# Cardiac Arrest Save



## LACoGurneyjockey (Dec 11, 2014)

You respond to the local gym for a reported cardiac arrest. Enroute dispatch updates there is an AED on site. Shortly after they advise the AED has shocked the patient twice. You arrive to find a late 50s male lying supine on the floor by the free weights, GCS of 5. Pulse is rapid and strong, breathing at 24 times a minute. Pupils are PERRL, lungs are clear, skin is warm pale moist. 
Your local community hospital is 7 minutes away and has very limited capability. Your Trauma/STEMI/Stroke center is 80 minutes away. 

What additional information do you need?
What are you going to do for this patient?
And what's your destination hospital?


----------



## PotatoMedic (Dec 11, 2014)

12 lead, iv, any trauma?, any chance we know what supplements he takes? Does he have a gag reflex?

Right now I want to see a 12 lead and start an iv.  Any capnography?  Right now I am thinking of bypassing the community and going to the hospital 80' away.  Also considering rsi.  Though I might try nasal incubation first.


----------



## EMT11KDL (Dec 11, 2014)

are you ALS or BLS Unit? How long was the down time before CPR started, what exactly was he doing before hand.  Does the gym have there members fill out a medical question card (Mine does and its updated every year with your membership, it ask basic medical history, medications, allergies).  

12 lead for sure! BG, Can I fly? and ROSC Care,

BLS unit, straight to Local Hospital.  ALS Unit, this is going to be a call in and talking to the provider and have him tell me where he wants the patient.  But if  I am having to transport, most likely to Community hospital for lab work, hypothermic treatment,  But a lot is going to be determined on the patients history


----------



## chaz90 (Dec 11, 2014)

LACoGurneyjockey said:


> You respond to the local gym for a reported cardiac arrest. Enroute dispatch updates there is an AED on site. Shortly after they advise the AED has shocked the patient twice. You arrive to find a late 50s male lying supine on the floor by the free weights, GCS of 5. Pulse is rapid and strong, breathing at 24 times a minute. Pupils are PERRL, lungs are clear, skin is warm pale moist.
> Your local community hospital is 7 minutes away and has very limited capability. Your Trauma/STEMI/Stroke center is 80 minutes away.
> 
> What additional information do you need?
> ...



12 lead, capnography, 2x PIV access. What do we have for a HR, rhythm interpretation, SpO2, and BP? Medical history? Medications? Signs of dialysis? ICE contacts in phone for further info? Did bystanders notice anything before he collapsed? How long before CPR, and how long did they do compressions?

I'd likely start an Amiodarone drip of 150 mg over ~10 minutes depending on the rhythm. Severe hypotension wouldn't surprise me in the slightest, so I'd be running 20-30 mL/kg of cold saline to initiate hypothermia along with ice packs in the groin and axilla. If he remains hypotensive (so many ROSC patients are), I'd have dopamine ready.

I'd obviously have pads on this patient for rapid defibrillation if necessary. I'd also likely have my LUCAS on the patient prior to transport in case he re-arrests during transport.

I'd also control the airway of this patient. We're going to need an advanced airway to cool, and his current level of consciousness likely precludes maintenance of his own airway. Standard orotracheal intubation if no gag reflex, otherwise RSI with etomidate and succinylcholine. I wouldn't keep the patient paralyzed after intubation unless something changed or he shivered a lot. 

The local facility might actually be a consideration if no STEMI is obvious on 12 lead. They could run labs, correct electrolyte abnormalities, start thrombolytics or a NTG drip if necessary along with other pressors or antiarrhythmics. As someone mentioned, possibility of flight to Cath lab facility? If I see a STEMI, I'd be far more tempted to just go to the more capable hospital. Either way, I'd be consulting with medical control regarding their thoughts on a transport decision. If unable to secure an airway or the patient re-arrests, obviously go to local facility.


----------



## LACoGurneyjockey (Dec 11, 2014)

Right now I 





EMT11KDL said:


> are you ALS or BLS Unit? How long was the down time before CPR started, what exactly was he doing before hand.  Does the gym have there members fill out a medical question card (Mine does and its updated every year with your membership, it ask basic medical history, medications, allergies).
> 
> 12 lead for sure! BG, Can I fly? and ROSC Care,
> 
> BLS unit, straight to Local Hospital.  ALS Unit, this is going to be a call in and talking to the provider and have him tell me where he wants the patient.  But if  I am having to transport, most likely to Community hospital for lab work, hypothermic treatment,  But a lot is going to be determined on the patients history



ALS unit P/B staffing with BLS Fire on scene.
No gag reflex.
He can't tell you and no one on scene knows that supplements.
12 lead shows sinus tach at 110 and RBBB.
3-5 min downtime, bystander cpr immediately and the AED was applied "in a minute or two" according to facility staff, before it shocked twice. Airship is available. BGL is 110. No further Hx, NKDA.
No trauma. They say "he was just lifting weights and then he collapsed. That's when they started cpr". BP 136/72. 
By the time you load him into the truck he is biting on the OPA, GCS has increased to 13.


