rock_shoes Posted January 23, 2013 Posted January 23, 2013 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!
Arctickat Posted January 24, 2013 Posted January 24, 2013 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.
scubanurse Posted January 24, 2013 Posted January 24, 2013 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.
chbare Posted January 24, 2013 Posted January 24, 2013 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.
Arctickat Posted January 24, 2013 Posted January 24, 2013 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.
rock_shoes Posted January 24, 2013 Author Posted January 24, 2013 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.
scubanurse Posted January 24, 2013 Posted January 24, 2013 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.
Jaymazing Posted January 24, 2013 Posted January 24, 2013 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
paramedicmike Posted January 24, 2013 Posted January 24, 2013 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?
scubanurse Posted January 24, 2013 Posted January 24, 2013 I would know pretty quickly if they were no longer effective at least?
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