EKG CASE STUDY #5: 75YO Cancer Patient Witnessed Cardiac Arrest

SCENARIO

You and your partner are working in an urban ALS service. At 0430, you are dispatched to an unresponsive party at a private residence, and are told en route by dispatch that the patient is possibly in cardiac arrest. An engine is dispatched for manpower, and arrives to the residence at the same time as your commission. Family members lead your crew through a crowded house upstairs to find your patient, a 75YOM, in full cardiac arrest. The patient’s wife states that the only know medical history that the patient has is prostate cancer and HTN; wife goes on to state that the patient was speaking to her around 0425, and appeared restless; mid-sentence the patient collapsed to the floor. Per family on scene, the patient is a full code.

MEDICATIONS

  • Flomax
  • Opana
  • Lisinopril

ALLERGIES

  • NKDA

INITIAL INTERVENTION

  • Chest compressions initiated
  • OPA/NRB @15lpm placed per local protocol
  • No secretions or obstructions noted in airway

INITIAL RHYTHM

75YOM Initial Rhythm

75YOM Defib #1.jpg

  • Patient presents in VF; 1st defibrillation @360J
  • Compressions resumed
  • Tibial IO established; 1.omg of 1:10,000 Epi
  • 2mg IO Naloxone administered due to Opana usage
  • Blood glucose assessed: 114mg/dl

FIRST PULSE CHECK

75YOM Defib #2

  • Patients persists in VF; 2nd defibrillation @360j
  • Compressions resumed
  • 300mg IO push Amiodarone
  • 250ml NS bolus

SECOND PULSE CHECK

75YOM Defib #3

  • Patient persists in VF; 3rd defibrillation @360J
  • Chest compressions continued
  • Second 250ml NS bolus initiated
  • 1.0mg 1: 10,000 Epi push
  • King LT placement
  • Capnography placed with initial reading of 39

THIRD PULSE CHECK

75YOM Defib #4

  • Patient presents in VF; 4th defibrillation @360J
  • Chest compressions continued
  • 150mg IO Amiodarone push
  • Third 250ml NS push
  • Halfway through CPR cycle, EtCO2 spikes to 72
  • Patient begins to exhibit purposeful movement of the upper extremities

ROSC 12-LEAD

75YOM EKG #1

POST ARREST V/S

  • BP: 94/72
  • HR: 80/irregular; 12-lead reveals A-Fib
  • Patient is currently being ventilated via BVM @10bpm
  • SpO2: 98%
  • Temp: 98.4° F

TRANSPORT

  • Patient transported emergently to closest PCI facility, approximately 10 minutes away
  • En route, patient begins to blink, gag on King airway, and flail arms around
  • After recycle v/s, no gross changes in HR, SpO2, or temp; BP: 104/52
  • 5mg IO Versed push for airway maintenance
  • 16g AC line established
  • Patient sustains ROSC throughout transfer to ED
  • Patient packed with cold pack for therapeutic hypothermia

With no obvious complaints of respiratory distress or cardiac symptoms prior to arrest, what are your thoughts on arrest etiology? 

What would you have done differently? 

Would your treatment modality have changed in a rural setting versus an urban setting? 

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