Med Controls orders that make you say, WTF!!!!!

[MedicBrew]

Called to a cardiac arrest of a 35 y/o male with pre-arrivals in progress, unknown down time.

Girl friend is hysterical and poor historian making any information very difficult.
Efforts started by LEO prior to arrival, so BVM w/ NPA and lucas placed. He was pinched in-between bed and dresser, of back room of course. Patient moved to cot then unit with BLS in progress. My paramedic student partner was at the head at that time. Then a FTO unit shows up and the FTO asked if his trainee could intubate as he needs an airway so he can be released. I say “No Problem”. To make a long story short, he is unable to open the patient’s airway. I assess it and after kicking myself for not checking earlier I realize that he is rigored.

MC contacted per protocol to cease efforts. To my surprise he orders sux!!!
I politely inform the Dr. the patient is asystolic with unknown down time and I was asking for cease efforts. He replied, continue and if that doesn’t work, try a nasal tube, continue transport….Click

So we continue our frivolous effort s and the FTO got his contact and eventually got an oral tube with an EtCo2 of 50. The ED works the poor fellow for 30 minutes and call him. By this time he has rigor to his upper extremities as well.

Has anyone EVER heard of giving Sux to a dead guy and why???

I’ve been doing this for awhile and have never encountered this before. I’ve done some research and can’t find anything.

Taking into consideration the patients relative young age, I fail to see the physician’s reservation to stop efforts.

Thoughts???

 

[Shishkabob]

EtCO2 of 50 makes me think that the Lucas was still getting decent cirulation with cell metabolism going on.




But sux for an arrest? Nope, haven't heard of it.

 

[DrankTheKoolaid]

First dont kick yourself for missing the (rigor). That was your students job to find it in the first place.

rant on* The thing that irks me about some interns. School is where you learn, Internship is where you learn to do it safely under my watchful eye. Should not have to be taught to look for that stuff or your protocols once in internship rant off*

Obviously you cant give us the full report you called in, but what did the man look like and how did you portray that to OLMC? still warm? skin color? (MD considering Trismus hence the sux order)

What was CM showing when you had a ETCO2 of 50?

 

[jjesusfreak01]

EtCO2 of 50 makes me think that the Lucas was still getting decent cirulation with cell metabolism going on.

Wouldn't that normally indicate that the patient had arrested more recently than you would expect if they were in rigor?

 

[DrankTheKoolaid]

Yup, my point exactly

 

[MedicBrew]

First dont kick yourself for missing the (rigor). That was your students job to find it in the first place.

rant on* The thing that irks me about some interns. School is where you learn, Internship is where you learn to do it safely under my watchful eye. Should not have to be taught to look for that stuff or your protocols once in internship rant off*

Obviously you cant give us the full report you called in, but what did the man look like and how did you portray that to OLMC? still warm? skin color? (MD considering Trismus hence the sux order)

What was CM showing when you had a ETCO2 of 50?

Initially, cyanotic face/chest/ upper ext's. Core slightly warmer than room temp, no lividity noted at all (hence the reason we started efforts), distal ext's cool to touch.

He stayed asystolic throughout. As far as the trismus, we were not getting anything from the gf, WAY to hysterical for any type of communication..

What I didn't mention in the OP was the Sux actually did loosen up the jaw enough to get the blade in to facilitate the intubation. Just was a first for me..

 

[STXmedic]

What I didn't mention in the OP was the Sux actually did loosen up the jaw enough to get the blade in to facilitate the intubation. Just was a first for me..

Then I would think this patient wasn't "rigor". Succ works on the ACh receptors to cause paralysis. Rigor is typically caused by intra cellular ATP depletion- thus Succ would have no effect on reversing this.

 

[medicsb]

I have heard of this being done. I've had patients in CA initially have trismus, which usually went away in a couple minutes. One was a pt. that coded in front of me. I noticed in one of the Seattle/King Co. ETI studies that a number of CA pts. were given succs.

Also, from what i know, it doesn't seem physiologically possible for succs to have any effect on rigor once it has begun to set in.

 

[DrankTheKoolaid]

re

Exactly. With his age I would be inclined to think a drug induced trismus, unless he had some other pathology.

 

[medicsb]

Then I would think this patient wasn't "rigor". Succ works on the ACh receptors to cause paralysis. Rigor is typically caused by intra cellular ATP depletion- thus Succ would have no effect on reversing this.

Also, it is the abnormal permeability of the cell membrane to Ca that causes the stiffness. The ATP is actually needed for relaxation. For succs to work, there would have to be an cell membrane electrochemical gradient of Ca and ATP stores in order to induce paralysis.

 

[MedicBrew]

Then I would think this patient wasn't "rigor". Succ works on the ACh receptors to cause paralysis. Rigor is typically caused by intra cellular ATP depletion- thus Succ would have no effect on reversing this.

