# Med Controls orders that make you say, WTF!!!!!



## MedicBrew (Feb 26, 2012)

Called to a cardiac arrest of a 35 y/o male with pre-arrivals in progress, unknown down time. 

Girl friend is hysterical and poor historian making any information very difficult.
Efforts started by LEO prior to arrival, so BVM w/ NPA and lucas placed. He was pinched in-between bed and dresser, of back room of course. Patient moved to cot then unit with BLS in progress. My paramedic student partner was at the head at that time. Then a FTO unit shows up and the FTO asked if his trainee could intubate as he needs an airway so he can be released. I say “No Problem”.  To make a long story short, he is unable to open the patient’s airway. I assess it and after kicking myself for not checking earlier I realize that he is rigored. 

MC contacted per protocol to cease efforts. To my surprise he orders sux!!!
I politely inform the Dr. the patient is asystolic with unknown down time and I was asking for cease efforts. He replied, continue and if that doesn’t work, try a nasal tube, continue transport….Click

So we continue our frivolous effort s and the FTO got his contact and eventually got an oral tube with an EtCo2 of 50. The ED works the poor fellow for 30 minutes and call him. By this time he has rigor to his upper extremities as well. 

Has anyone EVER heard of giving Sux to a dead guy and why???

I’ve been doing this for awhile and have never encountered this before. I’ve done some research and can’t find anything.  

Taking into consideration the patients relative young age, I fail to see the physician’s reservation to stop efforts. 

Thoughts???


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## Shishkabob (Feb 26, 2012)

EtCO2 of 50 makes me think that the Lucas was still getting decent cirulation with cell metabolism going on.




But sux for an arrest?  Nope, haven't heard of it.


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## DrankTheKoolaid (Feb 26, 2012)

First dont kick yourself for missing the (rigor).  That was your students job to find it in the first place.  

rant on* The thing that irks me about some interns.  School is where you learn, Internship is where you learn to do it safely under my watchful eye. Should not have to be taught to look for that stuff or your protocols once in internship rant off*

Obviously you cant give us the full report you called in, but what did the man look like and how did you portray that to OLMC?  still warm? skin color? (MD considering Trismus hence the sux order)

What was CM showing when you had a ETCO2 of 50?


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## jjesusfreak01 (Feb 26, 2012)

Linuss said:


> EtCO2 of 50 makes me think that the Lucas was still getting decent cirulation with cell metabolism going on.



Wouldn't that *normally* indicate that the patient had arrested more recently than you would expect if they were in rigor?


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## DrankTheKoolaid (Feb 26, 2012)

Yup, my point exactly


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## MedicBrew (Feb 26, 2012)

Corky said:


> First dont kick yourself for missing the (rigor).  That was your students job to find it in the first place.
> 
> rant on* The thing that irks me about some interns.  School is where you learn, Internship is where you learn to do it safely under my watchful eye. Should not have to be taught to look for that stuff or your protocols once in internship rant off*
> 
> ...



Initially, cyanotic face/chest/ upper ext's. Core slightly warmer than room temp, no lividity noted at all (hence the reason we started efforts), distal ext's cool to touch. 

He stayed asystolic throughout. As far as the trismus, we were not getting anything from the gf, WAY to hysterical for any type of communication..

What I didn't mention in the OP was the Sux actually did loosen up the jaw enough to get the blade in to facilitate the intubation. Just was a first for me..


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## STXmedic (Feb 26, 2012)

MedicBrew said:


> What I didn't mention in the OP was the Sux actually did loosen up the jaw enough to get the blade in to facilitate the intubation. Just was a first for me..


Then I would think this patient wasn't "rigor". Succ works on the ACh receptors to cause paralysis. Rigor is typically caused by intra cellular ATP depletion- thus Succ would have no effect on reversing this.


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## medicsb (Feb 26, 2012)

I have heard of this being done.  I've had patients in CA initially have trismus, which usually went away in a couple minutes.  One was a pt. that coded in front of me.  I noticed in one of the Seattle/King Co. ETI studies that a number of CA pts. were given succs.  

Also, from what i know, it doesn't seem physiologically possible for succs to have any effect on rigor once it has begun to set in.


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## DrankTheKoolaid (Feb 26, 2012)

*re*

Exactly.  With his age I would be inclined to think a drug induced trismus, unless he had some other pathology.


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## medicsb (Feb 26, 2012)

PoeticInjustice said:


> Then I would think this patient wasn't "rigor". Succ works on the ACh receptors to cause paralysis. Rigor is typically caused by intra cellular ATP depletion- thus Succ would have no effect on reversing this.



