In the Prehospital Emergency System where I work (from late 1996) we are historically used to manage cardiac arrest events with a deep “Stay and Play”, except for some sporadic cases (mostly pediatric patients) . The rising of A-V ECMO era (and in Florence there is a major ECMO center) and lastly of mechanical chest compression devices, took us to rethink the whole approach to the management of cardiac arrest.
Is there now a role for a “Load-Play and Go” approach in some selected patients.
Let’s try to figure out some of the major challenges that this new approach can pose to emergency physician working in a prehospital environment.
- Which are the inclusion criteria to choose, in a so urgent and confusing situation (as OHCA is), the right patient with a reasonable hope of good functional recovery.
- Do we have to change our ALS schedule and management in those selected cases?
Wich is the right patient
The all V-A ECMO process is a really expensive stuff in term of both, human and financial resources. So the development of criteria to predict wich patient is potentially a candidate to good neurological outcome is oriented to spare money (for the collectivity) and to avoid futility (for the patients).
For sure a relatively young age, and the absence of invalidant comorbidities can play a role in these decision. But also the “no flow” time,intended as the time from when the CA happened to the start of chest compressions in the witnessed CA and a shockable rythm finding or a potential reversible cause in non witnessed CA are sign of predictable good outcome.
The V-A ECMO, last but not least, needs a strict time schedule from the CA to the cannulation process to be effective and so the transport time to ECMO Center plays also a fundamental role in the decision making.
Putting all together these specification we can, with a good approximation, describe the right candidate for External Cardiac Life Support (ECLS).
But what about the pratical approach to those patients. Is still the classical ALS protocol the way to follow?
The six minutes approach to Load-Play and Go in OHCA
The basic skills are not different, but the real difference is the mind of the resuscitationist (S. Weingarth dixit) in these cases.
If you already decided this is the right patient the right time, we propose a six minute approach to manage all the features you need to perform in the first phase of a OHCA before “loading” the patients, “playing” during the “going” phase toward ECMO Center.