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47 year old male CC: Crushing chest pain – Conclusion

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Here is the conclusion to 47 year old male CC: Crushing chest pain.

You may want to go back and read the original case presentation to see how we got to this point.

When we left off we had this rhythm on the monitor and surprisingly the patient was conscious and talking! 

As usual there was an excellent discussion in the comments.

I certainly agree that the first step is to check the leads. I've seen artifact mimic VF before! When I worked in the Critical Care Stepdown Unit as a cardiac monitoring technician this would sometimes happen when a patient brushed their teeth.

However, this time it was the real McCoy (hyperlinked explanation of this idiom for my international friends).

  • This has the general appearance of Torsades de Pointes.
  • It's fast, wide and polymorphic.
  • There appears to be a "streamer" effect.
  • The patient is conscious.

However, several features point away from Torsades de Pointes.

  • The ventricular rate (using the small block method) is 375
  • The QTc of the underlying rhythm is 447 ms

The rate of TdP is typically in the 150 – 300 range. A QTc of 447 while technically prolonged is still < 500 ms which is generally considered to be "safe". 

It seems to go against everything we've been taught but could this patient have been conscious with VF on the monitor?

The answer is "Yes!" There are two reasons for this.

First, the onset of VF is often course and slow (relatively speaking). A ventricular rate of 375 is a lot different from a ventricular rate of 720. We like to think of VF as if it's all the same and it usually is from a treatment standpoint. But there is quite a lot of variability as I'm sure anyone who has worked on VF detection algorithms could tell you.

The second reason is that forward blood flow continues for several minutes after the onset of cardiac arrest. That's because there is a pressure gradient between aortic pressure and central venous pressure.

This chart from a white paper on the LUCAS device helps illustrate the point.

This is a busy chart but you will note that it takes several minutes for aortic pressure and central venous pressure to merge together after the onset of VF.

Mark Glencorse over at the (retired) 999Medic.com blog presented another case of transient VF where we had the same lively debate as to whether or not we were dealing with Torsades de Pointes.

Some of you are probably thinking, "It's not VF! It's polymorphic VT!" I will simply ask, isn't VF a form of polymorphic VT? At what rate does polymorphic VT become VF?

From a treatment standpoint it doesn't matter in this case because I'd treat both rhythms exactly the same. I'd apply the combo-pads and I'd give 2 g of magnesium sulfate while I was waiting to see if the patient lost consciousness. Tim Noonan (Scallywag Medic) will be disappointed in me for saying so but you really can't hurt a patient with MgSO4 and it might help.

In this case the treating paramedic didn't carry magnesium sulfate but he did apply the combo-pads.

About a minute and a half later the patient lost consciousness.

Now I think we'll all agree that the patient is in VF and we'll also agree on the treatment! 

After another 2 cycles the patient was shocked back into a perfusing rhythm. Interestingly, the patient "woke up" several times during chest compressions.

The patient regained consciousness after return of spontaneous circulation.

Another 12-lead ECG was captured.

Now we're back where we started! (Okay, it's a little worse.)

Advanced notification was given to the receiving hospital and the cardiologist was waiting for the patient. He was taken directly to the cardiac cath lab where angiography revealed a 100% occlusion of the proximal LAD.

The lesion was successfully stented and the patient made a full recovery.

Congratulations to Phil, the Intensive Care Paramedic from Australia (and his crew) for a job well done!

Got an awesome case? Submit it to the EMS 12-Lead blog at ems12lead@gmail.com

Posted by on August 17, 2011 • Filed under: ems-topics, patient-management • Tagged: , , , , , , , , , , , , ,

Fun and games with response time reporting

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As I've mentioned on several different occasions, it's a huge mistake to wait until a tragedy occurs to explain the truth about response times to your community.

Response times should be measured from the patient's perspective. In other words, from the moment the dispatcher picks up the phone and says, "9-1-1 what is your emergency?" to the moment a professional rescuer arrives at the patient's side.

