EKG Case Study #12: 55YOM Found Unresponsive

You are dispatched to an unresponsive party at a private residence; a BLS engine crew and your unit arrive at the same time. As you are moving your equipment into the house, you see the engine crew dragging the patient from a back bedroom to an open space in the living room. The engine captain tells you that the patient was “agonally breathing” in the back bedroom. As you make your way to the patient, you note that he is now pulseless, apneic, and unresponsive with no obvious signs of trauma or indicators of drug usage in the home. Chest compressions are initiated and an OPA and NRB @15lpm of oxygen is initiated due to local CCR protocols. The patient’s wife tells you that she woke up to the patient “snoring” and being “unable to wake him up” around 0400; she states that he was last seen normal around 2300 the evening before.

INITIAL RHYTHM

EKG Case Study #12- 55YOM Initial Rhythm 001

Chest compressions continued until defibrillator charged.

EKG Case Study #12- 55YOM 1st Defib 001

  • First defibrillation at 360 Joules
  • Chest compressions immediately resumed
  • 16g IV placed in the Left AC
  • 1.0mg of 1:10,000 Epinephrine IV
  • Blood glucose check results in 76mg/dl
  • 0.09% NS hung and 500ml bolus initiated
  • First two minute cycle completed

PULSE CHECK

EKG Case Study #12- 55YOM 2nd Defib 001

  • Patient remains in V-fib; second defibrillation at 360 Joules delivered
  • Chest compressions immediately resumed
  • 300mg IVP Amiodarone administered
  • Preparation for ETT set up
  • Second two minute cycle completed

PULSE CHECK

EKG Case Study #12- 55YOM 3rd Defib 001

  • Patient remains in V-fib; third defibrillation at 360 Joules delivered
  • Chest Compressions immediately resumed
  • 1.0mg Epinephrine 1:10,000 administered
  • Secondary access established with Left-sided Proximal Tibial IO
  • Second 500ml bolus of 0.09%NS initiated
  • Third two minute cycle completed

OVER THE NEXT TEN MINUTES…

  • Patient intubated with first pass success
    • Crew used channeled blade video laryngoscope with bougie stylette
    • Is video laryngoscopy changing the way we approach airway management in OHCA?
    • What is your departments first line airway? ETT? SGA?
  • Waveform capnography placed revealing EtCO2 values consistently in the mid-40s
  • Five pulse checks performed revealing bradycardic PEA in the 40s
  • Two more rounds of IV 1.0mg Epinephrine 1:10,000 administered
  • Exploring H/Ts
    • Patient has a previous history of renal cancer and HTN
    • He takes no medications
    • No prior complaint of illness recently
    • No access to opioids or previous ETOH/drug abuse noted
  • Crew contemplating transport decision due to quality capnography readings with CPR, and then…

PULSE CHECK

EKG Case Study #12- 55YOM 4th Defib 001

  • Presents with pulseless V-Tach; fourth defibrillation at 360 Joules
  • Chest compressions resumed immediately
  • 150mg IVP Amiodarone administered
  • Ninth two minute cycle completed

PULSE CHECK

EKG Case Study #12- 55YOM ROSC 12-Lead #1 001

  • Patient has a strong radial/carotid pulse
  • BP: 186/132
  • HR: 48bpm/irregular
  • EtCO2: 45
  • SpO2: 98%/intubated and being ventilated via BVM @15lpm at rate of 10bpm
  • Patient carried to stretcher and transport initiated to nearest PCI facility that is approximately 15 minutes away

SECOND 12-LEAD

EKG Case Study #12- 55YOM ROSC 12-Lead #2

  • EtCO2 dropping from 45 into the low 20s with no change in ventilatory pattern
  • Cold packs placed in the groin, axillary regions
  • Patient remains GCS of 3
  • Other vital signs remain similar to last check approximately 3 minutes prior
  • EtCO2 drops again from the low 20s to 18; pulse reassessed tube position and pulses; absent carotid pulses noted
  • CPR initiated again for one cycle; presented with bradycardic PEA
  • 1.0mg IV Epinephrine 1:10,000 administered
  • Two minute cycle completed

PULSE CHECK

EKG Case Study #12- 55YOM ROSC 12-Lead #3 001

  • Patient regains strong/irregular/slow carotid and radial pulses
  • What’s your interpretation?
  • BP: 164/96
  • HR: 24bpm; slow/irregular
  • EtCO2: 75
  • SpO2: 99%/intubated and being ventilated w/BVM @15lpm at a rate of 10bpm
  • Considered atropine and TCP but withheld due to compensatory BP

FOURTH 12-LEAD

EKG Case Study #12- 55YOM ROSC 12-Lead #4 001

  • Rate rapidly improves without pharmacological or electrical assistance
  • Vital signs outside of heart rate stay within similar ranges
  • Crew arrives at PCI facility and care is transferred to receiving ED staff

AFTER DELIVERY

  • Patient sustains ROSC after delivery
  • Patient’s vital signs begin to rapidly decompensate in resus bay
    • BP: 34/20
    • HR: 20
    • EtCO2: 24
  • ED initiates TCP; administer 0.5mg IV Atropine
  • Art Line established with 1L bolus of 0.09NS started
  • Initiates levophed and dopamine infusions
  • Vital signs stabilized in ED and sent upstairs to ICU

 

 

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