Scenario/Protocol Question

[FF/EMT Sam]

Dispatched for a male patient in full cardiac arrest at the local dialysis center. CPR in progress. Upon arrival approx. 3 minutes later, your pt. is seated upright on the bed, fully alert and oriented, with 2L via N/C flowing.

Staff advises that the pt. appeared to doze off, but they then noticed that he did not have a pulse. They started CPR and mouth-to-mask ventilation. Approx. 1 min. later, they stopped CPR so the AED could analyze. AED said "shock advised," but the nurse giving artificial repirations decided to give him one more breath before shocking. When he gave him that breath, the pt. gagged, coughed, vomited, and came back to life, asking why everyone was standing around him.

What do you do?

I ask because ALL of our post-resucitation protocols are for ALS providers. All we could do was 15L NRB and run like hell. Both of us are basics, but we thought that there really should be something that we could do (e.g. "recovery position," etc.) What are your local post resucitation protocols for basics?

 

[jeepmedic]

Over here all an EMT-B can do in this instance is place in recovery position, give 15lpm via NRB, call for ALS and high flow Diesel.

 

[Mercy4Angels]

high flow turbo diesel....

 

[Ridryder911]

Sounds like maybe the staff "took off" too much fluid. I really doubt that this patient was really ever really was in cardiac arrest, rather he "bottomed out" with the sudden removal of fluid and was in probably V-tach. When the patient vomited, this produced a cough conversion which is really common and converted his rhythm. The same as a "thump"..

Electrolyte imbalances and again hypovolemia might be the etiology. For BLS, if you could call for ALS intercept, then yes oxygen, continuous monitoring.

R/r 911

 

[Airwaygoddess]

Good assessment, It happens alot more than folks think. These folks labs values are already "off base" as is and depending on what they have been cheating on with food during the holiday season or missing a dialysis day, these folks are very brittle. Also alot of fluid overload too.

 

[FF/EMT Sam]

I really doubt that this patient was really ever really was in cardiac arrest, rather he "bottomed out" with the sudden removal of fluid and was in probably V-tach.
R/r 911

Can you please clarify this? Thanks.

 

[Jon]

Can you please clarify this? Thanks.

There are 2 rhythms that an AED will allow a shock for. The first is V-Fib, Ventricular Fibrillation. The second is V-Tach, Ventricular Tachycardia.

In V-Fib, the heart muscle is doing nothing more than quivering... It is supposed to look like a “sack of worms” In V-Fib, the heart isn’t pumping blood, so there is no pulse, and the only treatment is the ACLS algorithm of CPR, medications, and defibrillation (unsynchronized electrical therapy).

In V-Tach, the ventricles, the lower chambers of the heart, are beating too fast for the heart chambers to fill with blood; therefore the heart doesn’t pump blood throughout the body. In some instances, this causes cardiac arrest, the same as V-Fib does, where the heart isn’t moving blood and the patient has no pulse or respirations. The treatment for V-Tach without a pulse is the same as for V-Fib: the ACLS algorithm of CPR, medications, and defibrillation (unsynchronized electrical therapy).

However, V-Tach also comes in another form: V-Tach with a pulse. This patient can present as being somewhat stable, but the lower chambers of their heart are contracting too fast. They are still getting enough blood flow to be alive, and in some cases, conscious and talking. These patients are usually treated with medications and then, if needed, the V-Tach is stopped with synchronized cardioversion (unsynchronized electrical therapy).

If the patient is unstable, they fall into a gray area between the 2 algorythyms. These patients are treated first with synchronized cardioversion.

So, in short, RidRyder is saying that your patient was in V-Tach, not V-Fib. The staff fixed the problem, and the cough acted to cardiovert the heart without electrical energy.

 

[FF/EMT Sam]

However, V-Tach also comes in another form: V-Tach with a pulse. This patient can present as being somewhat stable, but the lower chambers of their heart are contracting too fast. They are still getting enough blood flow to be alive, and in some cases, conscious and talking.

Thanks. That was the piece that I was missing. I thought that V-Tach=Cardiac Arrest.

 

[Ridryder911]

Actually some patients can be in V-tach and conscious and alert and never have any symptoms. There are many patients that have experienced V-tach that never know it.

Patients that are on dialysis therapy often have electrolyte imbalance (such as potassium, sodium, magnesium, which are instrumental in causing nerve and muscle contractions) which may preclude ventricular tachycardia and many other arrhythmias.

That is why dialysis patients should have "extra" or differential treatment modalities when treating them.

R/r 911

 

[EMT007]

yeah all of these previous posts are why I would want to get a printout of the rhythm that the AED/monitor/whatever they had recorded on him. If not for you to look at (Basics should at least be able to recognize V-tach and V-fib - some of us have taken full class on EKG interpretation and will be able to recognize other rhythms) then at least for you to take to the ER for the docs there to check out.

For my assessment and treatment, I would check the strip they gave me, get him in shock position, get our 12-lead and high-flow O2 on him, and haul *** to the ER.

 

[KEVD18]

...I really doubt that this patient was really ever really was in cardiac arrest...R/r 911

really????

 

[Ridryder911]

Let us look at it this way.. how many "dead" people you know can cough?

R/r 911

 

[FF/EMT Sam]

I would want to get a printout of the rhythm that the AED/monitor/whatever they had recorded on him. If not for you to look at (Basics should at least be able to recognize V-tach and V-fib - some of us have taken full class on EKG interpretation and will be able to recognize other rhythms) then at least for you to take to the ER for the docs there to check out.

It was V-Tach, so the hypothesises about him not ever really being in cardiac arrest are probably right. EMTs where I work are trained to recognize V-Tach/V-Fib/PEA.

Let us look at it this way.. how many "dead" people you know can cough?

R/r 911

Only one or two....

 

[Ignacio_emt_vn]

Airway and O215lpm NRB and go to the hospital if close enough. Call for ALS if not.

Should be because of an electrolyte imbalance since the patient in dialysis is getting fluids remove from his body through blood. Homeostasis is disturbed, causing abnormalities in the body.