Any other sub-interval is smoke and mirrors (see HERE and HERE for previous posts on EMS response time reporting and other system failures).

There is no excuse for allowing our real response times to be ambiguous. It doesn't matter if some other organization does the dispatching. It's the EMS system’s responsibility to figure it out because we are ultimately responsible for the community's chain-of-survival.

In other words, if our chain-of-survival is broken (and it surely is if we have no idea how long call processing takes) then it's our responsibility to educate our citizens and our elected officials of that fact.

Remember, millions (perhaps tens or even hundreds of millions) of dollars in 9-1-1 taxes are collected each year in the United States. Where does the money go? Our inability (or unwillingness) to measure "9-1-1 call received" to "patient's side" is completely unacceptable and patients die because we pretend that our response times are better than they actually are.

Where's the accountability?

We must never allow ourselves to become acclaimated to things that would outrage members of the general pulbic once the facts become known.

Explaining why EMS wasn't there "in 4 minutes" to treat a child in cardiac arrest is not a particulary good backdrop to have this conversation with the taxpayers.

Posted by on June 30, 2011 • Filed under: ems-topics, patient-management • Tagged: , , , , , , ,

Conclusion to 60 year old male CC: Sudden cardiac arrest

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This is the conclusion to 60 year old male CC: Sudden cardiac arrest.

As you may recall the resuscitation was implemented using the choreographed or "pit crew" model.

This is characterized by:

  • Leadership
  • Skills and competencies
  • Teamwork and communication
  • Best practices
  • Rehearsal

Special emphasis is placed on:

  • Minimally interrupted chest compressions
  • Controlled ventilations
  • Defibrillation
  • Appropriate timing (e.g., pre-charging the defibrillator, shocking every 2 minutes, miminizing delays between stopping compressions and shocking)

This is not meant to miminize the importance of the chain-of-survival, including early activation of 9-1-1 and bystander CPR. Those links were intact for this case and that is extremely important.

As you might recall return of spontaneous circulation (ROSC) was achieved, the patient was loaded for transport, and a 12-lead ECG was captured.

Let's take another look.

The obvious question (and the one I usually ask) is whether or not this 12-lead ECG shows STEMI.

However, before we look at that, let's review some important comments from:

Regional Systems of Care for Out-of-Hospital Cardiac Arrest – A Policy Statement From the American Heart Association. Circulation 2010;121:709-729

Up to 71% of patients with cardiac arrest have coronary artery disease, and nearly half have an acute coronary occlusion. There is a high incidence (97%) of coronary artery disease in patients resuscitated from OOHCA who undergo immediate angiography and a 50% incidence of acute coronary occlusion. However, the absence of ST elevation on a surface 12-lead electrocardiogram after resuscitation of circulation from cardiac arrest is not strongly predictive of the absence of coronary occlusion on acute angiography (emphasis added). A case series of patients with unsuccessful field resuscitation suggested that in such patients, VF is more likely to be due to coronary disease than is asystole or pulseless electric activity. An autopsy study compared case subjects who died within 6 hours of symptom onset due to ischemic heart disease and who were not seen by a physician within 3 weeks with control subjects who died within 6 hours of symptom onset due to natural or unnatural noncardiac causes…Collectively, these studies suggest that patients who are resuscitated from out-of-hospital VF have a high likelihood of having an acute coronary occlusion (emphasis added).

The feasibility and efficacy of primary PCI in patients who survive cardiac arrest with STEMI have been well established. The combination of mild therapeutic hypothermia with primary PCI is feasible, may not delay time to start of primary PCI in well-organized hospitals, and is associated with a good 6-month survival rate and neurological outcome…Patients resuscitated from OOHCA with STEMI should undergo immediate angiography and receive PCI as needed. Immediate coronary angiography is reasonable for patients resuscitated from VF and may be considered in patients resuscitated from other initial rhythms who do not have a clear noncardiac cause of cardiac arrest (emphasis added).

