EKG Case Study #13: 45YOM with Abdominal Pain

You and your partner work in an urban ALS service and are called to a report of a seizure. En route to the scene, dispatch advises you that the call has been upgraded from a seizure to a cardiac arrest. When you arrive on scene, FD personnel tell you that they have been on scene for approximately three minutes, have completed one cycle of CPR and have delivered one defibrillation via AED. The patient’s family has a significant language barrier making history gathering significantly more difficult. To the best of the crew’s ability, they deciphered that the patient has been experiencing abdominal discomfort and weakness for approximately the last 24 hours, and that the patient has no know medical history, medications, or allergies. The FD has already placed an OPA and a NRB mask per local cardiocerebral resuscitation (CCR) protocols. You switch the pads over from the AED to your monitor, and this is what you find…

INITIAL RHYTHM

ECS13 Initial Rhythm 001ECS D1 001

  • 2nd defibrillation at 360 Joules
  • Chest compressions resumed immediately for another two minute cycle
  • IO established in the L Tibia
  • 1.0mg Epi 1: 10,000 IO
  • 250ml 0.09% NS Bolus initiated

PULSE CHECK

ECS13 D2 001

  • 3rd defibrillation at 360 Joules
  • Chest compressions resumed immediately for another two minute cycle
  • 300mg Amiodarone IO
  • Advanced airway placement preparation
  • Explored H/Ts
    • Blood glucose assessed and found to be 96mg/dl
    • No signs of illicit/prescribed drug abuse, ETOH consumption, or trauma noted

PULSE CHECK

ECS D3 001

  • 4th defibrillation at 360 Joules
  • Chest compressions resumed immediately for another two minute cycle
  • 1.0mg Epi 1: 10,000 IO administered
  • 250ml 0.09% NS Bolus administered
  • Unsuccessful ETI attempt
    • OPA replaced and BVM ventilation initiated

PULSE CHECK

  • Reveals bradycardic PEA (rate of 40s- not pictured)
  • Chest compressions resumed immediately for another two minute cycle
  • Supraglottic airway placed
    • Confirmed with an EtCO2 of 34
    • L/S confirmed; absent epigastric sounds
    • Tube fogging noted
    • Chest rise and fall noted
  • Secondary large bore IV access placed in the L Antecubital
  • Third 250ml 0.09% NS bolus initiated with no presence of pulmonary edema

PULSE CHECK

  • Reveals bradycardic PEA (rate of 40s- not pictured)
  • Chest compressions resumed immediately for another two minute cycle
  • 1.0mg Epi 1: 10,000 IO administered
  • Fourth 250ml 0.09% NS bolus initiated with no presence of pulmonary edema
  • Crew began to start contemplating transport decision; due to significant language barrier, crew opted to initiate transport due to inability to properly communicate with family; receiving hospital has access to interpretation lines.
  • While packaging patient for transport, crew notes a significant spike in EtCO2 from the mid-30s to 72mmHg
  • Crew confirms newly gained presence of carotid/femoral pulse

12-LEAD #1

ECS13- 12 lead 1 001

  • Crew initiates transport to the closest PCI facility approximately 10-15 minutes away
  • BP: 118/70
  • HR: 76
  • Patient remains a GCS of 3
  • SpO2: 96%
  • EtCO2: 68mmHg

12-LEAD #2

ECS13 12 Lead 2 001

  • Five minutes after initial EKG, crew notes a significant reduction in heart rate
  • BP: 134/72
  • HR: 44
  • SpO2: 97%
  • EtCO2: 40mmHg
  • Patient remains a GCS of 3
  • Cold packs placed in the groin, neck, and axilla

12-LEAD #3

ECS13 12 Lead 3 001

  • Crew notes a significant drop in EtCO2 from 40mmHg to 24mmHg while pulling into ambulance bay.
  • BP: 68/40
  • HR: 50
  • SpO2: 96%
  • EtCO2: 24mmHg
  • Administered 0.5mg IV Atropine
  • Initiates TCP gaining capture at 125mA at a rate of 70
  • Levophed initiated at2mcg/min
  • Patient remains a GCS of 3
  • Crew delivers patient to the ED

FOLLOW UP

  • ED staff continue levophed infusion titrating to a total of 20mcg/min
  • TCP continued
  • Patient transferred to cath lab, with stents placed
  • Patient maintains pulse post cath lab and transferred to Cardiac ICU

DISCUSSION

  • What would you have done differently?
  • Would your care changed if you were further away from definitive care?
  • Do you agree with the crew’s decision to transport due to ineffective family communication?
  • What are your department’s policies on ETI v. SGA usage in cardiac arrest? Impending arrest?

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