Full Arrest EKG

[exodus]

From a full arrest we ran the night before last, slightly less than 10 mins downtime, asystole on scene, to v-fib , shocked, gave more epi, to sinus tach with a pulse. Lost pulse as we were pulling into the ER, they only worked him for ~10 more mins before calling him. He even tried to start breathing on his own again, his thorax was moving like in an agonal respiration.

Edit: Look at that f'ing CO2.

 

[exodus]

We also had a legit OD today too, over 30 digoxin, and 60 metropolol, and then 80 of something else, all new refills.

Sinus brady with arythmia @30-40, BP of 60. Got 2 doses of activated charcoal down on him, called for orders for glucagon, but they were denied

 

[chaz90]

We also had a legit OD today too, over 30 digoxin, and 60 metropolol, and then 80 of something else, all new refills.

Sinus brady with arythmia @30-40, BP of 60. Got 2 doses of activated charcoal down on him, called for orders for glucagon, but they were denied

Haven't had a good OD in a long time...Just out of curiosity, why didn't you choose to pace?

 

[Carlos Danger]

We also had a legit OD today too, over 30 digoxin, and 60 metropolol, and then 80 of something else, all new refills.

Sinus brady with arythmia @30-40, BP of 60. Got 2 doses of activated charcoal down on him, called for orders for glucagon, but they were denied

SBP of 60 and you were denied orders for glucagon? Makes my brain hurt.

I wonder what the first thing was that the ED gave him?

 

[DesertMedic66]

We also had a legit OD today too, over 30 digoxin, and 60 metropolol, and then 80 of something else, all new refills.

Sinus brady with arythmia @30-40, BP of 60. Got 2 doses of activated charcoal down on him, called for orders for glucagon, but they were denied

What base station did you guys call?

 

[8jimi8]

i can't find the co2 what was it?

From a full arrest we ran the night before last, slightly less than 10 mins downtime, asystole on scene, to v-fib , shocked, gave more epi, to sinus tach with a pulse. Lost pulse as we were pulling into the ER, they only worked him for ~10 more mins before calling him. He even tried to start breathing on his own again, his thorax was moving like in an agonal respiration.

Edit: Look at that f'ing CO2.

 

[exodus]

Haven't had a good OD in a long time...Just out of curiosity, why didn't you choose to pace?

I wasn't the medic, but even if I was, I don't think I would have, he was still AO&4 and completely awake and alert, only a 12 minute transport time as well. If he would have became altered, then probably would have gotten paced.

What base station did you guys call?

DRMC.

Here's the protocol for it, I guess we could have gone with CaCl as well, I haven't ever seen that drug used.
http://remsa.us/policy/2014/4602.pdf

 

[exodus]

i can't find the co2 what was it?

From a full arrest we ran the night before last, slightly less than 10 mins downtime, asystole on scene, to v-fib , shocked, gave more epi, to sinus tach with a pulse. Lost pulse as we were pulling into the ER, they only worked him for ~10 more mins before calling him. He even tried to start breathing on his own again, his thorax was moving like in an agonal respiration.

Edit: Look at that f'ing CO2.

39, on the bottom left of the last strip.

 

[DesertMedic66]

I wasn't the medic, but even if I was, I don't think I would have, he was still AO&4 and completely awake and alert, only a 12 minute transport time as well. If he would have became altered, then probably would have gotten paced.



DRMC.

Here's the protocol for it, I guess we could have gone with CaCl as well, I haven't ever seen that drug used.
http://remsa.us/policy/2014/4602.pdf

I've only had one call where we pushed calcium. We called to get an order to stop CPR. Doc wanted us to empty the med box in the pt before we called.

 

[STXmedic]

We use CaCl all the time down here. We have a huge dialysis population here, and our MDs want it given as a 3rd line drug on all cardiac arrest patients that receive dialysis.

 

[Anjel]

Ya for us... Dialysis patient= Calcium and bicarb

 

[KellyBracket]

SBP of 60 and you were denied orders for glucagon? Makes my brain hurt.

I wonder what the first thing was that the ED gave him?