Does the first 12-lead ECG look like it might be an acute anterior STEMI? I would have to say yes (the 12-lead ECG captured on arrival at the hospital does not look like a classical STEMI — we'll get to that in a minute). However, my question for you is, should it matter?

The patient has been resuscitated from sudden cardiac arrest of presumed cardiac etiology. That alone is enough reason to send the patient emergenty to the cardiac cath lab, IMHO. That (along with other important post-resuscitation care like therapeutic hypothermia and ICDs) is why the AHA is advocating regional systems of care for out-of-hospital cardiac arrest.

Now let's look at the 12-lead ECG acquired on arrival at the hospital.

Now rather than ST-elevation in the anterior leads we see a different ECG abnormality that is also concerning. Namely, ST-elevation in lead aVR and V1 with ST-depression in leads I, II, III, aVL, aVF, V3, V4, V5 and V6.

(Side note: remember the "rule of proportionality" when you look at ST-elevation or ST-depression. The QRS complexes in the limb leads are very small. Hence, even a tiny bit of ST-elevation or ST-depression is significant).

This could indicate left main coronary occlusion, 3-vessel disease, or subendocardial ischemia. Again, this is just academic since you could argue that all patients resuscitated from VF arrrest should be emergently cathed.

On arrival at the hospital the attending ED physician grabbed the Code Summary out of the treating paramedic's hand and saw this rhythm strip.

As a happy coincidence this rhythm strip (which was captured in monitor mode) exaggerated the ST-elevation in lead V1. Perhaps the ED physician would have called the Code STEMI anyway. At any rate, the Code STEMI was called immediately.

Angiography revealed severe atherosclerotic disease that was not amenable to catheterization. The patient was taken emergently to the OR where he received a 5-vessel CABG.

The patient was discharged from the hospital a week later neurologically intact.

Posted by on June 3, 2011 • Filed under: ems-topics, patient-management • Tagged: , , , , , , , , , , , ,

60 year old male CC: Sudden cardiac arrest

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Here's a great case submitted by a faithful reader who wishes to remain anonymous. Some minor details have been changed to preserve patient confidentiality and some relevant comments and teaching points have been added.

EMS is called to a barbecue festival for 60 year old male, unconscious and unresponsive, possible cardiac arrest.

En route dispatch advises, "the caller states the patient is breathing, CPR in progress." 

While radio transmissions like this often make EMTs and paramedics chuckle, we know that agonal breathing helps predict survival from sudden cardiac arrest.

This is one of the reasons that "look, listen and feel" has been removed from the 2010 AHA ECC guidelines.

"Agonal gasps are common early after sudden cardiac arrest and can be confused with normal breathing. Pulse detection alone is often unreliable, even when performed by trained rescuers, and it may require additional time. Consequently, rescuers should start CPR immediately if the adult victim is unresponsive and not breathing or not breathing normally (ie, only gasping). The directive to "look, listen, and feel for breathing" to aid recognition is no longer recommended."

On arrival, bystander CPR is in progress. Specifically, continuous chest compressions without rescue breathing are in progress. An EMT takes over compressions and the following sequence happens very quickly.

  1. The LP12 is powered on.
  2. The combi-pads are deployed and attached to the patient.
  3. The LEAD button is pushed to get a paddles view.
  4. The monitor is charged to 200 J.

This is where the "pit crew" concept or "choreographed model" comes into play. There is no reason to hesitate. The monitor should be charged immediately with the expectation that it's a shockable rhythm so that the shock can be delivered as soon as possible.

(Since some are claiming this is "dangerous" please see:

M.S. Lloyd, B. Heeke, P.F. Walter, J.J. Langberg. Hands-on defibrillation: an analysis of electrical current flow through rescuers in direct contact with patients during biphasic external defibrillation. Circulation 117 (2008) (2510 – 2514).

