What is your opinion about this case? RSI or not?

[HMartinho]

I got a new job as an EMT-B, but this time on a ILS unit, manned by an EMT-B and a critical care nurse. The other day we were dispatched to a 43 y/o male, was playing soccer with his friends, he felt a pain in the chest and fell on the ground, unresponsive.

When we arrived, the patient had no pulse or breathing. The 3-lead ECG showed ventricular fibrillation. We insert an OPA and I started CPR while the nurse prepared the manual defibrillator. After the first shock, he still in v-fib, then the nurse started an IV, gave 1 mg of epinephrine. After 3 shocks without changing heart rythm, the nurse gave 300 mg of amiodarone and gave another shock, and the patient regained spontaneous circulation and ventilation, and his vital signs were:

Pulse: 110 bpm weak and irregular
RR: 9 bpm
B.P: 80/50
temp: 35.5 ° C / 95.9 ºF
SpO2: 79 on R.A.
Capillary refill: about 5 seconds

He is unconscious but responds to pain. We gave him O2, 15lpm by non-rebreathing mask, and the nurse decided to start an drip of saline and an infusion of amiodarone (I don't know exactly what was the dose). We load the patient into the ambulance and reassess vital signs and attached 12-lead ecg:

Pulse: 108 bpm weak and irregular
RR: 10 bpm
B.P: 85/63
Temp: 35.9 ºC / 96.62 ºF
SpO2: 82 with 15 lpm of O2
Capillary refiil time was about 5 seconds and his skin is a little bit cyanotic.
Breath sounds are normal.

According to the nurse, the ECG showed sinus tachycardia and PVC's, and during transport to the hospital, there were no changes in vital signs or in their condition.

When we arrived at the hospital, e.r. doctor began to call into question our treatment, and said that it was unacceptable a specialist nurse in emergency care have done that sh*t, that does not justify the amiodarone infusion, and why she did not have performed an RSI, and she said: despite our protocols do not include amiodarone in these situations, several international studies show that giving amiodarone in post cardiac arrest care, improves the survival rate of patients, and I do not intubate because the nurses can only perform an RSI in very specific situations , or in life-threatening situations, and I did not think that was one of those situations.

What is your opinion? What would be your treatment?

 

[Medic Tim]

In my training it is standard to do an amiodarone drip if there is ROSC. that being said follow your protocol or deviate if you have justification. You will always run into docs and or nurses that don't feel we should do certain things and there is just no pleasing them. Did the pt have a gag reflux? if not then an ET or BIAD should be attempted. at the very least assist the pt with a bvm.

 

[fma08]

If the pt. wasn't maintaining an airway or breathing on his own, he should have either been assisted with an adjunct or ideally have an advanced airway in place. I'm surprised that during an arrest or post arrest if warranted she's not allowed to intubate via protocols. But in any case, like stated above, follow your protocols, if they need something outside of the protocols, get a verbal order.

 

[Smash]

I've ranted at length about post-resus care (over herehttp://www.emtlife.com/showpost.php?p=320645&postcount=7
so I won't go into depth about the whys or hows.

What I would do:

Pressors for his crappy blood pressure.
Inubate (RSI post-arrest if need be) as he is clearly not oxygenating or presumably ventilating well, and because he needs some paralysis on board for the next step. If RSI is not an option, at the very least it seems he needs better oxygenation with some PEEP or something.
Therapeutic hypothermia - he is exactly the patient for whom ACLS and hypothermia is designed for.
No amiodarone infusion post-arrest unless some breaktrhough ventricular arrythmia occurs. I would like to see these studies that show that amiodarone improves survival from cardiac arrest.

 

[usalsfyre]

I'm just gonna say...

I echo Smash.

 

[Handsome Robb]

I agree with what everyone said. I'm surprised someone didn't recommend pressors before Smash did.

Our protocol and ACLS both say if they have ROSC with amiodorone onboard to hang 150mg in 100ccs over 10 minutes, so if this were my PT I'd be hanging the drip, however I'd want dopamine running as well to ward off the amio making this guy more hypotensive. I'll admit at this point I'm pulling the protocol card for the simple fact that I don't see a glaring reason to withhold it other than the hypotension which we can correct with pressors. Edit: Smash does a good job of explaining it in that post but I still am a little fuzzy on the details of when or why to withhold it.

Smash, why no amiodorone infusion post ROSC? I'm about to read the link you posted so my answer may be in there. Edit: It is, so no further explanation is needed.

