EKG Case Study #9: The Crashing DNR Patient

This was submitted to us by a friend of the show. A run I’m sure a lot of you have had, but with the understanding that there are multiple ways to manage this type of patient. 

You and your partner are working for an urban ALS service, when you are dispatched to an unresponsive patient on the outskirts of town. A BLS engine with four EMTs is on scene as you arrive, and state that they found the patient in the back bathroom. The patient, an approximately 85yof, is slumped over to the left side on the toilet. She is covered in vomit, and is only responding to firm painful stimuli. The patient’s daughter states that the patient has a Do Not Resuscitate order, but is unable to find the paperwork; she also reports that the patient was last seen acting normal (a GCS of 13 due to late stage Alzheimer Dementia) around 15 minutes prior to calling 911 (approximately 25 minutes ago now). No recent illnesses or trauma were reported; the patient’s daughter just felt like “something was wrong”, and went to check on the patient. The BLS crew has her on a NRB mask when you arrive.

INITIAL ASSESSMENT

  • GCS of 4; only moans to painful stimuli
  • Respiration appears bradypneic and shallow; ranging between 6-10bpm
  • Skin is cool, pale, and moist
  • Absent radial pulses, weak carotid pulses in the 60s noted and regular
  • No indicators of trauma present
  • Unable to assess pupillary response due to cataracts
  • L/S are diminished due to shallow respiration; clear/= throughout

INITIAL VITAL SIGNS

  • Unable to obtain B/P even with automatic cuff
    • Absent radial pulses; weak carotid
  • HR: Starting to brady down into the 50s/regular
  • Respiration starting to slow down to the 2-6bpm range
  • BGL: 149
  • 75% on R/A
  • EtCO2: 9mmHg

MEDICAL HISTORY

  • End stage Alzheimer Dementia
  • Hypothyroidism

MEDICATIONS

  • Patient takes no medications beyond daily vitamins

ALLERGIES

  • NKDA

DIAGNOSTICS AND TREATMENT

Due to the confined working conditions, crew opted to remove patient from scene to back of commission to begin to treatment.

  • Initial intact gag reflex noted; NPA placed
  • Assisted ventilation with a BVM
  • Bilateral large bore IV access initiated with 0.09% NS hung via pressure bags
    • 500ml bolus initiated with no change to V/S

85yof DNR Initial Rhythm 001

85yof 12-lead #2 001

This is what the crew sees originally. STEMI? Any other diagnostics you would run? 

Transport initiated to the closest hospital that is 15-20 minutes away (which is consequently a PCI/Stroke Center) after approximately a 10-15 minutes scene time. Patient’s daughter was not able to obtain a hard copy of the patient’s DNR order prior to transport. The patient is rapidly decompensating, and has gone from agonal respiration to apnea. NPA was exchanged for an OPA. EtCO2, which started off at 9mmHg, has now dropped to 5mmHg. Marked bradycardia ranging between the 30-40s has now started. Crew is still unable to palpate radial pulses, and is unable to detect a blood pressure via automatic cuff; weak carotid pulses are still present.

85yof DNR 12-lead #3 001

After this printout, crew places pads on the patient and initiates transcutaneous pacing.

85yof Pacing Initiated 001

Transcutaneous pacing initiated at a rate of 60bpm and 10mA; titrated up 40mA and still not obtaining mechanical capture. While first crew member is increasing the mA of the pacing, they are preparing to initiate a Levophed drip due to the marked hypotension. Lead medic calls report to the receiving hospital; as the medic is calling report, they notice a drop in EtCO2 from 5mmHg to 0mmHg. The patient is now in full cardiorespiratory arrest. 

The crew does not have a hard copy of the DNR order, but makes a request to medical control to withhold any further BLS/ALS intervention due to adamant family request. Permission is granted to withhold any further intervention.

85yof Pacing Terminated 001

DISCUSSION

  • What would you do differently?
  • When you have an actively dying DNR patient in front of you, how aggressive is your treatment?
  • Removing the DNR aspect, what are your thoughts on going straight to TCP instead of Atropine in this instance?
    • In the presence of an MI?
  • Would you have worked the patient as a full arrest instead of calling medical control?

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