ROSC Timing of Epi

So another topic that we want to talk about is what happens when we achieve rosc. So we've done such a great job staying on scene, we've secured the airway, we've done our timely intervention, whatever required. Now we have ROSC back. So really this algorithm is just the same as it is when we talk about the adult population. So if the child's over the age of one, you would have used your rescue pod. Right? So, so we need to make sure that the rescue pod gets removed. After that you have to do an assessment. Right? So whether or not your blood pressure cuff has made it on the child, whether or not the pulse ox has made it on the child, you really need to take these things and don't look at it as a tunnel vision that we have rosc. We've got to hurry up and get out of here. Look at it as, hey, we're moving towards the comprehensive pediatric center. Because remember the comprehensive pediatric center is, is where this child needs to be because if we don't make it there, they're going to get transferred there. And during that time, let your vital signs tell you what your next step is. Let your entitled CO2 and your pulse oximetry tell you your ventilatory rate, let your blood pressure be adjusted by starting with your fluid administration and know that if that doesn't work much like the adult population, you can go to the push dose pressure, epinephrine. That's okay, but remember, it's impossible for you to take it to the next level to maximize that child walking out of the hospital if you don't treat it like an adult arrest.

And I think that the brain needs a systolic pressure and the heart needs a diastolic pressure. So don't be fearful of fluids in cardiac arrest. So give it often, give it fast and let's have better outcomes because those two organs that need that pressure are waiting for that pressure to come. So just because you have an end tidal, just because you have ROSC and a pulse doesn't mean you're done. And I think fluids and push pressure, EPI definitely valuable. Yeah.

And I think when we think about these things as a whole too, and I don't want you to get, you know, I don't want you to get down in that conundrum of essentially the child's been down for a little while and you know, there's been no circulating blood in their system. And the entitled CO2 comes back off the chart, it comes back at like 8, 80 or 90. I don't want you to get overzealous with the bag, because what happens is, just like Dr. Anteve said, the brain needs that perfusion. Just remember, though, when you start doing this and you start causing that inner thoracic pressure, you cease blood flow. So remember, the body will try to normalize on its own, but we have to make sure that while we're trying to match the numbers and get the numbers right, really, we're very concerned about the perfusion.

I'm going to add on to that part. When you're squeezing the bag too much and your end tidal drops too quickly, you vasoconstrict in your brain. So hyperventilation not only does badly for the heart, it also hurts the brain. So be very careful. I think a lot of people have around the country and these studies that have been done for many years, they never realize that the BVM was the biggest killer rather than being the biggest savior. That's a great point.

Okay, the last topic, and I think one that we found very important over the last, at least the last year or two, is the timing of epinephrine. We're one of the first departments in the country to move away from using epinephrine in shockable rhythms. So V fib pulses, V tach, any of the shockable rhythms. EPI is no longer. That's for kids and for adults. So now what about the people who do need epinephrine? Paul Banerjee and Dr. Pepe put out a study in resuscitation in 2019 showing that if you bring down the time to EPI for a cardiac arrest down to around the seven and a half minute mark, and then they got it down to five minutes, then all of a sudden the survival, the neuro intact survival went way higher. So how do we do that? How do we get EPI on board quickly? You have to be a high performer. I call it like SEAL team six. And we practice it here at this department. As you all know, getting in there, bagging, chest, compression, drill, give epi. And if you can do that within five minutes of arrival, which I think is possible. Yes, you'll see the numbers and the outcomes get better. I want to throw in one pro tip here and that we've learned over time is that when you get to the scene of an infant or even a one, two or three year old, when you know the doses of epi are small, right. Under one year of age is going to be under 1 milliliter, go ahead and try and take that epi box, open it up, pop the cap, screw it down, use a 1mL syringe or a 3mL syringe and quickly drop three of those syringes, let's say 0.6ml three times, put those three syringes in that box and lay it right next to the IO so that if that position switches at any time, you know that 1 epi has been given, 2 epi has been given, or 3. I'm personally okay with after the third epi has been given on scene, that could be a green light to start saying, hey, let's move. Because I will tell you, with a great cpr, high performance bls and three doses of EPI and everything else being done correctly, that's when that child will have their opportunity to come back to life. Want to comment on that?

Yeah. So I never thought, you know, when Dr. Anteve first started working with us at Palm Beach County Fire Rescue, I never thought we would get to this point because we came in with this culture of stay on scene, do this there, do, don't rush away from the scene, do the drill, start the epi, put the Igel in. And I just thought, wow, culturally that's something totally different than we've ever been taught or we've ever practiced in the organization. But we're doing it. And that's the amazing part. Not we're doing it, you're doing it. And for us to make that change, we've already seen the case down in Battalion 5 with baby Stella. We're starting to get to actually see these outcomes and we're actually getting to watch the ROSC rates increase, we're seeing the on scene times increase, we're seeing that the interventions decrease in time. Like we're getting it done faster. So now what we're asking you to do is take it to the next step. We're actually going to start looking at when the time of the drugs go on, you know, timely defibrillation, reviewing the code stats. And I just, I'm so proud to be a part of this organization and to be able to reach that part where we're actually asking you to do more. But we know you can do it and I'm very thankful for what you've done so far.

We really encourage you to continue to really innovate and really show the rest of the country how it's done. We really appreciate you guys and what you all do. So thank you very much.

Yeah, thank you as well. And if I could echo anything you said is just keep up the good work, you know, we look forward to, you know, hopefully we don't run any of these calls in 2020, but the inevitable is there for us. And just keep doing what you do, and I'm proud to be a part of it.