Also, it is the abnormal permeability of the cell membrane to Ca that causes the stiffness.  The ATP is actually needed for relaxation.  For succs to work, there would have to be an cell membrane electrochemical gradient of Ca and ATP stores in order to induce paralysis.


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## MedicBrew (Feb 26, 2012)

PoeticInjustice said:


> Then I would think this patient wasn't "rigor". Succ works on the ACh receptors to cause paralysis. Rigor is typically caused by intra cellular ATP depletion- thus Succ would have no effect on reversing this.



This is along my thoughts as well, but his jaw coincidently relaxed approx 3 min after administration. 

Aw, another point I failed to mention. The ED staff usually asked us to leave the lucas in place while they continue the code, which we did while I finished my PCR.

When they were done, I went in to remove the device. When removed his arms stayed vertical as they were when secured to the device which seemed to confirm that it was rigor. 

Total patient contact time was 32 minutes.


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## 46Young (Feb 26, 2012)

I second the comments on Sux. Also, if the pt were indeed in rigor, the ETCO2 could not possibly rise to 50. ETCO2 in a viable arrest (not for hours such as in rigor) can range from below 10 (if prolonged downtime or from low quality CPR), to the mid 20's if the pt just went down. An ETCO2 of 50 is stongly suggestive of ROSC (CO2 washout immediately following ROSC can kick ETCO2 into the 50's, then it settles at a lower number), or perhaps the pt was never in arrest in the first place. If you drop a tube and the ETCO2 is 50 right away, the pt probably wasn't in arrest when the tube was dropped.

Edit: I don't have experience with the Lucas and quantitative capnography together. Is it possible to have an ETCO2 north of 30 mmHg with one in place and no spontaneous pulse?


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## MedicBrew (Feb 26, 2012)

46Young said:


> or perhaps the pt was never in arrest in the first place. If you drop a tube and the ETCO2 is 50 right away, the pt probably wasn't in arrest when the tube was dropped.



Asystole in all leads (I,II,II, Paddles, aVR, aVL, aVf). No electrical activity. ZERO. 


46Young said:


> or Edit: I don't have experience with the Lucas and quantitative capnography together. Is it possible to have an ETCO2 north of 30 mmHg with one in place and no spontaneous pulse?



As for the effectiveness of the lucas, I have actually asculatated a systolic pressure of 140 in an asystolic patient. Really impressive if you ask me. 

When the patient was initially intubated and 50 mmHg was noted, Compressions where halted for a pulse check, None. Rhythm check reveled persistent asystole.


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## DrankTheKoolaid (Feb 26, 2012)

Having a artificially created BP secondary to mechanical compressions is one thing.  But a ETCO2 of 50 = cellular processes still taking place and not rigor mortis.  Unless it is one of those cases I read about while doing coroners work when a patient essentially burns up almost all generated ATP just before death causing an "almost" instantaneous rigor mortis which is supposed to be like a 1 in a million.


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## MedicBrew (Feb 26, 2012)

Corky said:


> Having a artificially created BP secondary to mechanical compressions is one thing.  But a ETCO2 of 50 = cellular processes still taking place and not rigor mortis.  Unless it is one of those cases I read about while doing coroners work when a patient essentially burns up almost all generated ATP just before death causing an "almost" instantaneous rigor mortis which is supposed to be like a 1 in a million.




I agree, but the 50 mmHg lasted approx 5-7 min max, then decreased to 10 and stay around there. Sorry I may not have been very clear about that fact. Having a EtCo2 of 20 or below is fairly common in an arrest.


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## 46Young (Feb 26, 2012)

MedicBrew said:


> Asystole in all leads (I,II,II, Paddles, aVR, aVL, aVf). No electrical activity. ZERO.
> 
> 
> As for the effectiveness of the lucas, I have actually asculatated a systolic pressure of 140 in an asystolic patient. Really impressive if you ask me.
> ...



My understanding is that with CPR, you're really only pumping the rt ventricle, and with devices such as the Lucas or the Autopulse, it better encompasses the heart. I could see that ETCO2 during an arrest with the Lucas I suppose, but several hours after death???? Strange indeed. Can you ask the doctor on that call how that could be possible?


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## MedicBrew (Feb 26, 2012)

46Young said:


> My understanding is that with CPR, you're really only pumping the rt ventricle, and with devices such as the Lucas or the Autopulse, it better encompasses the heart. I could see that ETCO2 during an arrest with the Lucas I suppose, but several hours after death???? Strange indeed. Can you ask the doctor on that call how that could be possible?



I did and he had to scratch his head. I even asked if it may possibly have been a dystonic reaction. (unlikely, but not impossible). He was as puzzled as I was. 

I may have missed something, I don't know.