This is along my thoughts as well, but his jaw coincidently relaxed approx 3 min after administration.

Aw, another point I failed to mention. The ED staff usually asked us to leave the lucas in place while they continue the code, which we did while I finished my PCR.

When they were done, I went in to remove the device. When removed his arms stayed vertical as they were when secured to the device which seemed to confirm that it was rigor.

Total patient contact time was 32 minutes.

 

[46Young]

I second the comments on Sux. Also, if the pt were indeed in rigor, the ETCO2 could not possibly rise to 50. ETCO2 in a viable arrest (not for hours such as in rigor) can range from below 10 (if prolonged downtime or from low quality CPR), to the mid 20's if the pt just went down. An ETCO2 of 50 is stongly suggestive of ROSC (CO2 washout immediately following ROSC can kick ETCO2 into the 50's, then it settles at a lower number), or perhaps the pt was never in arrest in the first place. If you drop a tube and the ETCO2 is 50 right away, the pt probably wasn't in arrest when the tube was dropped.

Edit: I don't have experience with the Lucas and quantitative capnography together. Is it possible to have an ETCO2 north of 30 mmHg with one in place and no spontaneous pulse?

 

[MedicBrew]

or perhaps the pt was never in arrest in the first place. If you drop a tube and the ETCO2 is 50 right away, the pt probably wasn't in arrest when the tube was dropped.

Asystole in all leads (I,II,II, Paddles, aVR, aVL, aVf). No electrical activity. ZERO.

or Edit: I don't have experience with the Lucas and quantitative capnography together. Is it possible to have an ETCO2 north of 30 mmHg with one in place and no spontaneous pulse?

As for the effectiveness of the lucas, I have actually asculatated a systolic pressure of 140 in an asystolic patient. Really impressive if you ask me.

When the patient was initially intubated and 50 mmHg was noted, Compressions where halted for a pulse check, None. Rhythm check reveled persistent asystole.

 

[DrankTheKoolaid]

Having a artificially created BP secondary to mechanical compressions is one thing. But a ETCO2 of 50 = cellular processes still taking place and not rigor mortis. Unless it is one of those cases I read about while doing coroners work when a patient essentially burns up almost all generated ATP just before death causing an "almost" instantaneous rigor mortis which is supposed to be like a 1 in a million.

 

[MedicBrew]

Having a artificially created BP secondary to mechanical compressions is one thing. But a ETCO2 of 50 = cellular processes still taking place and not rigor mortis. Unless it is one of those cases I read about while doing coroners work when a patient essentially burns up almost all generated ATP just before death causing an "almost" instantaneous rigor mortis which is supposed to be like a 1 in a million.

I agree, but the 50 mmHg lasted approx 5-7 min max, then decreased to 10 and stay around there. Sorry I may not have been very clear about that fact. Having a EtCo2 of 20 or below is fairly common in an arrest.

 

[46Young]

Asystole in all leads (I,II,II, Paddles, aVR, aVL, aVf). No electrical activity. ZERO.


As for the effectiveness of the lucas, I have actually asculatated a systolic pressure of 140 in an asystolic patient. Really impressive if you ask me.

When the patient was initially intubated and 50 mmHg was noted, Compressions where halted for a pulse check, None. Rhythm check reveled persistent asystole.

My understanding is that with CPR, you're really only pumping the rt ventricle, and with devices such as the Lucas or the Autopulse, it better encompasses the heart. I could see that ETCO2 during an arrest with the Lucas I suppose, but several hours after death???? Strange indeed. Can you ask the doctor on that call how that could be possible?

 

[MedicBrew]

My understanding is that with CPR, you're really only pumping the rt ventricle, and with devices such as the Lucas or the Autopulse, it better encompasses the heart. I could see that ETCO2 during an arrest with the Lucas I suppose, but several hours after death???? Strange indeed. Can you ask the doctor on that call how that could be possible?

I did and he had to scratch his head. I even asked if it may possibly have been a dystonic reaction. (unlikely, but not impossible). He was as puzzled as I was.

I may have missed something, I don't know.

 

[jjesusfreak01]

Then again, there are a lot of suspected PE arrests in the ER that present with decent ETCO2 readings...I personally don't understand that either...

 

[46Young]

Then again, there are a lot of suspected PE arrests in the ER that present with decent ETCO2 readings...I personally don't understand that either...

I would expect the conscious pt with a PE to have a decreased ETCO2 due to the affected area being deprived of blood flow, and especially during a PE arrest. Normal ETCO2 readings in a PE arrest baffles me as well.

 

[mycrofft]

Maybve you said "rigor" and the controller thought "trysmus"?>