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

[zmedic]

From the MD perspective. First of all it's worth remembering that in some places the person you get on the phone is potentially someone with little EMS experience, who got 5 or 6 ride alongs in residency and that's it. So some of them just don't trust medics or EMTs, they tend to be more "bring them in so I can see what is going on." Not that it's right, just worth remembering.

Similarly it is hard to call a cardiac arrest over the phone on a 35 year old. I understand that dead is dead, that you aren't going to bring back someone from asystole. But it's harder to give up on young people. We tend to work them longer in the ER. And from a liability standpoint, I would think it's much more likely that someone is going to question stopping an arrest on a 35 year old who is relatively healthy than an 80 year old on 30 meds and lots of problems.

So I don't know about the succs. But I think I back a doc who says "the story I'm getting from EMS doesn't make sense. (ie good C02+rigor) I'm not going to call an arrest over the phone if I don't understand what's going on, so let's just have them transport."

You could aruge what's the downside of giving the guy succs. If it's really rigor, he's dead and can't get worse. If it's not rigor, maybe increases the chances of getting a tube.

 

[systemet]

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

You can have cardiac arrest patients presenting with "instantaneous rigor" (aka "cadaveric spasm", "instantaneous rigidity", "cataleptic rigidity").

A percentage of these patients are probably in a low output pseudo-PEA. There's a few case reports on Pubmed. Some respond to neuromuscular blockers, others don't and may require cricothyroidotomy.

True rigor normally takes an hour or two to develop, and as others have noted won't be responsive to neuromuscular blockers. It's caused by activation of troponin, allowing for cross-bridge formation in the absence of ATP to allow for disengagement. The cytoplasm is already full of [Ca2+], the cell's already depolarised, and it's not triggered by nAChR binding.

Lee JH, Jung KY.
Emergency cricothyrotomy for trismus caused by instantaneous rigor in cardiac arrest patients.Am J Emerg Med. 2011 Jun 13. [Epub ahead of print]

 

[MedicBrew]

You can have cardiac arrest patients presenting with "instantaneous rigor" (aka "cadaveric spasm", "instantaneous rigidity", "cataleptic rigidity").

A percentage of these patients are probably in a low output pseudo-PEA. There's a few case reports on Pubmed. Some respond to neuromuscular blockers, others don't and may require cricothyroidotomy.

True rigor normally takes an hour or two to develop, and as others have noted won't be responsive to neuromuscular blockers. It's caused by activation of troponin, allowing for cross-bridge formation in the absence of ATP to allow for disengagement. The cytoplasm is already full of [Ca2+], the cell's already depolarised, and it's not triggered by nAChR binding.

Lee JH, Jung KY.
Emergency cricothyrotomy for trismus caused by instantaneous rigor in cardiac arrest patients.Am J Emerg Med. 2011 Jun 13. [Epub ahead of print]

After reading more about it, this seems plausible.

thanks for the references systemet!!

 

[systemet]

After reading more about it, this seems plausible.

thanks for the references systemet!!

No problem man!

I've had no personal experience with this, although I have one of those "a guy I know told a guy I know" sort of EMS tall stories from a crew I worked with who ran an arrest that started off as a "stat" transfer out of a small rural ER. They had a guy in VF, who they had to push sux on. At the time I assumed that they had seen some sort of seizure artefact on the ECG and mistaken it for VF. Then I read a little more.

I also recall there being something about this in the ACLS guidelines as well.

(I have had the crazy preoxygenated patient who stays conscious for 10 seconds of VF though. Freaky.)

 

[MedicBrew]

(I have had the crazy preoxygenated patient who stays conscious for 10 seconds of VF though. Freaky.)

I’ve seen something similar, luckily I wasn’t lead. I did however have a patient that started out in CHB, so we started pacing. Did a rhythm check and he was in Asystole, and when I paused the TCP he would go unconscious for a few seconds. Un-pause it and he would start up at the exact point in conversation that he left.

This was in a rural area so we called for a helicopter. The little flight nurse seen that the combo pads were not compatible and just ripped them off. He went out and she seen the monitor and put her’s on right quick and in a hurry. And I’ll be danged if he didn’t pick up his conversation where he left it. Damnedest thing I ever seen