Cardiac Arrest/Combative Patient

[Chief1C]

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.

[rock_shoes]

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.

[paramedicmike]

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.

[scubanurse]

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.

[paramedicmike]

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.

[HarryM]

What was his GCS before you intubated?

[rock_shoes]

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.

[chbare]

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.

[rock_shoes]

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.