Edelson DP, Robertson-Dick BJ et al. Safety and efficacy of defibrillator charging during ongoing chest compressions: a multi-center study. Resuscitation. 2010 Nov;81(11):1521-6.)

Once these actions are complete, everyone clears the patient with the exception of the chest compression man. When the lead paramedic gives the command (in this case a nod of the head) the chest compression man clears the patient, the lead paramedic confirms that VF is on the monitor, and the shock is delivered with minimal delay between stopping compressions and shocking.

Compressions are resumed immediately. The pulse check does not occur until another complete 2 minute cycle is complete.

Incidentally, some of the highest performing EMS systems in the country handle this in differrent ways. Some perform continuous chest compressions with a non-rebreather mask, some follow the 30:2 recommendation of the AHA (occasionally with a ResQPOD attached to the BVM), others drop a blind insertion airway device like the King LTS-D and deliver asynchronous ventilations at a rate of 8-10/min. (every 6-8 seconds), and some capture the airway with a tracheal tube without interrupting chest compressions.

As the next 2-minute cycle is nearing completion the monitor should be charged again to 300 J (or whatever energy setting your protocols dictate for the second shock). Again, the idea is to avoid ineffficiency.

It shouldn't look like this:

  1. Stop compressions
  2. Read the monitor and decide the patient needs a shock
  3. Start compressions again
  4. Charge the monitor
  5. Stop compressions
  6. Confirm that a shockable rhythm is on the monitor
  7. Go through a lengthy "I'm clear, you're clear, we're all clear" process
  8. Deliver the shock

On the other hand, it is very important that the paramedic who interprets the monitor pay close attention to whether or not it's a shockable rhythm before pushing the SHOCK button.

This can be diffficult when the defibrillator is pre-charged, everyone's watching, and you're trying to balance minimizing the delay between stopping compressions and shocking with making sure the shock will confer a benefit to the patient.

After the second shock it was noted that the patient was "pinkening up."

The defibrillator was pre-charged prior to the end of the next 2 minute cycle. However, this time there was a rhythm on the monitor. It looked something like this.

The patient started to breath spontaneously at a rate of about 30/min which was somewhat surprising. The "airway man" attached the waveform capnography to the BVM and timed small bag squeezes with the patient's spontaneous ventilations. 

This works beautifully if you haven't tried it! Waveform capnography is a very useful tool.

Once the patient was loaded in the back of the ambulance a 12-lead ECG was captured.

Vital signs were assessed.

RR: 20
Pulse: 150 Irregular
NIBP: 155/123 (presumed spurious)
SpO2: 97 and rising

An EMT attempted to confirm the BP by auscultation but was only able to confirm a BP of 150/P.

At this point it was noted that the patient was moving and there was a small amount of vomit in the patient's mouth. 

The patient's airway was suctioned (with difficulty due to a clenched jaw). After a minute or two the patient's jaw relaxed.

The OPA was removed in case the problem was a return of the patient's airway reflexes. By this time the respiratory effort was adequate and the decision was made to switch the patient out to a non-rebreather mask. The patient's head was turned to the side.

This had a positive effect and within a minute or two the patient followed a command to open his eyes.

Another 12-lead ECG was captured.

By arrival at the hospital the patient was confused but talking.

Questions for discussion

Do you follow a "pit crew" concept or choreographed model for sudden cardiac arrest?

What is a normal response in your jurisdiction for sudden cardiac arrest?

Have you read the 2010 AHA ECC Guidelines?

Do you emphasize minimally interrupted chest compressions, controlled ventilations, and shocking in a 2-minute cycle?

Are all other interventions secondary?

Do you think this patient needed antiarrhythmics?

What do you think of the patient's 12-lead ECGs?

What should this patient's post-resuscitation care look like?

See also:

Conclusion to 60 year old male CC: Sudden cardiac arrest

High performance CPR – Seattle Style!

