patients.

Our mission is to find which is this group. Our mission is to train our system to take those patients to the right place in the shortest possible time.

Until that time many “wrong” patients will be taken to the hospital, and also many “right” patients will be left on the field, wasting money and allowing futility.

But when that time will come, cardiac arrest treatment will have a new prospective to really improve the quality of life.

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