For a living dog is better than a dead lion.
Ecclesiastes 9:4
EMS
Effective BLS can provide a small but critical volume of oxygenated blood to the brain and heart, assisting in preserving their function and buying enough time until reversible causes of the cardiorespiratory arrest can be identified and treated. For instance, effective CPR can extend the time that VF is present and the heart potentially amenable to defibrillation and a spontaneous restart. Meanwhile, there is no medication that has been shown to improve long-term survival after a cardiac arrest.
At a cardiac arrest situation, bystander or clinician priorities are toward prompt, effective CPR and defibrillation without delay, whilst seeking for and treating any reversible causes. Where there is cardiorespiratory arrest, start CPR and attach defibrillator pads. Then decide if you need to give a shock—this is Basic Life Support (BLS)—or give drugs, or both. This is the approach for one type of patient: the nominally dead.
When called to an emergency, however, first work out whether the patient has arrested; whether the patient is “dead”. While the first instinct is (should always be) to start CPR if there are no signs of life (or if there is any doubt), to call for help, and to attach defibrillator pads, this all implies a recognition that the patient might be “dead.”
There are then, in any genuine emergency, two potential types of patients: the living and the dead. Both scenarios will instinctively be approached with DRS ABCDE system in mind; but, where signs of life are confirmed, the focus will be different.
Consequently, just as the physician dexterously moves between two pathways of the ALS in an attempt to reanimate the dead, the physician’s mind should just as deftly be able to move from the management of the living to the management of the dead (and vice versa). Because too often when called to review a deteriorating patient, the living suddenly become the nominally dead and the physician obliged to switch their point of approach in going through the DRs ABCDE, to the 4Hs and 4Ts, while still performing CPR and defibrillation. Where all goes well, equally the physician has to be just as prepared to switch from the focus on the “dead” to the living in their DRS ABCDE—to that of clinical observations.
Do not confuse management of the living with the algorithmic pathways for the “dead,” but remain ever mindful for a switch between the two; a switch that comes just as easily and as comfortably as the ability to switch between the two pathways (shock and no shock) of the ALS itself. Because, while oxygen saturations and blood pressure remain critical pieces of information for managing the living, they are worse than useless in managing the dead.
For wisdom is justified of her children. For if they (observations in the dead) were only useless, then that would be one thing. But they are worse than useless because they distract the resuscitation provider from the point of focus. In the living, the DRs ABCDE focuses on clinical observations like oxygen saturation, blood pressure, 12-lead ECG, et al. But in those not breathing, in the “dead”, once again just start good CPR and attach the defibrillator pads—in search of a shockable rhythm—and during which time focus instead on the 4Hs and 4Ts—on finding ANY reversible cause of the arrest amenable to immediate treatment.
Just as there are two pathways in the ALS algorithm—the shockable rhythm (VF / pVT) and the non-shockable rhythm (PEA / asystole)—there are two pathways to consider at the very outset of any emergency—a pathway for the living and a pathway for the dead. One requires a focus on ABCs (oxygen, fluids, cardiac monitoring) and clinical observation, the other on ABCs (CPR and defibrillation) and 4Hs and 4Ts. In one the provider is asked to adopt a salvage and more defensive posture. In the other the provider must move into attack or counter-attack mode. Keep the breathing alive (defend the position). Reanimate the dead (an all-out “attack”).
Dot confuse the living and the “dead.” Treat both. Indeed, treat each with the DRS ABCDE approach. Only treat each with a different posture—clinical observations for the living, 4Hs and 4Ts for the dead. Defend the one. But “attack” the other.
When called to an emergency, there should be a mindset in your head about how to approach the scenario such that if it were put into algorithm might go something like this:
Become deft at switching from alive to “dead” (and vice versa). In both the alive and the “dead”, the “SHAVED” acronym recalls the 5 things immediately to hand that must never be overlooked (these are also incorporated within the 4Hs and 4Ts of ALS):
- Sugar → dextrose push
- Haemorrhage → compression bandage, fluids ± blood
- Anaphylaxis → adrenaline
- VF → defibrillate
- Epilepsy → nasal / buccal midazolam
- Drugs → e.g. calcium, potassium
For beyond defibrillation, this is where the provider can make a difference. This is where the provider may reanimate the dead.
In the “dead,” having quickly accounted for SHAVED, move to a more systematic consideration of reversible causes, the 4Hs and 4Ts; and be prepared to act on mere suspicion.²
Rule out the obvious, such as bleeding in the post-operative patient or the patient on anticoagulation, STEMI in the cardiac patient, VTE in the immobile or cancer patient, and treat on suspicion alone: e.g. intercostal catheter, IV fluids ± blood transfusion, dextrose bolus, serum K+, serum Mg2+, FAST for tamponade with pericardiocentesis, thrombolyse, cool or warm the patient, etc. Whatever it takes. Even open thoracotomy if it comes to that. Call the cardiac surgeons down stat.
Because it is exactly that, a situation of extremis, drugs are given in boluses to the dead: e.g. 1 mg adrenaline, 5 mmol potassium. Doses a physician would never dream of giving to the living. Instead, the living are given infusions ; but boluses never given (except bolus glucose or by those rare-skilled anaesthetists/intensivists). Giving a bolus of potassium in the living is ill advised. A 1 mg push of adrenaline will quickly turn the living into the dead, having induced a life-threatening arrhythmia. The living have a circulation and a metabolism that will not tolerate bolus arrest-doses. The dead have neither, but need an extreme dose to “kick-start” the heart and liven circulation. The living need care, albeit sometimes with a firm hand. The dead need a jolt of life. The dead are no more unless you drastically intervene—now.
Reference
- Advanced Life Support Level 1. Third Australian Edition. Apr 2016. Australian Resuscitation Council (ARC).
- Phillips, Nathaniel D., Hansjörg, Neth; Jan K. Woike, Jan K., and Gaissmaier, Wolfgang. “FFTrees: A toolbox to create, visualize, and evaluate fast-and-frugal decision trees.” Judgment and Decision Making 12(4), July 2017: 344-368.