Sudden Cardiac Arrest podcasts from EMS Today 2011

Posted by on May 25, 2011 • Filed under: ems-topics, patient-management • Tagged: , , , , , , , , , ,

Wake County EMS cardiac arrest survival rate among the highest in the country

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via NBC 17 News

In these trying economic times, wouldn't it be nice to enjoy these bragging rights?

It's not so easy for elected officials to cut your budget when you can prove you're a vital public service! 

It feels good to save people, too. As noted by the panelists of the HeartRescue Project at EMS Today 2011, cardiac arrest survivors are powerful allies!

Bring one to a meeting and watch the "anti-champions" crawl under the nearest rock.

Congratulations to Wake County EMS!

See also: On Scene and Hospital Hypothermia – D2B October 2010 Webinar with Brent Myers, M.D.

Posted by on May 19, 2011 • Filed under: ems-topics, patient-management • Tagged: , ,

High Performance CPR – Seattle Style!

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Editor's note: Since it's all over the news that Seattle's "save rate" for cardiac arrest (witnessed collapse, presumed cardiac etiology, shockable rhythm) is over 50%, I asked Dave Hitlz of the HEARTsafe Community page on Facebook if I could re-post an article he and Mathias Duschl wrote about their experience at the Resuscitation Academy. He graciously agreed.

High Performance CPR: Seattle Style!

Written by:

Mathias Duschl, from Gattikon, Switzerland
David B. Hiltz, from Westerly, Rhode Island

Recently, the two of us had the tremendous opportunity to attend the Resuscitation Academy, whose mission is to improve survival from out of hospital cardiac arrest.

The Academy, conducted by Seattle Medic One and King County EMS, convenes EMS managers, EMS directors and EMS medical directors in a “mini-fellowship” program that consists of Pre-Fellowship assigned readings, a 4-day intensive and immersive experience discussing Quality Improvement (QI), education, science and leadership in system approaches to optimizing outcomes from out of hospital cardiac arrest (OOHCA), and post-fellowship QI projects.

The experience was remarkable, and provided both of us with improved knowledge, understanding and perception of complex subjects relating to the public health issue of cardiac arrest. Despite having people from different continents, we all had the same mind set and came together to work on strategies that can help save more lives in our communities.

The evolution of discussions at the Academy led to the identification of deliberate approaches to optimizing outcomes from OOHCA. We truly believe that the experience gained through the mini-fellowship program to be highly beneficial and we encourage agencies, EMS systems, local governments and administrations (like county boards of health in the U.S.) to send representatives to the Academy with a goal of developing localized strategies to save lives. 

Among the essential components of a system of care for cardiac arrest victims is “high performance CPR” (HP-CPR) and we have decided to share this, our perspective, on the subject. Neither of us intends to portray ourselves as experts and all-knowing, but simply applying one viewpoint on one subject in a cardiac arrest QI montage.

High quality resuscitation and improved outcomes are highly dependent on a foundation of high quality CPR by prehospital care providers. Advanced cardiac life support must be positioned in a way that does not get in the way of, but instead enables this high quality CPR. The approach requires a teamwork approach by EMS systems, agencies and providers alike.

The American Heart Association has released the revised BLS for HCP course. In Europe, the European Resuscitation Council ERC provides PowerPoint presentations, posters etc. about the new BLS strategies as downloads in several languages via their website. These materials, in the hands of qualified instructors, will continue to be a cornerstone in resuscitation education for countless providers. But AHA-ERC certification is just the beginning…not an end point in our efforts to save more lives.

Resuscitation training and education should not be thought of as a course or single “event”, but rather a long-term progression in development of CPR quality and an ongoing quest for better insight on the science, practice and performance of resuscitation. Continuity in education and repetitive training in CPR can lead to better results in real-life situations. A goal of highly choreographed HP-CPR is extremely desirable, but like most things, it won’t happen through desire alone. Action is required if we are to expect improvement.