----------



## chaz90 (Dec 11, 2014)

LACoGurneyjockey said:


> Right now I
> 
> ALS unit P/B staffing with BLS Fire on scene.
> No gag reflex.
> ...


Improving GCS, good vitals, and no STEMI? Again, consult with med control, but a nice slow ride to the local hospital is sounding fine.


----------



## DesertMedic66 (Dec 11, 2014)

I was going to type out a long response but I'm lazy so im just going to second everything chaz90 has said (well we don't have RSI for my area)


----------



## LACoGurneyjockey (Dec 11, 2014)

This scenario has a great twist of an ending, but I was just informed by my supervisor not to pass this information on in any way. Boy do I feel like **** for starting this one now...


----------



## chaz90 (Dec 11, 2014)

Hahaha. Oh well. We can just start guessing...Knowing that it's a twist, how about that he just vagaled out, never arrested, and was shocked twice inappropriately? Super unlikely, but it would certainly qualify as twist! 

And yes, I realize you can neither "confirm nor deny" any guesses


----------



## NomadicMedic (Dec 11, 2014)

I've not heard of any recent cases of inappropriate shocks delivered by an AED, when used correctly by a bystander, never mind 2. That would be an interesting download to look at.


----------



## chaz90 (Dec 11, 2014)

DEmedic said:


> I've not heard of any cases of inappropriate shocks delivered by an AED, never mind 2. That would be an interesting download to look at.


Yeah, I haven't either. Just trying to figure out what kind of twist ending it could be. Perhaps they were frantically shaking the pads at a V Tach-ish frequency? Sounds unlikely to me too...


----------



## NomadicMedic (Dec 11, 2014)

Maybe those supplements led to sinus tach with a nice wide qrs that looked like vtach to the box?

Or, it was just a "woke up after 2 shocks".


----------



## chaz90 (Dec 11, 2014)

DEmedic said:


> Maybe those supplements led to sinus tach with a nice wide qrs that looked like vtach to the box?
> 
> Or, it was just a "woke up after 2 shocks".


He does have a RBBB and is still a bit tachy now, so the wide complex tachycardia open to computer algorithms is a possibility.


----------



## Tigger (Dec 11, 2014)

LACoGurneyjockey said:


> This scenario has a great twist of an ending, but I was just informed by my supervisor not to pass this information on in any way. Boy do I feel like **** for starting this one now...


Well that's silly...


----------



## MedicDank (Dec 11, 2014)

Your not giving out any personal info, we don't even know what service you work for. Why does it matter??


----------



## PotatoMedic (Dec 11, 2014)

Because his supervisor obviously looks on the forum and told him to stop.  And since I think he likes being employed he is listening even if he is not breaking any laws.


----------



## LACoGurneyjockey (Dec 11, 2014)

FireWA1 said:


> Because his supervisor obviously looks on the forum and told him to stop.  And since I think he likes being employed he is listening even if he is not breaking any laws.


Winner winner...


----------



## Ewok Jerky (Dec 12, 2014)

That's dumb.


----------



## DesertMedic66 (Dec 13, 2014)

beano said:


> That's dumb.


Not really. It's called good PR.


----------



## Carlos Danger (Dec 13, 2014)

DesertEMT66 said:


> Not really. It's called good PR.



Good PR for who?


----------



## DesertMedic66 (Dec 13, 2014)

Remi said:


> Good PR for who?


the company and it allows the citizens (well maybe just a couple) to say they saved a life. Without going into further detail I can't say.


----------



## Ewok Jerky (Dec 13, 2014)

DesertEMT66 said:


> Not really. It's called good PR.


We're not talking to the local news about a less than favorable outcome here, were talking about a teachable moment among professionals. In an anonymous internet forum no less.


----------



## DesertMedic66 (Dec 13, 2014)

beano said:


> We're not talking to the local news about a less than favorable outcome here, were talking about a teachable moment among professionals. In an anonymous internet forum no less.


Teachable moment among professionals? Yes. Anonymous forum? Hardly.


----------



## LACoGurneyjockey (Dec 13, 2014)

Everybody who needs to know already does. Let's leave it at that and let them have their little moment.


----------



## PotatoMedic (Dec 13, 2014)

Wrong spot...


----------

