First cardiac arrest as a medic

[Epi-do]

We just got back from the hospital a little bit ago and I am unable to sleep, so I thought I would post.

We were dispatched for an overdose and enroute are informed that it is an arrest. We get to the house and the wife meets me at the door. She points me in the direction of the bedroom and as I am walking in I ask when she last saw the patient. She tells me about 10 minutes ago, but goes on to say that she has been walking past the bedroom and the patient had went to bed earlier in the evening. I then ask when she last talked to the patient and she tells me almost two hours ago. PD is already there and has pulled the patient off the bed and onto the floor.

I check for a pulse and there isn't one, and he obviously isn't breathing so my partner begins bagging and one of the medics off the engine that walked in right behind me begins CPR. I put the pads on the patient and turn on the monitor to find him in asystole. I then intubate. The second medic off the engine is looking for IV access for me. We find out there are 25 methadone missing and also find an empty pill bottle for something else that was filled yesterday.

My plan is to get IV access, push a couple rounds of drugs and call the hospital for orders to stop. Well, the guy has no veins at all. There are three medics and we all take turns looking. We make a couple attempts and aren't successful so we get the EZ-IO out. One of the other medics goes to put it in the humerous, finds his landmarks and suddenly says something doesn't feel right. The needle bent - I've never seen that before, but what can you do.

The other medic off the engine then puts the IO in the tibia. He felt a pop, the needle went right in like it should, but the line won't run at all. (I know that an IO doesn't run exactly like an IV, but absolutely nothing was infusing.) Well, I know the hospital won't give me orders to stop without pushing a couple rounds of drugs, so we go ahead and transport. We continue to try and get some sort of access on the way to the hospital but just have no luck at all.

I call in and give the receiving ER a report, and after getting him there and moved over they try to get access. They are also unsuccessful, so the doc decides to put the drugs down the tube and then call it.

It didn't go quite how I had hoped it would go, but I did get that first arrest under my belt. Seeing the ER unable to get any sort of access did make me feel a bit better about that part of it, but I really wish we hadn't had to transport him at all. It just seemed like a waste of resources to me.

Well, I really need to head off to bed and get some sleep. I think I have finally wound down enough to be able to finally go back to sleep.

 

[johnrsemt]

I miss Indiana where we can work a patient on scene and call the ER, and get permission to call a code on scene.

here we are expected to transport; in my case from our base is at least 45 minutes, emergent to a small hospital, 1h 15 min to a Level I. and if we are off base, add another 20-90 minutes, and most of that is off road. (4 wheel drive amb are neccessities).

congrats, on getting first code, good luck with all.

 

[el Murpharino]

Did you try narcan IM? I understand that it may not absorb well due to the poor perfusion, but it's better than the ET route - which is still an option if you ABSOLUTELY have to...but you and I both know that it's essentially worthless. Plus if you're doing good compressions, you may get it in circulation - somewhat. But at least you would have made some attempt to correct a possible cause of the asystole.

I recently put an IO in a guy's tibia the other day as well, and let me tell ya, the meds to push hard through those. Also (for future references), it helps to have a pressure infuser handy for the bag of saline.

Sounds like you did what you could. At least it was a good learning experience. The next one will run smoother - the first one always seems to run like a clusterf*ck...and something always goes wrong.

 

[Ridryder911]

Did you try narcan IM? I understand that it may not absorb well due to the poor perfusion, but it's better than the ET route - which is still an option if you ABSOLUTELY have to...but you and I both know that it's essentially worthless. I recently put an IO in a guy's tibia the other day as well, and let me tell ya, the meds to push hard through those. Also (for future references), it helps to have a pressure infuser handy for the bag of saline.

Any med given IM in aystole is worthless. One does NOT have to have a commercial grade infuser..... got an extra BP cuff? They work great, and I have NOT seen an I/O that did not require one.

R/r 911

 

[Grady_emt]

Whe we had out EZ-IO inservice, the rep said to take a 10cc flush on an unconscious pt, or per our guidelines, a 10cc Lido prefill and "slam it in there, it'll open some of the fiberous-ness of the marrow and help the drugs/fluids flow better"


In the month we have had them I've used it 3 times. One arrest that resulted in ROSC before arrival at ER after 2epi, 2 atro, 1 bicarb. Second pt was uncon DKA/stroke/GI bleed (yes, all 3 at once, no contact by family for 3days) again inserted without any difficulty, hung a bag and used a manual infuser to run the fluids. 3rd pt was a dialysis pt with severe CHF and had 0 access (tried before, no EJ, no nothing, ER has difficult time with central line). Inserted without difficulty, pushed the lido and then lasix without any problems.

 

[Epi-do]

I miss Indiana where we can work a patient on scene and call the ER, and get permission to call a code on scene.

Yes, it is a nice option. Too bad things didn't work out that way for me. I just see no point in transporting a corpse with lights and siren to the ER. It serves no purpose whatsoever.

Did you try narcan IM?