One potential method to improve CPR is to develop a “team strategy” with clear roles and is translated into “team practice” of HP-CPR. View the videos from the Resuscitation Academy, where a team approach is portrayed. Whether you call it Choreographed CPR, HP-CPR, Crisis Resource Management in CPR or use of an Incident Command strategy at the scene of a cardiac arrest, the essential goal is improved teamwork, and teamwork requires PRACTICE.

Initiating team practice does not have to be elaborate or complicated. Informal and formal practice sessions are both reasonable and recommended strategies to improve future performance. Use of observers with equipped with stopwatches, checklists, video recorders, and/or instrumented manikins along with practiced and non-punitive debriefing skills will improve results.

Use a “let’s just do it” approach. Don’t wait for an overly-detailed plan to begin the process of quality improvement. Read the Guidelines for CPR and ECC and understand the science Make resuscitation quality a priority (culture of excellence) Use courses like the AHA BLS HCP course to establish baselines Begin practicing HP CPR Collect CPR performance data through observation or instrumentation.

Ongoing and routine debriefing regarding CPR performance

All personnel involved in practice should have an opportunity to contribute to the QI process. Exercise facilitators should use a structured and consistent approach to debriefing of rescuers. The practice of clinical event debriefing can also be very valuable in the QI process and development of HP CPR.

Improving OOHCA outcomes is challenging to say the least. Individual clinical excellence is just one factor in a life-saving formula…but at the same time an integral and core component in a process that involves the implementation of strategies to optimize recognition, response, care and outcomes for cardiac arrest patients. The incremental value of ongoing system quality improvement (public health surveillance), early recognition and emergency number activation, pre-arrival instructions, bystander initiated CPR, really fast “shock strategies”, HP- CPR, and regional systems of care (incorporating therapeutic hypothermia and other evidence based recommendations) is essential.

Performing high quality CPR, with minimal delays and interruptions is a core strategy to improving outcomes. Quality improvement strategies should aim to encourage, enable, and direct the ongoing practice and pursuit of high performance CPR. High Performance CPR is not, and should not be complicated. In fact, we believe it is relatively easy to implement. It does however require action in order to get the process going, commence practice, and begin the process of developing a culture of excellence.

“Measure, improve, measure, improve, measure, improve”- Dr. Mickey Eisenberg.

See also:

Resuscitation Academy

HEARTsafe Community page on Facebook

Posted by on May 13, 2011 • Filed under: ems-topics, patient-management • Tagged: , , , , , , , , , ,

91 year old female CC: Seizure (A strange situation) – Discussion

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I’ve been receiving some emails from readers who would like to know what happened with the 91 year old female (DNR patient) who went into PEA as she was loaded into the ambulance.

Here is the 12-lead ECG that was captured just as she went into cardiac arrest.

Here’s another that you haven’t seen.

She died. The paramedics did not interfere.

I posted the case because as long as I’ve been a paramedic, I’ve never had to deal with this situation.

It would be very difficult for me (and I suspect most paramedics) to stand by and do nothing while someone dies, even though we can rationalize that it respects the patient’s wishes.

When I discussed this case with my girlfriend (an advanced practice nurse) it became clear to me that DNRs are not always cut and dry.

We’ve all heard the saying “DNR does not mean Do Not Treat.”

But what does it mean? Exactly?

Does it mean we treat conditions that might be reversible?

What is a “heroic” measure?

I was discussing end of life wishes with my parents several years ago (a very difficult thing to do) and neither one wanted to be on life support.

But when I changed the question to something like, “What if you were only life support for a few days and then recovered?” or “What if you were on life support just long enough to see whether or not you would recover?” the response changed to “That sounds reasonable.”

DNRs, by their very nature, simplify things that are complicated.

The subject of DNRs warrants a lot more discussion than paramedic students are getting in school.

