Arrest

[Smash]

57 year old male. History of asthma, no known allergies, takes albuterol reliever.

Ambulance called by family for shortness of breath. First crew (ILS) arrive to find patient severely short of breath, speaking words only with great difficlty, very poor air entry globally, no wheeze on auscultation and a prolonged expiratory phase of the respiratory cycle. Patient was administered albuterol and ipratropium via updraft, IV access gained and loaded to rendezvous with ALS.

En-route to rendezvous pt deteriorates, becomes catatonic, respiratory effort decreases. IM epinephrine is administered (2 x 300mcg), but pt respiratory arrests, then cardiac arrests.

You arrive to find pt in brady-asystolic arrest (PEA on monitor, rate of 10) with CPR being performed, Oropharyngeal airway in situ and being ventilated with difficulty.

Hospital is 40 minutes + transport time, HEMS is not available.

What do you do and why?

 

[mycrofft]

Two tweaks

Catatonia is a psychological/psychiatric diagnosis.
You mean unresponsive or obtunded? (Funny how much value we put on whether the eyelids are oen or closed). Other wise, nice scenario.

What were VS's? EKG was needed too. Brady in response to those drugs means cardiac. We stopped giving inmate Alupent because they would kill them selves trying to self-tx a cardiac insufficiency with Alupent; literally, a couple had their MDI's removed from their dead fingers.

In my experience, when the words aren't coming, you better be going, mas alles! Like battle signs and raccoon eyes, not an early finding (unless there is an upper airway embarassment or other laryngeal challenge or insult).

 

[Smash]

Catatonic used in this context where I work relates to the degree of unresponsiveness although not necessarily of a psychological cause. Obtunded. Eyes open, not-responding, "thousand yard stare", GCS three but holding posture and maitaining own airway.

Anyway, he's arrested when you arrive. Brady-asystolic, wide complexes with rate of ~10 on monitor, no output, CPR in progress. Prior to that, tachycardic (sinus tach) and hypertensive (BP 210/110) becoming hypotensive and progressively bradycardic following respiratory arrest until cardiac arrest about 5 minutes prior to your arrival.

 

[MrBrown]

IV adrenaline; .5mg IVP and hang a drip of 1mg in 1 litre KVO

Would consider a more advanced airway; gaining a seal with an LMA may be difficult given the very high airway pressure. If possible, intubate the patient but either way ventilate at 6 a minute to avoid dynamic hyperinflation which I fear my have already occured.

Some corticosteriods and magnesium sulfate would be nice right about now.

 

[wolfwyndd]

At this point it sounds like the asthma is a red herring. Breathing treatment had no effect and (generally) if it's asthma related there's plenty of wheezing going on.

Since we are on the topic of breath sounds in this SOB patient, what kind of breath sounds are there? Any? Any medical history from family, like COPD or emphysema? It SOUNDS as if this patient has an airway issue that needs to be resolved.

 

[mycrofft]

All right! Keep it rolling.

Other meds?

Asthma may not be THE cause which kicked the pins out from under, but it is/will be a very important dx and tx factor, as well as any remedies taken by the pt before he went down.

 

[taporsnap44]

Is JVD present?
Are lung sounds absent on either side?
Any subcutaneous air around the neck or chest?
Any trachea deviation?
Also how is the chest during compressions? Is it really rigid?

For some reason I am thinking of a possible Tension Pneumothorax.

 

[Simusid]

I'm only a basic, and a new one at that but I'm going to throw out my very first thought and that is pulmonary embolism.

 

[usalsfyre]

Secure an advanced airway (preferably ETT), administer continuous nebs via in-line neb. Assess BBS and chest rise for possible pneumothorax. Does the chest look distended like auto-PEEP is a problem? A manometer would also be a great help here. Greatly diminished breath sounds and prolonged expiratory phase initially are sugestive of RAD, but try to assess for other airway/breathing issues that may have popped up.

Also, pace the agonal rhytm to see if you can get a response, and continue ACLS algorhythm. Fluid bolus as this pt is very likely to be hypovolemic. This may be a case of irreversible air trapping and nothing you do will help. Consider (carefully and fully) bicarb to reduce acidosis caused by extended CO2 retenetion...

 

[Smash]

Alright, usalfyre is continuing to treat according to ACLS arrest algorhythm which is a good start. Size 9 ETT passed on first attempt, secured: EtCO2 180mmHg, SpO2 90% and he's difficult to ventilate. Epi boluses given, no effect on rhythm Atropine given, no effect on rhythm. He does become slightly easier to bag.

Breath sounds: Slight 'Squeak' when ventilating. JVD hard to assess due to obesity, no tracheal deviation, no subcutuaneous emphysema, what breath sounds can be heard seem equal. Temperature is 98.9F/37.1C. Blood glucose is normal.

No other history is able to be elicited from the family other than asthma as noted in the first post, and the fact that he was taking his own inhalers during the day.

At least usalfyre is treating the dead guy!

Anything else?

 

[daedalus]

Notify Dr. G of an incoming patient and wait to see her pathologist report.

 

[usalsfyre]

Alright, usalfyre is continuing to treat according to ACLS arrest algorhythm which is a good start. Size 9 ETT passed on first attempt, secured: EtCO2 180mmHg, SpO2 90% and he's difficult to ventilate. Epi boluses given, no effect on rhythm Atropine given, no effect on rhythm. He does become slightly easier to bag.

