EKG CASE STUDY #4: Evolution of Sudden Cardiac Arrest

This case was submitted by our friends some of our friends in a neighboring county EMS service.

County ALS rig and BLS fire service are dispatched to a private residence for a 54 YOM complaining of mid-sternal, “crushing” chest pain. The patient states that this has been going on for the last hour, and that he was just released from the hospital three days prior due to cardiac catheterization and having two stents placed.

INITIAL ASSESSMENT

  • Patient is a GCS of 15
  • Bounding/Regular radial pulses detected
  • Patient appears mildly dyspneic
    • L/S are clear= throughout
    • Equal rise and fall of the chest
  • Skin is ashen, diaphoretic, and cool

VITAL SIGNS

  • BP: 214/154
  • HR: 108/Regular
  • RR: 28/mildly dyspneic
  • SpO2%: 96 on R/A

INITIAL TREATMENT

  • 324mg ASA
  • 15lpm O2 via NRB
  • Saline Lock established

INITIAL RHYTHM AND 12-LEAD

54YOM Initial Rhythm

54YOM EKG #1

  • Crew withholds nitroglycerin due to elevation in the inferior leads.
  • Any other diagnostic tests to look at?
  • Crew initiates transport to the closest PCI facility that is approx. 15-20 minutes away
  • En route, crew options to continue serial 12-leads watch for any changes; this is what they see…

12-LEAD #2

54YOM EKG #2

  • Any differences between the two 12-leads?
  • Any concerns that you’re starting to have?
  • No changes in patient mentation or vital signs

12-LEAD #3

54YOM EKG #3

  • No changes in mentation or vital signs
  • 12-leads transmitted to receiving facility
  • No other interventions initiated at this time

12-LEAD #4

54YOM EKG #4

  • BP has dropped to 184/108 without chemical intervention
  • HR has increased from the 100s to the 120s
  • Any other developments that you’re starting to notice?
  • Patient appears to be experiencing growing anxiety and restlessness

12-LEAD #5

54YOM EKG #5

  • No changes in mentation or vital signs

12-LEAD #6

54YOM EKG #6

  • Patient is growing increasingly agitated and mildly combative
  • What considerable changes are present in this 12-lead from the first?
  • THESE CHANGES HAVE HAPPENED IN THE SPAN OF 18 MINUTES!!

12-LEAD #7

54YOM EKG #7

  • Patient is severely lethargic with dropping respiratory rate, increased pallor and diaphoresis
  • BP: 168/132
  • HR: 120s
  • Anything you could be preparing for?

And the Pièce de résistance…

  • About 6-7 minutes away from the hospital, the patient goes unresponsive, apneic, and pulseless…
  • This is what you see…

54YOM Defib #1.jpg

  • Crew deliver 1st Defibrillation at 360J.
  • OPA placed with NRB @15lpm per local CCR protocols
  • Chest compressions initiated
  • 1mg 1:10,000 Epi
  • 300mg Amiodarone

FIRST PULSE CHECK

54YOM Defib #2

  • Second Defib @360J
  • CCR continued
  • Third pulse check reveals V-fib (Strip not submitted)
  • Third Defib @360J
  • Second round of 1mg 1:10,000 Epi
  • 150mg Amiodarone

Crew arrives at emergency department of PCI facility; ED staff continue to work patient for additional twenty minutes; patient continues in refractory VF; ED continues routine Epi administration, Amiodarone drip, Magnesium Sulfate drip, Sodium Bicarbonate administration. Definitive airway secured with waveform capnography in the 20s. Patient pronounced dead in ED.

This is a fascinating case study. We didn’t post it because of a good outcome, but because this run is a reminder that patient’s crash in a matter of minutes. We need to continue to be vigilant in monitoring our patients. We would like to point out, though, that the first 12-lead was acquired within TWO minutes of patient contact, as well as the first defibrillation being delivered within seconds of patient arresting. Although the patient expired, this crew handled a difficult situation well. 

Is there anything you would’ve done differently?

Any other considerations for patient management?

 

 

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