It warrants more discussion with the people who sign DNRs, too.

Before I receive any hate mail, I am not suggesting that the paramedics did anything wrong in this case, and I am not suggesting that this woman’s ribs should have been crushed.

I’m saying that the paramedic curriculum should spend more time on health care ethics.

I’m also suggesting that EMS protocols that say “DNR patients don’t go on the monitor” might be problematic because the ECG can be helpful in diagnosing a lot of reversible conditions.

There are shades of gray in the field of ethics and I’ve noticed that paramedics often demonstrate an intolerance of ambiguity.

As Einstein said, “Things should be made as simple as possible — but not simpler.”

Posted by on February 24, 2011 • Filed under: ems-topics, patient-management • Tagged: , , , , , , ,

56 year old female with a “cardiac disorder”

17 comments

Here’s an interesting case submitted by Mike from Massachusetts.

Here’s the story in Mike’s own words:

EMS is contacted by a local rehabilitation facility for a female patient with a cardiac disorder. Initial dispatch is an ALS ambulance, ALS squad, and a BLS engine company.

Approximately 20 minutes prior to EMS arrival, patient began experiencing palpitations (“fluttering”) and reported this to staff. Oxygen has been applied by non-rebreather mask @ 15 L/minute. An initial set of vital signs and an ECG tracing were obtained.

Vital signs as follows:

Heart Rate (on monitor): 214 (Wide-complex)
Pulse: 40
Blood pressure: 114 / 94
Respiratory rate: 22

The ALS ambulance crew arrives first (my parther and I) and finds a morbidly obese (> 180 kg) 56-year-old female patient resting semi-fowlers in bed. Patient is undergoing inpatient rehabilitation following pneumonia. Patient is pleasant, alert and oriented x4 and does not appear to be in acute distress. Patient is conversing appropriately with staff, continues to complain of palpitations, but denies other symptoms.

EMS’ LifePak 15 is applied, paddles only, showing the following rhythm.

While in the process of obtaining vascular access and applying the 12-Lead, the patient becomes unresponsive and apneic. Her cardiac rhythm is noted to deteriorate to a wide-complex rhythm with an electrical rate at over 300 bpm. The LP15 is charged and the patient is defibrillated at 200 J within 15 seconds of the arrest.

There is near-immediate return of spontaneous circulation and patient quickly regains consciousness. Patient does not recall the event, but otherwise remains alert and oriented.

Vital signs as follows:

Heart rate: 90 bpm (Sinus rhythm with occasional multi-focal PVCs)
Blood pressure: 125 / 74
Respiratory rate: 18
SpO2: 100% (100% FiO2)

Intravenous access is obtained. Lidocaine, 180 mg IV bolus is administered and a Lidocaine infusion @ 2 mg / minute is initiated.

A 12-lead ECG is obtained.

Transport time to nearest facility (non-PCI) is less than three minutes.

What do you think of the initial rhythm and arrest rhythm?

Do you see anything to worry about on the 12-lead ECG?

Why or why not?

Posted by on February 23, 2011 • Filed under: ems-topics, patient-management • Tagged: , , , , , , , , , , ,

EMS EduCast Episode 91: Cardiac arrest (and skill retention)

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Thanks to the EMS EduCast for inviting me back on the show last Wednesday night!

We had a spirited and interesting discussion about cardiac arrest.

You can listen to (or download) the episode here:

Skill Performance Reinforcement and More: Episode 91

The Facebook page is HERE. The Twitter profile is HERE.

See also our previous discussion about 12-Lead Education here:

12 Lead ECG Education: Episode 56

Posted by on February 21, 2011 • Filed under: ems-topics, patient-management • Tagged: , , , , , , ,

Physio-Control and BeneChill enter strategic partnership to launch RhinoChill IntraNasal cooling system in Europe

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Physio‐Contro (@PhysioControl) and BeneChill (@RhinoChill) announced today a strategic partnership to launch the RhinoChill IntraNasal Cooling System in Europe. RhinoChill is a non‐invasive, portable system for transnasally cooling the head and lowering the body’s core temperature immediately following cardiac arrest, stroke or traumatic brain injury.

