Answer: You are right that you are stuck between a rock and a hard place: Knowing that definitive treatment for a STEMI is to relieve the coronary obstruction and that without defibrillation, they will deteriorate, as you state. In this tough scenario, and according to the ALS-PCS companion document:
In the event a ROSC is achieved and the patient re-arrests en route, Paramedics will adhere to the following sequence:
- Pull over
- Initiate one immediate rhythm interpretation
- Defibrillate as appropriate (1 shock max) AND
- Continue with transportation to the receiving facility.
If in the opinion of the Paramedic(s) the patient would benefit from further analysis/defibrillation, a patch with a BHP would be indicated for direction.
References:
Auble TE, Menegazzi JJ, Paris PM. Effect of out-of-hospital defibrillation by basic life support providers on cardiac arrest mortality: a meta-analysis. Ann Emerg Med 1995 May;25(5):642-64
Berg et al. Precountershock Cardiopulmonary Resuscitation Improves Ventricular Fibrillation Median Frequency and Myocardial Readiness for Successful Defibrillation from Prolonged VentricularFibrillation:A …Annals of Emerg Med.2002;40(6):563-570
Cheskes S, Schmicker RH, Verbeek PR et al. The impact of peri-shock pause on survival from out-of-hospital shockable cardiac arrest during the Resuscitation Outcomes Consortium PRIMED trial. Resuscitation 2014 Mar;85(3):336-42
Kensch M, Stendell M, Berkell et al. Early prediction of prognosis in out-of-hospital cardiac arrest. Intensive Care Med. 1990 Sep;16(6):378-383
Nolan JP, Soar J (2009). Defibrillation in clinical practice. Curr Opinion Crit Care 15; 1070
Roth R, Stewart RD, Rogers K et al. Out-of-hospital cardiac arrest: factors associated with survival. Ann Emerg Med 1984 13:237-243