Clinical ride cardiac arrest

NYMedic828 said:
Mobitz I is usually presumed to be vagal induced.

Mobitz II is usually infranodal and not affected by vagal tone.
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Anecdotally, I rarely see Mobitz I after vagal stimulation. Mobitz II is more common followed by 3rd degree/AV diss and then some people have sinus arrest and just go into Junctional/Ventricular escape. That is just personal experience but I see it quite frequently. Very common to see with out patients on Chemo.
 
ChaseZ33 said:
Anecdotally, I rarely see Mobitz I after vagal stimulation. Mobitz II is more common followed by 3rd degree/AV diss and then some people have sinus arrest and just go into Junctional/Ventricular escape. That is just personal experience but I see it quite frequently. Very common to see with out patients on Chemo.
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Point taken. I am going off of textbook knowledge. I have literally seen Mobitz II once and it was on a rotation. The crew gave atropine and didn't pace...

Wish I knew better at the time. Patient might of had a chance... (they never did a 12 lead, gave 0.5mg of atropine, no effect. Got to ER, they discover major II/III/AVF elevation. Begin pacing, pretty sure she didn't make it.
 
Where'd the OP go?

I still wanna see a 12 lead.

Assuming the story is factual, people should save strips from these kinds of things for self education and education of others who may never have/will see one.
 
Don't try this at home...

In my medic class, one of our classmates, a marine, volunteered to be paced without sedation.

So we hooked him up to the LP 10 at 70ma and 70 beats.

He was able to tough out the first shock. By the second he had tears in his eyes and after the third he tore the pads off.

We also tried holding a nitro in our ungloved hand and taking one to see how bad and how long the headache lasts.

Just some of the many exploits that make it amazing we are still alive.
 
Doczilla said:
There's easier ways to work out your arms :)
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I did feel the burn. Lol

On kid took his to the max at 175 on his leg. Hilarious.
 
NYMedic828 said:
Point taken. I am going off of textbook knowledge. I have literally seen Mobitz II once and it was on a rotation. The crew gave atropine and didn't pace...

Wish I knew better at the time. Patient might of had a chance... (they never did a 12 lead, gave 0.5mg of atropine, no effect. Got to ER, they discover major II/III/AVF elevation. Begin pacing, pretty sure she didn't make it.
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Like I said its just anecdotal. I rarely see sustained Mobitz II, usually just isolated runs.

I remember a guy who came into the ER in Type II in the 20s. Initially he was somewhat stable so they transQ paced him but then lost capture and did a transvenous at the bedside. It was pretty hectic, he got a PPM in the morning.
 
Having paced myself on several occasions it's just plain mean to dial up the mA too quickly. It makes the muscle contractions more violent. They are far more tolerable when you increase the energy gradually. I capture at 110-120 mA with AP pad placement. Interestingly, the energy has to drop below 90 mA for me to lose capture (then all the way back up to 110-120 mA to achieve capture again). I would consider being paced uncomfortable -- a painful "prickly" feeling, but not intolerable. Having said that, I was choosing to do it and knew I could stop at any time. I think the loss of control and anxiety aspect contributes to a patient's suffering.
 
I believe the movie was named Flatliners!

Kiefer Sutherland was in it.

Be careful out there!
 
This was an interesting case to review. I noticed that the OP hasn't chimed in so I'm guessing all the responses are academic.

I agree that the issue here was likely a primary cardiac event. I don't agree that a 12 lead "always" (NYCMedic828) needs to done before pacing. It certainly is preferable and should be very high on the priority list. I try to obtain a 12 lead along with the first V/S. Depending on the capabilites of my partner and 1st responders, that is easier said than done sometimes.

I didn't like seeing the first set of vitals until after the patient had been moved to the truck. Specifically the BP. I'm confident that isn't exactly the way it was. Hopefully they had V/S from the FD but it simply wasn't listed. That being said, the shock and failure to recognize it and treat it early on might have been that only thing to be done that could have prevented this catastrophic collapse of the patient's condition. Was sufficient supplemental oxygen was provided? Was the patient kept in as much of a Trendelenburg position as possible? Fluid resuscitation might have been helpful prior to moving that patient but I don't believe it's presence or absence likely made a difference in this case. For the sake of argument, I will assume basis O2 and pateint positioning was done. If all that is true then I'd guess the EMS team did everything they could to help this patient.

I didn't really follow the comments about pacing and Atropine. I think there was some sarcasm there. But I beleive pacing was the most appopaite course of action at the time when the patient's condition detiorated.

It always good to see how these scanarios develop for others.
 
Since when was trendelenburg shown to be beneficial for anything in the pre hospital setting?
 
We always called trendelenburg "the king county fluid bolus". :)
 
http://www.cjem-online.ca/v6/n1/p48

Trendelenburg has never been proven to have any positive effects. Blood return from the legs is not assisted much by gravity so much as it is by the skeletal muscle pump in the legs which the body will use to compensate on its own.

Other studies I've read also state it is has negative effects on the inferior vena cava because the raising of the legs pushed the abdominal organs towards the heart potentially further limiting venous return.
 
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NYMedic828 said:
http://www.cjem-online.ca/v6/n1/p48

Trendelenburg has never been proven to have any positive effects. Blood return from the legs is not assisted much by gravity so much as it is by the skeletal muscle pump in the legs which the body will use to compensate on its own.

Other studies I've read also state it is has negative effects on the inferior vena cava because the raising of the legs pushed the abdominal organs towards the heart potentially further limiting venous return.
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Thanks for the link. I'm a "just the facts, ma'am" kinda of guy.

