Asystole WITH a pulse

[BoCat9]

Ok, a case was presented to us in class, actual call that took place sometime last week. We were told we could use any source to find the answer.

Ambulance service brings a mid-50 y.o.m. into the hospital. Found pt unresponsive, put pt on the monitor showing asystole. Crew checked a pulse, found a pulse in the carotid and brachial pulse. Pt cyanotic from nipple line up. HR ranged from 70-200, erratic. Pt had a BP or 110/70-200 systolic. Pupils dilated, nonreactive. Agonal resp, medics tubed the pt. Pt placed on 3 different monitors, leads and pads changed with the monitor. I monitor on the back of the ambulance, 2 monitors in the hospital. Hospital staff continued to work the pt for an hour and a half, each time they stopped to pronounce him, he would sit up, look around and then lay back down. Has anyone ever heard of this happening or have any idea what may have caused this?

[maverick56]

Not a clue. But that's super freaky and has me curious to see what others have to say.

[akflightmedic]

Ok, a case was presented to us in class, actual call that took place sometime last week. We were told we could use any source to find the answer.

Ambulance service brings a mid-50 y.o.m. into the hospital. Found pt unresponsive, put pt on the monitor showing asystole. Crew checked a pulse, found a pulse in the carotid and brachial pulse. Pt cyanotic from nipple line up. HR ranged from 70-200, erratic. Pt had a BP or 110/70-200 systolic. Pupils dilated, nonreactive. Agonal resp, medics tubed the pt. Pt placed on 3 different monitors, leads and pads changed with the monitor. I monitor on the back of the ambulance, 2 monitors in the hospital. Hospital staff continued to work the pt for an hour and a half, each time they stopped to pronounce him, he would sit up, look around and then lay back down. Has anyone ever heard of this happening or have any idea what may have caused this?

I am gonna have tor esearch as well, but first...are you sure there is no punch line the instructor is waiting to throw on you guys??

[Aussieaid]

Ok, there's so many things wrong with that story I don't know where to start.....

First off unless you are doing CPR when they check the pulse it is impossible to have a pulse with "true" asystole. True asystole means there is no electrical activity happening in the heart and (unless you are artificially pumping the heart with CPR) the heart will not beat on it's own without an electrical impulse. So they either checked for a pulse while someone was doing CPR or there was something wrong with the monitor/s or leads or you are not getting the full story. Also you are not going to get a BP with asystole for the same reason.

Next why are they treating a monitor? If you have a BP and a pulse why are they doing CPR? If the pt also sits up in between compressions and looks around that is usually a sign that he is perfusing something and not requiring CPR as well (unless it is some kind of post mortem or spinal reflex that was misinterpreted because I have heard of corpses sitting up because of the gas build up in them). You also can't pronounce someone with a pulse and a BP unless they are brain dead with lots of tests needing to be completed first.

Some of the specific causes of cyanosis from the nipple line up are a hemopericardium, dissecting thoracic aortic aneurysm, traumatic asphyxiation and superior vena cava syndrome (or SVC syndrome). I am sure there are more but these are just some of the ones I could think of right now. It can also be seen with a non-traumatic cardiac arrest with no special significance attached to it.

So I think there is either a lot more to this story or it has been twisted a little. Or something...

If there is some interesting new condition to be learned about I am all ears and always open to learning more...

[Timmy]

I think I saw that on TV once...

[DwayneEMTP]

Yeah girl, there is truly nothing about that story that makes any sense..

From the story there was never any indication for CPR, regardless of how many monitors showed asystole, the patient was not asystolic with a pulse and b/p.

If 'each time', implying multiple times, that they attempted to discontinue resuscitation attempts the pt sat up and looked around then the treating facility needs to stop treating pts as it sounds as if this patient was doing much better when they stopped treating him than when they were.

Either you got the story wrong, or someone is bullshitting you babe...

Dwayne

[mobey]

I am sure you have all seen some low-ass voltage QRS complex's out there. It is not beyond reason that the monitor possibly filtered them out leaving the appearance of asystole.