OP this guy needed BVM if his SpO2 is that low and he is cyanotic, not an NRB. I'd be shooting for a tube, personally. Our ground units don't have RSI so if he has trismus or a gag reflex I'm stuck up sh*t-creek without a paddle unless I can get a nasal tube in him.

Edit: Hey I'm referenced in that post! After reading it I do remember that post.

 

[EMSLaw]

I'm going to go with a "no" on the RSI for this one, but only for this reason:

You inserted an OPA. The patient didn't reject it (or you didn't say he did) during transport. There is no active gag reflex. Therefore, no need to RSI under the circumstances, at least as I understand them. Just drop the tube. He's unconscious. He won't object.

I'm curious, though, as to why the patient's airway wasn't secured immediately. Even if your nurse/partner wasn't able to perform an endotrachial intubation, don't you have supraglottic airways as an intermediate unit? I understand the urgency of getting the cardiac drugs onboard, but inserting a King airway or something like that takes only a moment more than putting in an OPA.

If the patient was cyanotic, he was not perfusing sufficiently with a BVM alone, and I think an advanced airway would have been called for.

 

[Veneficus]

I do not intubate because the nurses can only perform an RSI in very specific situations , or in life-threatening situations, and I did not think that was one of those situations.

When we arrived, the patient had no pulse or breathing. The 3-lead ECG showed ventricular fibrillation.?

Does it get more life-threatening than this?

Once you got this kid back, you need to keep the tube in him, hypothermia would be the treatment of choice.

Can see both arguments for the amio drip, honestly I don't think it matters one way or the other.

 

[firecoins]

As clearly mentioned, the patient was in a life threatening situation. He didn't need RSI but intubation certainly needed to be done. And a dopamine drip.

 

[HMartinho]

Thank you all for your feedback. Today I was checking protocols, and they say:

All pre-hospital critical care nurses should be pre-qualified and trained in endotracheal intubation. The nurse is free to perform endotracheal intubation, without the authorization of med-control in the following situations:

- Cardiac arrest
- Respiratory arrest
- Post cardiac arrest care, when indicated.
- Severe TBI, with "deep" coma
- immediate risk of death situations.

In all other situations, nurses and emt-b must recognize the need to perform an RSI, and obtain a verbal order of the med-control, or ask for an ALS unit backup. Alternatively, for less experienced professionals, or the difficulty of putting the tube correctly, can be used the Combitube or the LMA.

Yes, the patient had no gag reflex.

 

[Handsome Robb]

Thank you all for your feedback. Today I was checking protocols, and they say:

All pre-hospital critical care nurses should be pre-qualified and trained in endotracheal intubation. The nurse is free to perform endotracheal intubation, without the authorization of med-control in the following situations:

- Cardiac arrest
- Respiratory arrest
- Post cardiac arrest care, when indicated.
- Severe TBI, with "deep" coma
- immediate risk of death situations.

In all other situations, nurses and emt-b must recognize the need to perform an RSI, and obtain a verbal order of the med-control, or ask for an ALS unit backup. Alternatively, for less experienced professionals, or the difficulty of putting the tube correctly, can be used the Combitube or the LMA.

Yes, the patient had no gag reflex.

Sounds like your nurse-partner botched this one. This case fits perfectly into that protocol.

 

[RocketMedic]

I'd have intubated with a full ET if at all possible, and if not, King LT/Combitubed it. Not so much worried about airway, but I do want some security...

Dopamine @ 15mcg/min, and 150mg/100cc/10mins amiodarone, BVM assistance, rapid transport to cardiac cath center, try and get o2 sats to around 95ish, but capnography is your gold standard here- I'd be looking to keep him between 35-40 if possible. Other massive concerns here are reentry dysrhythmias and dumping too many meds in, so for me personally, I'm going to be watching perfusion like a hawk. I'm leery of forcing his heart to work extra-hard with a probable blockage, so for me, if I've got a decent carotid pulse, I'm not terribly worried about peripheral perfusion. Last thing I want to do is worsen the infarct chasing numbers on the BP. That being said, this patient screams dopamine to me, and I want it at a relatively high dose.

What sort of anatomy did he have, and how confident was the nurse with her intubation ability? I can understand not intubating if you've got little chance of successfully pulling it off, but for an active 43 yo M, I can't see why you wouldn't be able to in most cases.

 

[MedicPatriot]

RSI? I don't know. What really boggles me is why nobody did BVM on someone post-arrest with 02 sat not coming up from 82%.

I don't know enough about amiodarone, so I can't comment. I would have given another dose of Lidocaine per my protocols to suppress recurring VF, so I would imagine the amiodarone drip would be doing the same thing...but I speak in ignorance.