"...Recognizing that the quality of the research is poor,..."1 I was a little worried until I got to that sentence. I have never researched this particular treatment. I have recognized that the one position available for this position on cots is pretty extreme for many patients. Goodness, the discomfort from the position alone can cause enough anxiety to defeat any benifits. I've used pillows and such to fabricate more reasonable angles in the past. All that being said, in the first moments positioning and supplemental oxygen are helpful (in my experience). They are also sometimes overlooked.

1: http://www.cjem-online.ca/v6/n1/p48
 
Eli said:
Thanks for the link. I'm a "just the facts, ma'am" kinda of guy.

"...Recognizing that the quality of the research is poor,..."1 I was a little worried until I got to that sentence. I have never researched this particular treatment. I have recognized that the one position available for this position on cots is pretty extreme for many patients. Goodness, the discomfort from the position alone can cause enough anxiety to defeat any benifits. I've used pillows and such to fabricate more reasonable angles in the past. All that being said, in the first moments positioning and supplemental oxygen are helpful (in my experience). They are also sometimes overlooked.

1: http://www.cjem-online.ca/v6/n1/p48
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The full conclusion is a lot more damning.

"The Trendelenburg position is taught in schools and on the wards as an initial treatment for hypotension. Its use has been linked to adverse effects on pulmonary function and intracranial pressure. Recognizing that the quality of the research is poor, that failure to prove benefit does not prove absence of benefit, and that the definitive study examining the role of the Trendelenburg position has yet to be done, evidence to date does not support the use of this time-honoured technique in cases of clinical shock, and limited data suggest it may be harmful. Despite this, the ritual use of the Trendelenburg position by prehospital and hospital staff is difficult to reverse, qualifying this as one of the many literature resistant myths in medicine."

I think you will find that most emergency treatments in critical patients do not have strong research studies.

The reason isn't because of lack of interest, the reason is because of the ethical and legal ramifications.

You will never see studies like: CPR vs. no CPR or The Latest Thing We Could Think of Compared to Time Recognized Standards...

In order to do shock research, I had to resort to neonates because ethics bodies will not approve new or control treatments in adults.

With neonates, the mantra is: "we don't know if the same treatments will work" and it is actually easier to get ethical approval despite the pathophysiology being exactly the same.
 
Eli said:
Thanks for the link. I'm a "just the facts, ma'am" kinda of guy.

"...Recognizing that the quality of the research is poor,..."1 I was a little worried until I got to that sentence. I have never researched this particular treatment. I have recognized that the one position available for this position on cots is pretty extreme for many patients. Goodness, the discomfort from the position alone can cause enough anxiety to defeat any benifits. I've used pillows and such to fabricate more reasonable angles in the past. All that being said, in the first moments positioning and supplemental oxygen are helpful (in my experience). They are also sometimes overlooked.

1: http://www.cjem-online.ca/v6/n1/p48
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The position on stretchers is actually like "Trendelenburg lite". The actual surgical position is much more extreme.

Supplemental O2 (for a patient that probably has an ungodly high PaO2 anyway) and positioning are unlikely to do anything. How much experience are you basing this off of?
 
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Veneficus said:
the ritual use of the Trendelenburg position by prehospital and hospital staff is difficult to reverse
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It may be more accurate to say that the TEACHING of Trendelenburg is inextricably woven into prehospital medicine. Its actual PRACTICE, in my experience, is not particularly embraced.
 
usalsfyre said:
Supplemental O2 (for a patient that probably has an ungodly high PaO2 anyway) and positioning are unlikely to do anything.
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Define unlikely. Then define whether the potential benefit might be outweighed by the potential risk. Many cardiac arrests we work have less than 1% chance of survival. Should we not treat them? Is that the philosophy that I'm hearing in these threads?

usalsfyre said:
How much experience are you basing this off of?
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25+ patients/week through the 80's and 90's in an urban system where physicians and EMS workers drove the practice based on balancing quality/value vs. profit.
 
I hate when the reply I am typing disappears.

Firetender is a much better writer than I am.

I humbly encourage you to read this.

http://emsoutsideagitator.com/

Eli said:
Define unlikely. Then define whether the potential benefit might be outweighed by the potential risk. Many cardiac arrests we work have less than 1% chance of survival. Should we not treat them? Is that the philosophy that I'm hearing in these threads?
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A shorter version:

Blunt traumatic arrest is not worth trying to resuscitate at all. We should not be doing it.

Penetrating is better but still comes in <10% most places. (usually around 6%)

VF/VT from medical cause have a much higher rate, the worst reported numbers in the US I have seen is 9%.

asystole/pea arrests are no longer counted. With the exception of a few immediately identifyable and reversible causes or already in a healthcare facility with a known cause, these people are for all intents and purposes, dead. We should not waste resources trying to resuscitate them.

I have written extensively about supplemental O2, bottom line: Unless the specific pathology requires it, it is a waste and we should not be doing it. That is especially true in trauma.

Positioning in trauma was covered above, but I will just reiterate, it is a waste of time and there is no reason to bother.


Eli said:
25+ patients/week through the 80's and 90's in an urban system where physicians and EMS workers drove the practice based on balancing quality/value vs. profit.
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The game has changed considerably. Value for the patient (or relatives) is no longer even part of the equation in the US. Now it is all about profit.

We also realize we are no longer in combat with death. Survival is measured to neuro intact discharge, not by a pulse in the ED.

Welcome to the forum.
 
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