We do not have the option of narcan IM here. We can give it intranasally, but quite honestly, I didn't even think of that as an option. Like R/r mentioned regarding giving it IM in an arrest, I would think that IN would not be very effective.

Also (for future references), it helps to have a pressure infuser handy for the bag of saline.

We did have a pressure bag thingy that slipped over the saline and you would pump it up, similar to a BP cuff. It just refused to infuse.

Whe we had out EZ-IO inservice, the rep said to take a 10cc flush on an unconscious pt, or per our guidelines, a 10cc Lido prefill and "slam it in there, it'll open some of the fiberous-ness of the marrow and help the drugs/fluids flow better"

We are to flush the line as well, with the same proceedure. We just use saline in an arrest, but will use lido if we have a patient that is going to feel the pain.

 

[Hastings]

It's too bad you couldn't get that IV access. Might have gotten something with Intubation and Narcan IV.

Always have to treat the underlying reason for being in cardiac arrest. And in this case, an overdose may have been a good place to start.

 

[jrm818]

Well really the direct cause of the cardiac arrest is probably respiratory arrest secondary to opioid overdose isn't it? The primary threat to life in opioid overdose is apnea. Ventilation cures that, I'm curious if narcan would really have made much of a difference...I would think probably not.

 

[marineman]

Your protocols honestly have you transporting a pt in asystole with lights and sirens? I'm just a ride along for school now so I'm not exactly sure the companies protocol for transport vs no transport but I know for sure if the pt is PNB the only way we transport emergency is if they have a shockable rhythm.

 

[Hastings]

Well really the direct cause of the cardiac arrest is probably respiratory arrest secondary to opioid overdose isn't it? The primary threat to life in opioid overdose is apnea. Ventilation cures that, I'm curious if narcan would really have made much of a difference...I would think probably not.

Cardiac arrest, caused by respiratory arrest, caused by Opioid overdose.

Fix Opioid overdose which fixes respiratory arrest (with intubation that I mentioned, bagging), fixes cardiac arrest.

Haha, if only it were so simple.

 

[jrm818]

Agreed, but you are already treating the respiratory arrest by ventilating through the ET tube. What more can Narcan do? The pt. isn't going to start spontaneously breathing if they are asystolic.

 

[KEVD18]

there are practitioners still giving drugs down the tube????????

also, if the pt is already deteriorated to asys, its unlikely that narcan is going to be your wonder drug. this game is pretty much over

 

[Epi-do]

Your protocols honestly have you transporting a pt in asystole with lights and sirens?

Yep, that is how we are expected to transport all cardiac arrests. I know there is plenty of info out there about how much time emergent transports save (pretty much none), but that is another topic for another day.

there are practitioners still giving drugs down the tube????????

That's what I thought too. He actually told us that we should have went that route as well. His reasoning was that since we didn't have anything else to work with, it wasn't going to hurt anything.

Of course, this was coming from someone who told the ER staff that they were going to push the drugs just so they could say that they did it. If you have already decided that you are going to call it, why even bother with the drugs?

 

[Scout]

I'm going to steep in here and this is way over my scope but

His reasoning was that since we didn't have anything else to work with, it wasn't going to hurt anything.

Of course, this was coming from someone who told the ER staff that they were going to push the drugs just so they could say that they did it. If you have already decided that you are going to call it, why even bother with the drugs?

Whats he got to loose, the cost of the drugs? He might as well give it a shot as the pt is lying there, not going to get any better without the drugs, and the addition of the drugs will not cause any negitive effect and may have a VERY slim chance of doing something.

So why not, it causes no extra effort and he has nothing to loose.

but as i say way above my paygrade i could be wrong

 

[KEVD18]

it was a waste of drugs, time and effort. the pt was dead. very very not alive. drugs via ett was never incredibly effective early in the code. it certainly isnt going to do the job 40 minutes later.

 

[Jeffrey_169]

I agree

If it been after 40 min, then its pretty much over. But then again, we all have a conscious to follow, and really it couldn't hurt to try.

 

[Ridryder911]

If it been after 40 min, then its pretty much over. But then again, we all have a conscious to follow, and really it couldn't hurt to try.

Actually, my conscious is much cleaner to call a code than to work one. Realistically, we know we will not resuscitate them. There is < than a 6% chance of sucess and that is if we (EMS) perform the code < if it was in a hospital setting. Also all the planets aligned, CPR, time and the Grace of God that it will be sucessful. Then what is called success is limited.

Am I saying we should never try, no. Let's be realistic though. We are also saving the family thousands of dollars as well and unrealistic expectations.

Unfortunately, my service still is lacking and that is something that I am still am getting used to, but I have been known to a verbal DNR's.

R/r 911

 

[el Murpharino]

Any med given IM in aystole is worthless. One does NOT have to have a commercial grade infuser..... got an extra BP cuff? They work great, and I have NOT seen an I/O that did not require one.

R/r 911

Agreed on the BP cuff - it's what ends up being used most of the time anyways due to not wanting to fish around a cabinet for the pressure infuser.