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## jjesusfreak01 (Feb 26, 2012)

Then again, there are a lot of suspected PE arrests in the ER that present with decent ETCO2 readings...I personally don't understand that either...


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## 46Young (Feb 26, 2012)

jjesusfreak01 said:


> Then again, there are a lot of suspected PE arrests in the ER that present with decent ETCO2 readings...I personally don't understand that either...



I would expect the conscious pt with a PE to have a decreased ETCO2 due to the affected area being deprived of blood flow, and especially during a PE arrest. Normal ETCO2 readings in a PE arrest baffles me as well.


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## mycrofft (Feb 26, 2012)

Maybve you said "rigor" and the controller thought "trysmus"?>


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## zmedic (Feb 26, 2012)

From the MD perspective. First of all it's worth remembering that in some places the person you get on the phone is potentially someone with little EMS experience, who got 5 or 6 ride alongs in residency and that's it. So some of them just don't trust medics or EMTs, they tend to be more "bring them in so I can see what is going on." Not that it's right, just worth remembering. 

Similarly it is hard to call a cardiac arrest over the phone on a 35 year old. I understand that dead is dead, that you aren't going to bring back someone from asystole. But it's harder to give up on young people. We tend to work them longer in the ER. And from a liability standpoint, I would think it's much more likely that someone is going to question stopping an arrest on a 35 year old who is relatively healthy than an 80 year old on 30 meds and lots of problems. 

So I don't know about the succs. But I think I back a doc who says "the story I'm getting from EMS doesn't make sense. (ie good C02+rigor) I'm not going to call an arrest over the phone if I don't understand what's going on, so let's just have them transport."

You could aruge what's the downside of giving the guy succs. If it's really rigor, he's dead and can't get worse. If it's not rigor, maybe increases the chances of getting a tube.


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## systemet (Feb 27, 2012)

MedicBrew said:


> Has anyone EVER heard of giving Sux to a dead guy and why???



You can have cardiac arrest patients presenting with "instantaneous rigor" (aka "cadaveric spasm", "instantaneous rigidity", "cataleptic rigidity").  

A percentage of these patients are probably in a low output pseudo-PEA.  There's a few case reports on Pubmed.  Some respond to neuromuscular blockers, others don't and may require cricothyroidotomy.

True rigor normally takes an hour or two to develop, and as others have noted won't be responsive to neuromuscular blockers.  It's caused by activation of troponin, allowing for cross-bridge formation in the absence of ATP to allow for disengagement.  The cytoplasm is already full of [Ca2+], the cell's already depolarised, and it's not triggered by nAChR binding.

Lee JH, Jung KY.
Emergency cricothyrotomy for trismus caused by instantaneous rigor in cardiac arrest patients.Am J Emerg Med. 2011 Jun 13. [Epub ahead of print]


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## MedicBrew (Feb 28, 2012)

systemet said:


> You can have cardiac arrest patients presenting with "instantaneous rigor" (aka "cadaveric spasm", "instantaneous rigidity", "cataleptic rigidity").
> 
> A percentage of these patients are probably in a low output pseudo-PEA.  There's a few case reports on Pubmed.  Some respond to neuromuscular blockers, others don't and may require cricothyroidotomy.
> 
> ...



After reading more about it, this seems plausible. 

thanks for the references systemet!!


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## systemet (Feb 28, 2012)

MedicBrew said:


> After reading more about it, this seems plausible.
> 
> thanks for the references systemet!!



No problem man!

I've had no personal experience with this, although I have one of those "a guy I know told a guy I know" sort of EMS tall stories from a crew I worked with who ran an arrest that started off as a "stat" transfer out of a small rural ER.  They had a guy in VF, who they had to push sux on.  At the time I assumed that they had seen some sort of seizure artefact on the ECG and mistaken it for VF.  Then I read a little more.

I also recall there being something about this in the ACLS guidelines as well.

(I have had the crazy preoxygenated patient who stays conscious for 10 seconds of VF though.  Freaky.)


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## MedicBrew (Feb 28, 2012)

systemet said:


> (I have had the crazy preoxygenated patient who stays conscious for 10 seconds of VF though.  Freaky.)



I’ve seen something similar, luckily I wasn’t lead. I did however have a patient that started out in CHB, so we started pacing. Did a rhythm check and he was in Asystole, and when I paused the TCP he would go unconscious for a few seconds. Un-pause it and he would start up at the exact point in conversation that he left. 

This was in a rural area so we called for a helicopter. The little flight nurse seen that the combo pads were not compatible and just ripped them off. He went out and she seen the monitor and put her’s on right quick and in a hurry. And I’ll be danged if he didn’t pick up his conversation where he left it. Damnedest thing I ever seen


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