With a bradycardia and hypotension, and a presumed huge digoxin OD, the first drug I'm ordering is Digibind. For a true dig OD, everything else is just window dressing. I imagine that will take some time to come from the pharmacy, though, so the first drug the patient would actually receive would be a pressor, like NE.

Glucagon is fine, but I doubt you carry more than 2 mg in your rig. The dosing is high for BB OD, and I would probably have to wait for that to arrive as well. Not sure why your protocol lists CaCl for BB OD - not great evidence for that. Insulin infusions have been touted lately, and seem to have good evidence.

FWIW, there is a (recently debunked) myth about the theoretic harm of giving calcium to a digoxin-toxic patient.

 

[blindsideflank]

sbp of 60 and you were denied orders for glucagon? Makes my brain hurt.

I wonder what the first thing was that the ed gave him?

l
e
v
o
p
h
e
d

Edit: just read above and I was beaten to it. So ill say probably dopamine because its easier
for a doctor to order nurses to get dopamine going than NE

 

[teedubbyaw]

Maybe it's been a long day, but that doesn't look like sinus tach.

 

[DesertMedic66]

Maybe it's been a long day, but that doesn't look like sinus tach.

Using the triplicate method I would put the rate between 100-150. More around 110-115bpm.

 

[unleashedfury]

With a bradycardia and hypotension, and a presumed huge digoxin OD, the first drug I'm ordering is Digibind. For a true dig OD, everything else is just window dressing. I imagine that will take some time to come from the pharmacy, though, so the first drug the patient would actually receive would be a pressor, like NE.

Glucagon is fine, but I doubt you carry more than 2 mg in your rig. The dosing is high for BB OD, and I would probably have to wait for that to arrive as well. Not sure why your protocol lists CaCl for BB OD - not great evidence for that. Insulin infusions have been touted lately, and seem to have good evidence.

FWIW, there is a (recently debunked) myth about the theoretic harm of giving calcium to a digoxin-toxic patient.

I've seen Calcium Gluconate dripped in the ED with a Beta Blocker OD. Insulin I've heard a little bit about that from our medical director. But what about your Insulin Dependent diabetics? how well are they going to handle a insulin infusion or is it a matter of fix the Brady/Hypotension first and worry about the sugar later?

ETA - Our protocol calls for possible MC orders for Glucagon in BB OD. CaCl, is reserved for known dialysis patients, and Calcium Channel Blocker OD's.

 

[KellyBracket]

You infuse dextrose to maintain euglycemia.

This is more commonly described for Ca-channel blocker OD, but a case report od its use in BB OD can be found at http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3550395/.

 

[Aprz]

Using the triplicate method I would put the rate between 100-150. More around 110-115bpm.

I think the issue is lack of any real discernable p-wave.

By the way, the monitor says 114 on the left side. I assume that's the heart rate. You can also do 300/# of big boxes (300, 150, 100, 75, 60, 50) or 1,500/# of small boxes (300 x 5 = 1,500 because 5 small boxes in one big box). Ratios. I would have said the rate is between 115 - 125.

big boxes: small boxes
300: 250, 214, 187, 167
150: 136, 125, 115, 107
100: 94, 88, 83, 79,
75: 72, 68, 65, 62,
60: 58, 56, 54, 52
50

Not useful to remember these, but I did the math so many times when interpreting 12 - leads for Emergency Physicians that I know 'em, lol. I'll be like "300, 150, 137, 125, 115" starting off with big boxes than little boxes.

 

[teedubbyaw]

Using the triplicate method I would put the rate between 100-150. More around 110-115bpm.

Not the rate I'm looking at. That is not sinus by any normal standards that I'm aware of. Wide complex, biphasic P? retrograde? I'd want a 12 lead to really look at it (obviously not so much on this patient)

 

[VFlutter]

SBP of 60 and you were denied orders for glucagon? Makes my brain hurt.

I wonder what the first thing was that the ED gave him?

Did you want an IVP of glucagon or a drip? A push isn't really all that helpful without a follow up drip and I doubt you have enough for a drip. The half life is so short you probably only get ~5mins out of it.

Not "you", but the OP.