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Cardiac Arrest/Combative Patient

Signs of Life Prior to ROSC   9 votes

  1. 1. Have you ever worked a cardiac arrest with obvious neurological signs of life prior to ROSC?

    • Yes
      6
    • No
      3
    • I don't believe you!
      0

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Posted · Report post

This is a patient I recently dealt with while working targeted ALS. It was a highly unusual situation and I think it's well worth throwing out for the EMTCity local to play with. Let's start with how you would manage this patient and go from there. I'll chime in with what I actually did and the outcome later on.

Initial dispatch info:

85 y/o female patient, Chest Pain with SOB.

Initial Contact:

BLS (PCP crew so think EMT-I) arrived first to patient with declining LOC, Bradycardia, SOB, Pale, diaphoretic. Patient arrested in BLS presence with CPR, PPV, AED applied immediately (one non-shockable rhythm analyzed prior to our arrival).

We arrived to BLS crew working the arrest 4 minutes into the resuscitation. The patient patient was found to be in an asystole with absent pulses. The kicker (pun intended) is that the patient was also combative with good CPR (kicking, pulling at the BVM, I'm talking a 2-2-5 total of 9 GCS).

That's all I'm giving up for now.

GO!

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Posted · Report post

Transported a guy once who could actually give me feedback if I needed to improve my CPR. If I stopped he'd GCS 3, but if I was doing good compressions he'd remain alert and oriented. This was years before ALS was available and we didn't even have a monitor. When we got to the hospital they got the monitor on and discovered a Sinus brady of 10 - 20. Transported him for a pacemaker insertion and he lived for many more years. That was the best CPR learning experience EVER!!! I learned exactly what worked best, how hard, fast, and deep was ideal, and he only complained about us beating on his chest once...and it was more of a "Man, this is uncomfortable but better than the alternative" complaint.

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Posted · Report post

not really sure what you're wanting as far as a scenario...this guy would get the same ACLS treatment and rapid transport regardless of combative behavior during good compression cycles.

I'm not even sure I would do anything to prevent her from becoming combative because at least you know she's getting blood to her brain and vital organs.

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Posted · Report post

It's important to realise that something known as pseudo PEA can exist where you may still have ventricular contraction and limited systolic pressures with foreword blood flow in an apparently "dead" patient. True PEA mandates complete electrical-mechanical dissociation. Unfortunately, differentiating between the two typically requires the ability to perform cardiac sonography.

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That's was my conclusion too Chris. Basically, the pump was working, but so poorly that we couldn't palpate a pulse and that on it's own the brain wasn't being perfused. However, with the compressions the job was getting done. I just wish I could have had a way to determine what the exact mechanism was. Was it the CPR alone? Were our compressions causing the heart to actually beat more effectively and faster? Without the monitor we'll never know.

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Posted · Report post

Transported a guy once who could actually give me feedback if I needed to improve my CPR. If I stopped he'd GCS 3, but if I was doing good compressions he'd remain alert and oriented. This was years before ALS was available and we didn't even have a monitor. When we got to the hospital they got the monitor on and discovered a Sinus brady of 10 - 20. Transported him for a pacemaker insertion and he lived for many more years. That was the best CPR learning experience EVER!!! I learned exactly what worked best, how hard, fast, and deep was ideal, and he only complained about us beating on his chest once...and it was more of a "Man, this is uncomfortable but better than the alternative" complaint.

I suspect that call is forever in the memory banks as being one of the most interesting you've ever had!

not really sure what you're wanting as far as a scenario...this guy would get the same ACLS treatment and rapid transport regardless of combative behavior during good compression cycles.

I'm not even sure I would do anything to prevent her from becoming combative because at least you know she's getting blood to her brain and vital organs.

Why are you transporting a dead body as an ALS provider? I understand why Arctickat did in the past working BLS (now he would probably pace that patient and bring him in for a pace-maker). If her heart isn't circulating any blood she is in fact dead and her brain just doesn't know it yet. At that point in time the only thing keeping this patients brain alive was high quality CPR. Why would I want to risk compromising that by trying to transport prior to ROSC?

It's important to realise that something known as pseudo PEA can exist where you may still have ventricular contraction and limited systolic pressures with foreword blood flow in an apparently "dead" patient. True PEA mandates complete electrical-mechanical dissociation. Unfortunately, differentiating between the two typically requires the ability to perform cardiac sonography.

Interesting thought. I had a very similar thought a little further into the arrest (I'll explain shortly). Standard ACLS doesn't address this particularly well.

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Posted · Report post

Why are you transporting a dead body as an ALS provider? I understand why Arctickat did in the past working BLS (now he would probably pace that patient and bring him in for a pace-maker). If her heart isn't circulating any blood she is in fact dead and her brain just doesn't know it yet. At that point in time the only thing keeping this patients brain alive was high quality CPR. Why would I want to risk compromising that by trying to transport prior to ROSC?

They aren't a dead body.... they have a significant pump problem with their heart...pump problems we can potentially fix in the hospital. I'm going to transport her to a higher level where they can fix it or declare it.

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Posted · Report post

I would acquire an ecg and 12-lead, then promptly share it with the good folks of EMTcity. :)

Did atropine/epi+pacing+bolus have any benefit? This is a tough scenario to play out without seeing what we're dealing with. *hint hint*

*****i see now that it says asystole. I missed that at first.

*************apparently I should pay more attention

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They aren't a dead body.... they have a significant pump problem with their heart...pump problems we can potentially fix in the hospital. I'm going to transport her to a higher level where they can fix it or declare it.

Do you think you can maintain effective compressions in a moving vehicle?

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Posted · Report post

I would know pretty quickly if they were no longer effective at least?

