EKG Case Study #14: Mid-70s Male C/O Acute Weakness and Diarrhea

You and your partner work for an urban ALS system. At approximately 2300, you are dispatched to a choking with an unresponsive party. As you arrive on scene, a BLS engine crew member alerts you to the fact that they have a mid-70s male in full cardiorespiratory arrest just outside of a downstairs bathroom. Family members advise that the patient starting to feel “ill” around 2100, complaining of a sudden onset of weakness followed by an acute onset of diarrhea around 2230. They also relay that they heard the patient “struggling” in the bathroom and becoming notably dyspneic. You note frothy sputum around the corners of the mouth. As your crew initiates chest compressions and an OPA/NRB combo due to local CCR protocols, you find a med list and history that reveals: A-fib, HTN, COPD, CHF. Patient’s family also state that the patient has a history of DVTs, PEs, and has had three cardiac stents placed. Your partner places the defib pads on the patient and you take a look at your initial rhythm.

INITIAL RHYTHM

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PULSE CHECK

  • Due to potential respiratory etiology of arrest, crew bypasses local CCR protocols and assumes standard ACLS procedures, placing OPA and ventilating patient approximately 8-10bpm.
  • Chest compressions continued
  • IO established in L tibial tuberosity
  • First round of 1.0mg 1: 10,000 Epi IO
  • Crew recognizes PEA and no defib delivered

PULSE CHECK

  • Patient remains in PEA
  • Chest compressions resumed
  • IO fluids hung with pressure bag placed wide open
  • EtCO2 line placed and measured at 12mmHg
  • BGL assessed and noted to be 92mg/dl
  • No obvious signs of trauma noted; no forms of ETOH use or illicit drug use noted; patient is not on any known opioids

PULSE CHECK

  • Patient remains in PEA
  • Second round of 1.0mg 1: 10,000 Epi IO
  • Chest compressions resumed
  • Patient vigorously suctioned due to foaming secretions; intubated with first pass success with channeled blade video laryngoscope and bougie stylette
  • EtCO2 improves to 22mmHg

PULSE CHECK

  • Patient remains in PEA
  • Chest compressions resumed
  • Secondary IV access obtained with fluids hung wide open with pressure bag; approx. 750ml have been infused thus far
  • 50meq Sodium Bicarbonate IO
  • EtCO2: 20mmHg

PULSE CHECK

  • Patient remains in PEA
  • Chest compressions resumed
  • Third round of 1.0mg 1: 10, 000 Epi IO
  • EtCO2: 23mmHg
  • Crew begins to approach family about the fact that ten minutes of resuscitation have taken place with no gross changes and initiates conversation about end of life decisions; family states that the patient has no known end of life arrangements in place, and request that despite no gross changes, patient be transported regardless of ROSC.

PULSE CHECK

  • Patient remains in PEA
  • Chest compressions resumed
  • Approximately 1.2L of 0.9% NS have been infused at this time
  • Crew gathers backboard and other packaging equipment, but stop long enough to note that the EtCO2 has risen to 67mmHg from the low 20s
  • Confirmed ROSC noted at this time

ROSC 12-LEAD

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  • BP: 102/48
  • EtCO2: 49mmHg
  • HR: 116
  • Pupils are dilated and unresponsive
  • Patient remains GCS of 3
  • What do you see on the 12-lead?
  • Crew initiates transport to local PCI center approx. 10 minutes away from residence; approximately five minutes into transport, patient arrests a second time.
  • Chest compressions initiated again.

PULSE CHECK

  • Patient is found in PEA
  • Chest compressions resumed
  • Fourth round of 1: 10,000 Epi IO
  • EtCO2: 25mmHg; towards end of cycle of CPR, crew notes another spike in EtCO2 to 56mmHg
  • Crew confirms that they have ROSC again

SECOND ROSC 12-LEAD

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  • BP: 74/42
  • HR: 88
  • EtCO2: 52mmHg
  • Patient continues to ventilate without difficulty
  • What do you see on the 12-lead?
  • Approximately 2.5L of 0.9NS have been infused at this time
  • Crew initiates norepinephrine drip at 2mcg/min per crew’s protocol

ED HANDOFF

  • Patient codes a third time
  • Ongoing resuscitation in the ED lasts for another 30 minutes with no ROSC
  • Patient found have to have pulmonary embolus and pronounced in the ED

DISCUSSION

  • What would you have done differently?
  • Do you think that there is a place for thrombolytics in routine care for post arrest patients from possible thromboembolism?
  • What do you think the role of prehospital ultrasound is?

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