You are in the midst of a wonderful Sunday afternoon shift (The Vikings are in the 1st quarter and much of the state remains momentarily sober while transfixed to a television broadcast from somewhere other than your emergency department.) Calm reigns in the 'Land of Clear Blue Water."
You sense the charge nurse approaching from behind as you finish your last "late" dictation." You hear her foot tapping as you dictate the final period of your last sentence.
“Paramedics called ahead, they are bringing in a 75 year old female in cardiac arrest. They are 5 minutes out. They didn't give any more info. Also, I'm worried about the patient in room 15. EMS just brought him in. He's having chest pain and difficulty breathing. He's hypotensive.
So much for a peaceful Sunday.
You head to room 15.
You walk in the room and see a man working hard to breath. He is noticeably uncomfortable. He is sweating. Nurses and EMTs are swarming, placing IVs, hooking up monitor, and placing the patient on oxygen. EMS reports that the patient was sitting at home going to the bathroom when he suddenly developed shortness of breath. He now describes some moderate chest pain and some abdominal pain.
Once on monitor you see the following: BP 70/55 HR 130 Sat 83%
You glance at the initial ekg which shows subtle t wave inversions inferiorly but nothing else significant.
You do a quick primary survey:
Airway: Patent, able to speak
Breathing: Respiratory distress, 1-2 word sentences, breath sounds present bilateral an no significant rales or wheeze.
Circulation: Faint radial pulse present. No cardiac murmur.
Disability (Nuerologic Status): Pt is alert but in significant distress. Moving all 4 extremities.
You are about to move to your secondary survey when the patient's eyes roll back and he becomes unresponsive.
You check a pulse: absent
You look up at the monitor and see this narrow complex rhythm:
You determine this to be a PEA arrest.
You immediately begin CPR...(you remember that the ABC's are now the CAB's: Circulation, Airway, Breathing). One EMT begins to bag the patient and another goes to get the Lucas. Pharmacy arrives and begins to draw up epinephrine. Nurse pages the respiratory therapist and begins working on a second IV access. You call for your partner to help intubate the patient.
You begin down the ACLS algorithm.
After 2 minutes you stop CPR (no more than 10 seconds), check for a pulse: (still absent) and note that the rhythm is unchanged (still PEA).
You resume CPR.
Epinephrine is given.
Your partner arrives and helps you to intubate the patient while CPR is in progress.
The nurse gently points out that the patient has a cast on his leg and that his chart indicates that he was recently seen for a dislocated ankle.
You suspect possible Pulmonary Embolus. You ask the pharm-d to draw up TPA and have it ready for administration. However, you don't want to anchor on the diagnosis of pulmonary embolus so you and your partner begin to discuss other possible causes..."let's take a second to think about the H's and T's......hmmm....hypothermia... hypovolemia...hypoxia...h?...h?...how many h's are there??? Ok let's think about the T's...trauma...tension pneumothorax...what were the other h's????"
You continue around the circular ACLS algorithm, pausing every 2 minutes to check pulse/rhythm and administering epinephrine every 3-5 minutes.
You feel yourself getting dizzy.
You feel yourself becoming more lost and confused.
Suddenly you recall September's Virtual Journal Club article.
Sound effect: DING, DING, DING!!!
This is QRS NARROW!!!
You grab the ultrasound: No pericardial effusion, normal lung movement, the right ventricle seems slightly enlarged.
You look at the patient's cast and decide to administer TPA.
You continue around the circular ACLS algorithm, pausing every 2 minutes to check pulse/rhythm and administering epinephrine every 3-5 minutes.
After the fifth cycle of ACLS, you feel a pulse. CPR is held. Blood pressure improves. O2 Sats improve. You call the ICU and get the patient a bed.
You wonder on down to help your partner with his new patient.
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Amidst the chaos of your bumbling attempt to recall the H's and T's your partner disappeared to take care of the new cardiac arrest patient brought in by EMS.
The paramedics relate the following story:
This is a 75 year old woman in cardiac arrest. She was found unresponsive at home, pulseless and apneic. She has a history of MI, CHF, and Chronic Renal Failure. Immediate bystander CPR was initiated. EMS arrived 7 minutes after call, assumed CPR, and initiated ACLS ventricular fibrillation protocol. After defibrillation in the field, post shock rhythm was the following:
Total down time is @20 minutes.
Your partner does a quick primary survey:
Airway: Intubated
Breathing: Paramedic reports that the patient is bagging easily.
Circulation: Pulse is palpable with compressions, otherwise absent.
Disability (Nuerologic Status): Pt unresponsive, no spontaneous movement.
Your partner continues around the circular ACLS algorithm as above.
Your partner recalls September's Virtual Journal Club article.
Sound effect: DING, DING, DING!!!
Your partner determines that the patient is an a QRS Wide complex PEA.
An amp of calcium is given (treatment for hyperkalemia.)
An amp of bicarb is given (treatment for both sodium channel blocker toxicity and hyperkalemia...although suspicion for sodium channel blocker toxicity is low)
Your partner continues around the circular ACLS algorithm without significant change. The QRS widens and the ventricular rate slows. Bedside ultrasound shows eventually shows cardiac standstill.
Resuscitation efforts are discontinued after 45 minutes total time.
Autopsy reveals acute extensive inferior-posterior MI with evidence of previous large anterolateral MI.
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Study Questions
1. Which of the following should be a part of every primary survey:
a. Airway assessment
b. Breathing assessment
c. Circulation assessment
d. Disability (Neurologic) assessment
e. All of the above
2. True or False: the H's and T's have been shown to prioritize most likely cause of PEA arrest and help direct care?
3. QRS narrow PEA (also known as "pseudo-PEA") is associated all but which of the following:
a. Cardiac Tamponade
b. Tension PTX
c. Pulmonary Embolism
d. MI
4. QRS Wide PEA (also known as "true-PEA") is associated all but which of the following:
a. Severe Hyperkalemia
b. Sodium Channel blocker toxicity
c. Acute MI
d. Pulmonary Embolism
5. The "true" first name of the physician pictured above is:
a. Warren
b. Raymond
c. Nicolas
d. Jack
answers
1. e
2. false
3. d
4. d
5. d (jack elum) (character name is Nikolas Van Helsing)...other names are random/made up.