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Posted · Report post

Had something similar w/ an AAA. Patient had eye movement, facial movement and moved his fingers during CPR; then we'd have ROSC/R for a few minutes; and he'd arrest again. Happened on scene, all the way to the ER; in the ER. They applied the MAST in the ER, and patient survived to surgery then died.

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Posted · Report post

I would acquire an ecg and 12-lead, then promptly share it with the good folks of EMTcity. :)

Did atropine/epi+pacing+bolus have any benefit? This is a tough scenario to play out without seeing what we're dealing with. *hint hint*

*****i see now that it says asystole. I missed that at first.

*************apparently I should pay more attention

Ask and ye shall receive.

With the initial presentation I elected to go a little bit old school and make an attempt at pacing. I was able to achieve excellent electrical capture but was unable to obtain sufficient mechanical capture to produce a palpable pulse. The first attempt of pacing was ceased and continuous CPR maintained (stopping to analyse a rhythm q 2 minutes. My service is currently participating in a 30:2 versus CCC ROC trial). Once vascular access was obtained it was straight into the epinephrine q3 minutes (admitedly access took longer than I would have preferred but when doesn't it in a code situation?). Also an epinephrine infusion was initiated at 3mcg/min between the second and third round of epinephrine 1mg.

After the third round of epinephrine the patient had converted into a wide complex PEA (third degree block) at 26 BPM. At that time I elected to make a second attempt at pacing with success (ROSC paced at 70 BPM with 140 mA). The patient was intubated at that time with what I would refer to as "brutane" by my partner (wishing I had ketamine and paralytics on my truck for this one believe me). ROSC, pacing, and the epi infusion were maintained to hospital. The epi infusion was bumped up to 6mcg/min when the patient's BP dropped to 72/26. Sedation was relatively minimal (2.5mg IV midazolam) unfortunately because we only have relatively vaso-active agents available to us right now (morphine/midazolam). Ketamine is on its way but not yet available.

I wish I had a 12-lead to share with you but I didn't do one. I was actively pacing the patient making a diagnostic 12-lead impossible at the time.

I'll add a little more regarding patient follow up later on.

I would know pretty quickly if they were no longer effective at least?

You would. The risk vs. reward ratio for this patient of trying to move her prior to some stabalization (ie. ROSC) is pretty clear in my opinion. The numbers don't lie. CPR on the move is not nearly as effective.

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I would know pretty quickly if they were no longer effective at least?

Yes. I think you would know. Then what? Stop transporting so you could do more effective compressions? Or continue transporting while doing ineffective compressions for the patient?

I agree with Rock Shoes. The risk vs reward here is not pointing in a favourable direction. If you can't stabilize the patient and everything stops when compressions stop then you don't have a viable patient.

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Posted · Report post

I just went back and looked at what I originally responded because the comment about compressions while transporting threw me off... ACLS I believe does say imply a code should be worked on scene and then rapid transport... I did not intend to mean that I would do ACLS while rapid transport but I think that's how it was interpreted...

Seems a lot of that is going on with my posts lately.

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Posted · Report post

Rapid transport in the case of ROSC. Rapid transport does not follow if you do not have ROSC.

Brain injury and cardiovascular instability are the major determinants of survival after cardiac arrest. So, you don't have ROSC, you're transporting and not doing good compressions in the ambulance, in the presense of pretty blatant cardiovascular instability, and you're not doing anything for the patient.

Medically, there's no reason to transport. Ethically, however, transport determination is a different discussion.

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Posted · Report post

What was his GCS before you intubated?

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What was his GCS before you intubated?

Her GCS ranged between 7-8 from one minute to the next. We did make use of lidocaine spray, so once it had a chance to take full effect she wasn't fighting the tube. Like I said far from ideal for intubation. My conundrum with this particular patient really came from how limited my pain management and sedation options are right now. I have morphine and midazolam without any paralytics; both of which are relatively vaso-active and on my serious no no list for a patient who just had no blood pressure at all.

A little more follow up.

After arrival at hospital ED staff continued with the pressor drip and pacing. A central line and transvenous pacer were placed with ROSC maintained for at least the next couple of hours. When I stopped in to check on her progress she was still intubated but awake and communicating with a BP of 110/70 and paced transvenously. Survival to discharge I don't know, but I do know she's 85 and we gave her the opportunity to say goodbye to her family.

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Posted · Report post

I am not convinced this patient had a true, non-perfusing rhythm however. This is a likely candidate for the pseudo PEA mentioned earlier. This scenario occurred with me some years ago where EMS brought a patient into the ER with chest compressions in progress. The patient would move and groan during compressions, then become unresponsive and apparently "dead" when compressions were stopped. The patient was in a high grade AV block and limited cardiac output was noted with bedside sonography. The patient received a transvenous pacemaker as a bridge to permanent pacemaker and ended up doing well. A good case that illustrates unconventional situations in any event. Thank you for sharing.

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I am not convinced this patient had a true, non-perfusing rhythm however. This is a likely candidate for the pseudo PEA mentioned earlier. This scenario occurred with me some years ago where EMS brought a patient into the ER with chest compressions in progress. The patient would move and groan during compressions, then become unresponsive and apparently "dead" when compressions were stopped. The patient was in a high grade AV block and limited cardiac output was noted with bedside sonography. The patient received a transvenous pacemaker as a bridge to permanent pacemaker and ended up doing well. A good case that illustrates unconventional situations in any event. Thank you for sharing.

That was basically my thought process with this one. Thus the early decision to trial pacing. Certainly an atypical presentation.

I asked my partner (35+ years working targeted ALS) about it and he said he's seen it about once every 4-5 years.

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