Breath sounds: Slight 'Squeak' when ventilating. JVD hard to assess due to obesity, no tracheal deviation, no subcutuaneous emphysema, what breath sounds can be heard seem equal. Temperature is 98.9F/37.1C. Blood glucose is normal.

No other history is able to be elicited from the family other than asthma as noted in the first post, and the fact that he was taking his own inhalers during the day.

At least usalfyre is treating the dead guy!

Anything else?

Masive air trapping related to refactory bronchospasm causing cardiac output to be so impaired he arrest...This guy is screwed. Could try something like a Res-Q-Pod, but mainly get ready to call the JP.

 

[mycrofft]

Get his watch.

Sorry had to stay in character.
Good deal! We pick up so much during eval simultaneously but to describe and learn it we have to go linearly.

 

[MCGLYNN_EMTP]

Not sure what you're actualy looking for..I'd treat the immidiate problem here which is the fact that they are in cardiac arrest...Give some epi because the're in PEA...epi also has beta 2 effects which will hopefully loosen up the bronchospasms that this pt. is prob. having....Have to remember that even tho no wheezing is heard on auscultation doesnt mean there isnt bronchospasms....the worst ones sound like clear lung sounds or absent sounds. If Epi doesnt work we can try another albuterol treatment..intubate the patient and give it nebulized through the bag...(kind of hard to rig up but it can be done) go on and give your atropine because the rate is under 60...continue with the algorithm until you change or call the code off... check for allergic reactions too...but again...the epi should help that out.

 

[Smash]

Thought there might be a better turn out than ths. Mind you it's not trauma so maybe it's not that exciting.

I'll give the "answer" then (how I worked it anyway)

CPR continued, epi 1mg given with no change. Intubated, size 9 tube, no extensions or so forth to minimize dead space in the circuit. Initial end tidal of 160mmHg, SpO2 of 77%. Ventilated at a rate of about 6/min with a Vt of about 8-10ml/kg. ILS crew continued giving epi and CPR under direction.

Then the kicker: bilateral chest decompression with pneumocaths- immediate release of copious free air from both sides with an almost immediate ROSC, AF rate of 150, BP 170/100. Occassional agonal respiratory effort, increasing with time, and pt starts to not tolerate the tube so well but GCS remains 3.

SpO2 increased to 98% EtCO2 trending down to about 100mmHg on arrival at hospital. Chest is still tight, but now has biphasic wheeze and is significantly more compliant.

So, now we have an output, how would you continue management?

So, now we have got an output

 

[Melclin]

Aside from some things already mentioned:

AP (our basics)

- Gentle lateral chest pressure and hold the vents for a minute after the loss of cardiac output.

- Vent with a reduced Vt but increased pressure @ 5-8 a minute.

-IM adrenaline - 300mcg

MICA (our ALS)

- Bilat decompression - standard MICA treatment for asthmatic arrests with suspected tension pneumo.

- Dexamethasone - 8mg (if they were there before the arrest).

- IV salbutamol 250mcg loading dose, maintenance doses of 125mcg 5 minutely up to a max of 500 mcg OR 15mcg/minute infusion (in severe distress or ROSC).
- RSI/SFI (again, prob before arrest).

 

[WTEngel]

Don't forget the benefits of chest percussion therapy to release plugging. Be ready for aggressive suctioning in the ET tube, as large plugs of mucous could be released.

 

[BLSBoy]

Don't forget the benefits of chest percussion therapy to release plugging. Be ready for aggressive suctioning in the ET tube, as large plugs of mucous could be released.

How about chest percussion to evaluate for pneumothorax?

 

[WTEngel]

I have found chest percussion only assists in diagnosis of a possible HEMOthorax, as the hyper-resonance heard from the fluid is distinctly different than that of the free air heard from a pneumo.

The idea for chest percussion in this patient is not for diagnosis however, it is to release mucous plugging that prevents the small airways from exchanging gases.

 

[VentMedic]

I have found chest percussion only assists in diagnosis of a possible HEMOthorax, as the hyper-resonance heard from the fluid is distinctly different than that of the free air heard from a pneumo.

The idea for chest percussion in this patient is not for diagnosis however, it is to release mucous plugging that prevents the small airways from exchanging gases.

Fluid will give a dull, "thud" type sound and not the hyperresonant sound found in air filled cavities.

Chest percussion therapy will be of little use in an acute phase of an asthmatic bronchospasm as the inflammatory response must be addresssed to reduce the narrowing of the airways. Hydration will also be required to move the mucus. Rarely will the mucus be in the large airways or can be just "coughed" or "beat" out until after the corticosteriods and fluids have had a chance to work.

If one believes the patient has bilateral pneumos, use caution with the decompression. You might create more problems than alleviate. We have had some mistake the decreased breath sounds for pneumos and do several needle sticks into the chest because they did not immediately get a rush of air. What they failed to realize is there may not have been a pneumo until after they started sticking. As well, a needle decompression will only be effective for a short time and if a code is being worked, a chest tube will have to be inserted to maintain the decompression especially if possitive presssure ventilation is continued.