A 12 lead would remove the filter.

You can also crank up the gain (size) on the monitor.

However... This story is FULL of holes. Why would someone who has the capability of sitting up & looking around, let people do CPR on him?

What was the GCS?

Edited June 10, 2010 by mobey

[croaker260]

Actually, I may have the answer....

We recently recived a notice on a patient in our area with a new ventricular assist device. I will see if I can find the info on it. Im pretty sure it is still in the experimental phase, but with this device it is possible to have the patent in periods of Asystole witha pulse (that is generated by the machine) for periods at a time. It comes with a 1-800 number to call BEFORE beiginning CPR due to the fagility of the connections and the device.

May not be what your instructor was refereing too, but there you go.

[emtannie]

I agree with other posters that this scenario is hard to believe…

Ambulance service brings a mid-50 y.o.m. into the hospital. Found pt unresponsive, put pt on the monitor showing asystole. Crew checked a pulse, found a pulse in the carotid and brachial pulse. Pt cyanotic from nipple line up. HR ranged from 70-200, erratic. Pt had a BP or 110/70-200 systolic. Pupils dilated, nonreactive. Agonal resp, medics tubed the pt.

If a patient is truly asystole, they would be apneic and have no pulse. Since the patient had a BP and a pulse, why would you do CPR? If the patient had a BP and pulse, but wasn’t breathing effectively, you would assist ventilations, but you wouldn’t start CPR.

Cyanosis from the nipple line up? I am curious – was patient truly cyanotic from that point, or was that as far as the medics opened his shirt? (and before anyone gets mad at me, you know and I know, crap like this happens when someone doesn’t do a complete assessment)

Did the patient have any facial injuries? There have been cases of asystole or severe bradycardia upon stimulation of optic and trigeminal nerves, but this should have resolved with medications and compressions.

Pt placed on 3 different monitors, leads and pads changed with the monitor. I monitor on the back of the ambulance, 2 monitors in the hospital. Hospital staff continued to work the pt for an hour and a half, each time they stopped to pronounce him, he would sit up, look around and then lay back down. Has anyone ever heard of this happening or have any idea what may have caused this?

Again, if the patient had a pulse, not sure why the hospital staff would “work him.” Treat the patient, not the monitor.

I think I would like to know more about what the hospital staff did… were they doing CPR? If they were, someone needs to take them back through basic CPR criteria.

His pulse was between 70 – 200… If his pulse was at 200, did they cardiovert? If his pulse slowed significantly, did they pace him?

I seem to remember reading about something like this either on this site or on another site some time ago, but can’t find the link right now, where the discussion was on the remote possibility of the cyanosis being a dissecting aorta with complicating cardiac tamponade. If the aneurism ruptured into the pericardium, it could produce cardiac tamponade and the cyanosis from the nipple line up – very rare, supposedly. The patient should have the tamponade signs though – edema and JVD. I will keep looking for the link… D*** Google doesn’t find it when I want it to.

[mobey]

Actually, I may have the answer....

We recently recived a notice on a patient in our area with a new ventricular assist device. I will see if I can find the info on it. Im pretty sure it is still in the experimental phase, but with this device it is possible to have the patent in periods of Asystole witha pulse (that is generated by the machine) for periods at a time. It comes with a 1-800 number to call BEFORE beiginning CPR due to the fagility of the connections and the device.

May not be what your instructor was refereing too, but there you go.

YES YES YES....

Y ou are on to something!!

There is a gentleman in Calgary Ab whom is awaiting a heart transplant who has one of these "Pumps". I believe it even sits outside his body.

Google here I come.

Here's a link

http://www.newscientist.com/article/dn18969-arizona-man-is-first-to-take-artificial-heart-home.html

Forgot they were sending these guys home with these things. It still has to be hooked to an air compressor of sorts though, so you would have seen it.

Good memory jog though.

Edited June 10, 2010 by mobey