Dead or Alive?

[paramedix]

I need some advise about an incident I assisted with today...

We happened to be at our base hospital in the tea room when a car pulled up to the ambulance bay and someone screamed for help.

We found a lady in her late 50's in the back of the car with cyanosis around the neck area and very pale, clammy skin. Known Lupus patient. (and shes a sister working in peads ward)

Some HX:
The patients GCS was 7/15 (E1;V2;M4). The patient was placed on the resus trolley and wheeled into RB. Whilst busy with the patient she was combative, moving around and gasping. I was doing airway at the time, assisted vents etc.
We elected to intubated the patient. Pt received Scoline, intubated - complete protocol. Approx 2 minutes post intubation, pt arrested and cpr began. Stomach immediately started to distend... NG tube = blood. No other HX known.

Need Advice:
We resussed for approx 20 minutes and suddenly the pt started moving around, we stopped...no pulse, appears to have 3-5 breaths per minute, but doesn't look agonal. Continued with cpr and the patient opened her eyes and followed the sister from the right side to the left... she even turned her head. Stopped CPR, no pulse, no breathing... continued, moments later the patient grapped the BVT device and with the other hand grabbed my partners sleeve. WE STOPPED AGAIN... NO SIGNS OF LIFE... This carried on constantly through CPR...

Eventually the doctors called it and the patient was still moving around. She moved for about 5 minutes afterwards... We all checked, rechecked for vitals and changed equipment from another RB to ensure nothing is faulty.

What gives?
I have never seen something like this! I have experienced a similar thing where a patient moved his arm during cpr and had agonal respirations afterwards. I understand that some "movements" or rhythms can be drug induced, but this was something we have never experienced.

1. Is there a name for this?
2. Is this common?
3. Why does it happen?
4. Where can I read up about this?
5. ??

 

[JPINFV]

First,
[YOUTUBE]http://www.youtube.com/watch?v=vpkzhvZ_CFM[/YOUTUBE]

[unwritten rule, any Lupus case gets a Dr. House Youtube].

Second there was a case on the TV show "Real Stories of the ER" (interesting, humorous, or amazing ER stories that were dramatized (in contrast to Trauma: Life in the ER where the events were taped and not reproduced), but narrated by the physician) on the Discovery Channel where they chronicled an arrest where it seemed that the patient would become conscious during CPR. Unfortunately, they were not able to save him either.

 

[LucidResq]

Holy crap. I wish I could tell you about this but I've never heard of anything like that either. That must've been disturbing, to say the least.

 

[MSDeltaFlt]

What was on the monitor when pulseless? I say this because once ER MD ordered me to maintain CPR during Dx'd tampenade to maintain BP. So, I wonder...

 

[paramedix]

What was on the monitor when pulseless? I say this because once ER MD ordered me to maintain CPR during Dx'd tampenade to maintain BP. So, I wonder...

The monitor presented with asystole the whole time. There was no change in the rhythm.

 

[BruceD]

A few questions: Just for my edification.
1. Was the cyanosis *just* around her neck, or was that just where you immediately noticed it? What about the mucosa and extremities? Was there pallor below t4?
2. You said the stomach started to distend 2 mins post intubation and immediately upon commencing CPR with blood return via NG tube. What quantity of blood? Was there no blood prior to this?
3. How long was she down?

As for the movement/grabbing/grasping, a few possibilities that come to my mind.
1. Lower motor neurons, in effect, are responsible for initiating reflexes when they receive the proper input, while upper motor neurons are required to arrest reflexive motions. It's possible, that during cpr something simply triggered a reflexive grasping. This really does not require brain function (I don't think grasping is a learned motor behavior as newborns grasp instinctively). This would be my first thought, unless there was some indication of thought involved, such as, did she attempt to pull the mask up or off her head.
Sometimes, unfortunately, these types of reflexes can be mis-interpreted by family members of acerbic patients in hospitals, giving false hope that their loved one is still 'alive'.
(a quick google search yielded some useful info on Reflexes )

2. It's possible, I suppose, that you had one of those truly rare cases where cpr was *just* able to meet the oxygen needs of the brain. Perhaps she did regain some brain function just while cpr was being performed. Although, I doubt any higher functions could have existed at the time.

3. Last that I can think of would be the electro-chemical imbalances that occur during that first little while of death, when the brain has ceased but the muscles maintain some ability to function.

Any of my ideas may be wrong... even WAY wrong, feel free to correct me (I'll thank you for it).

Thanks for sharing your experience.
-B