Cardiac Arrest: A Story Told With EKGs

[fiznat]

I will let the images do most of the talking. This is a 65 y/o male found pulseless + aepnic in an office building. He was a witnessed arrest with immediate bystander CPR. Unknown Hx/Rx/etc.

This is actually the 3rd shock (1st shock as noted on the paper, but we had switched monitors), but to abbreviate:

link to a bigger version (1500 pixels wide) of the 12 lead here.

here is the URL to the big version-- try copy+paste into a new browser, EMT city frames resize the image for me:

http://i62.photobucket.com/albums/h99/fiznat/12leadBig.jpg

Never got a chance to do epineprhine. The patient got 1mg Atropine for the brady rhythm, followed by a 100mg Lidocane bolus and then a 2mg/min Lidocane drip*. He began to buck the tube enroute the hospital and was given 4mg Versed. He was taken to the cath lab immediately based on our 12 lead and found to have a complete occlusion of the RCA. Stented and sent to the ICU, where he was cooled according to the new ROSC hypothermia protocol.

6 days later, he walked out of the ICU under his own power without any neuro deficits.

My first code as a licenced paramedic. 8)

**Now I know some of you are going to mention this, so I'd like to talk about it. It appears from the 12 lead that the patient is in a 3rd degree AV block. I did not see this at all during the call. To be honest, I gave it pretty much a cursory look considering all else that was going on- noticing the inferior MI and moving on. The lidocane drip happily dripped away the whole time. What do you guys think of that?

[Just Plain Ruff]

now that's a feel good story.

[chbare]

Great story and good strips to document your work. It looks like he had a massive inferior wall MI. It also looks like he hit the posterior wall as well, and I bet the right ventricle also took a hit. The bradycardia is actually quite common with this type of MI. The RCA supplies the nodes in a significant portion of the population. From the strips, it looks like the block was transient and self limiting.

Take care,

chbare

[AZCEP]

Is that CPR being done in the first strip? If so, the wonders of bystander CPR show up again. If not, you must have walked in at just the right time.

At the beginning of the first strip, it looks like there is a PEA showing. Maybe your third degree AVB was there the whole time. Having just the one lead (paddles) set in what is probably lead II doesn't tell you much. You might consider setting your LP12 so that it will show three leads at once. This isn't a hard thing to do, and makes the information readily available.

Now for the lidocaine. I'm not entirely sure that it was necessary. You did have a period of VF, so it's indicated, but with the presence of an AVB post defibrillation, it may not be the best thing to do. A dose of atropine is somewhat useful, but the TCP would probably be my treatment of choice. Easier to control, and less damaging effects to an apparent MI.

You got him back, and the cath lab fixed the problem. Hopefully his brain wasn't hypoxic long enough to cause a problem down the road.

Good work.

[Dustdevil]

Congrats, Fizzy! Definitely an interesting and educational case. This guy was certainly having "the big one," and is very lucky to have survived it. The shock woke up both pacemakers and brought out a CHB, but it appears that it quickly lost the SA node again and went strictly junctional for awhile before the Ps eventually kicked back in. I'm not sure they ever synchronised though, as it doesn't appear so in that final 12 lead. I wish you had a rhythm strip from that time frame where we could better determine the underlying rhythm. As tempting as it might be, post v-fib, I don't believe that I would have gone with lidocaine, based on what I see there. Considering the profound ischemia and infarct that is obvious, both nodes are likely to crap out on you under the influence of lidocaine. Lidocaine and heart blocks are not good bedfellows. It doesn't appear that your patient is any worse off for it though.

You'll get to a point to where that "cursory look" is all you need to accurately read a rhythm. EKGs are like a language. And the more you practise, the more fluent you get, until the day comes that you identify the words (rhythms) on sight, without having to actually sound them out letter by letter. A world of stress disappears from your shoulders the day that happens!

[scottymedic]

YAY always good to get a feel good story in here in amongst all the doom and gloom that seems to otherwise clouds the place.

[ERDoc]

Great case. This is a good example where you can see the anatomy on the EKG.

[ncmedic309]

Your first code as a paramedic and in turns out to be a TRUE SAVE! That's awesome! It sounds like you did a great job managing the patient. I would have been a little more cautious with Lidocaine administration due to the AV block but otherwise it seems you did an excellent job. Keep it up!

[Ridryder 911]

Congrat's on your call. You mean codes actually become "saved"? Sorry, it has been so long since any of my arrests even had a squiggly line......I forgot.

R/r 911

[Medic26]

Nice Job and Great Strips to see.