Heart Laceration

mttbdtd

mttbdtd

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3am CPR in progress goes out. We arrive less than 5 minutes from our tones. Mid 60's male, was complaining of heartburn then slid out of chair and onto floor. Only has history of hypertension. My partner and I are first on scene. A male family member is doing what appears to be effective compression only CPR. We do not follow ACLS where I work we use high performance CPR. Pulseless confirmed, compressions, pads on he's in course v-fib. Shock, back on compressions. CPR see through shows what looks to be an agonal PEA. Fire arrives we continue on. Long story short over the course of the code he received 7 shocks, 9 epi, bicarbonate, lidocaine, ETT, blood sugar is good, ETCO is showing around 38 with a spike to 72 that ended up not being rosc. Only showed course v-fib and agonal pea throughout. High suspicion it is an AMI but I can find nothing else with h's and t's. Worked for 40 minutes and after PEA persisted I called for termination. Autopsy comes back with a heart laceration most likely caused by CPR with no mention of tamponade or thrombus. Any similar experiences or thoughts on this? Seemed a very viable candidate with a very poor result.
 
I second the AMI, especially with the complaint of heartburn prior to collapse. What did the autopsy say was the cause of death (as I'm assuming the lac to the heart is incidental)? Sometimes, when it is time to go, its time to go. This guy probably needed a cath lab, and there's really nothing you could have done out in the field that would've changed the outcome barring potentially lysing him.
 
I heard about the heart lac third hand through my boss. They seemed to be making a big deal about the heart lac but listing it as contributing. I did not get an answer on the major cause.
 
Patients sustain all sorts of injuries from CPR. Usually never hear about it because they don't usually get autopsied. Even for patients with the best prognosis, death will occur for the majority.
 
$h!t happens when you party in resus mode. CPR is brutal. I'm sure most of my CPR patients have had all sorts of thoracic injuries. Your supervisor likely has no idea what he's talking about.

My wife (medic/CPR instructor) had a 50ish guy with no previous MI history have an SCA in front of her at Wal Mart a couple of weeks ago. She initiated CPR and the local FD happened to be outside doing fill the boot. He literally had a less than 1 minute response time with CPR from moment of arrest. They got a ROSC but he never regained consciousness and later died. You can't win them all, AHA and EMT scenarios lied to you. A lot of times you do everything right and they still die.
 
Sounds like bollocks - unless somebody unbeknownst to you stabbed him in the chest and cause a laceration to his pericardium, as this would be the only clinically significant injury in the setting of PEA.

As an aside, the Hs and Ts are a bit of a waste of time in the prehospital cardiac arrest if you ask me. People like to rattle them off as "reversible causes" however most of them are only "reversible" in a theoretical sense i.e. you must have reached the patient in an appropriate timeframe, have access to appropriate information to allow a clinically strong possibility of a reversible cause to become obvious within an appropriate timeframe, and have access to appropriate treatment within a timeframe which is will be therapeutic.

Patients like this one described, who have otherwise positive prognosticative factors except they remain in VF or VT, and no major contraindications for doing so, are probably likely to be, in the not too distant future, taken to a cath lab with mechanical CPR in place to attempt pPCI. It would not at all surprise me in the slightest if the first places in the world to do this are London, Brisbane/Gold Coast and possibly somewhere in the US.
 
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