Initially, the partnership will focus on bringing the RhinoChill System to market in the United Kingdom, Germany, Austria, Switzerland, Belgium, Netherlands and Luxemburg during the first quarter of 2011, utilizing Physio‐Control’s extensive European distribution network. Additionally, as part of this strategic alliance, the two companies will work jointly to develop additional applications for BeneChill and work towards making the RhinoChill System available in the U.S.

The RhinoChill System uses a non‐invasive nasal catheter that sprays a rapidly evaporating, inert coolant liquid into the nasal cavity, a large area situated beneath the brain that acts as a heat exchanger. As the liquid evaporates, heat is directly removed from the base of the skull and surrounding tissues via conduction and indirectly through the blood via convection.

The system is battery‐powered, compact and does not require refrigeration, making it ideal for use in pre‐hospital settings. Each coolant bottle holds enough liquid to cool a patient for 30 minutes at nominal flow, and bottles can be easily exchanged to maintain the cooling process.

See a video at the company website HERE. The YouTube channel is HERE.

I’ve got to admit that this technology looks interesting. I’d like to see how it stacks up against iced saline and external cooling (which is pretty inexpensive).

This blog post derived in part from a press release by Physio-Control with whom Tom Bouthillet and the EMS 12-Lead blog have no conflict of interest.

See also:

Physio-Control announces LIFENET System 5.0, partnership with AirStrip Technologies

Posted by on February 9, 2011 • Filed under: ems-topics, patient-management • Tagged: , , , , , , , , , , ,

Transcutaneous pacing (TCP) for asystole

16 comments

We all know by now that transcutaneous pacing (TCP) is no longer recommended for asystolic arrest.

But what about patients who experience return of spontaneous circulation?

Consider the following case.

EMS is called to an assisted living facility for a 79 year old female who is found collapsed outside her apartment door.

On arrival, the staff is providing adequate chest compressions.

The cardiac monitor is attached.

Chest compressions are continued, the airway is captured with a tracheal tube, an IV is initiated, and 1 mg of epinephrine is given IV.

The patient has a faint pulse but a blood pressure cannot be auscultated. The patient is prepared for transcutaneous pacing (TCP).

The pacer is set to 80 PPM and paramedics report capture at 110 mA.

With this rhythm on the monitor the patient’s BP is 118/68 and she radial pulses that correspond to the monitor.

Do you agree that capture has been achieved?

Is there anything else you would want to do at this point?

You are 10 minutes from your local receiving hospital.

See also:

Transcutaneous pacing (TCP) – The problem of false capture

Transcutaneous pacing (TCP) with a Lifepak 12

Using capnography to confirm capture with transcutaneous pacing (TCP)

58 year old male CC: Unconscious (Transcutaneous pacing failure in the setting of hyperkalemia)

Posted by on February 1, 2011 • Filed under: ems-topics, patient-management • Tagged: , , , , , , , , , , , , , ,

The “pit crew” concept in cardiac arrest

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While the drivers and owners may get most of the credit a good "pit crew" is essential for team success in NASCAR.

 

 

So what makes a good pit crew?

Leadership

A good pit manager will ensure that the pit crew is ready and that all the necessary resources are in place. That includes ensuring that the appropriate number of people have been assigned to critical tasks, and that equipment is organized in a logical manner.

Skills and Competencies

Individual team members should possess all of the skills and competencies to perform their functions quickly, efficiently, and accurately. For example, the tire replacement crew should know when the tires need to be replaced, where the tires are kept, and whether wet or dry tires are required. Similar skills are required of the team members responsible for refueling and repairing mechanical breakdowns.

Teamwork and Communication

Fluency in communication can make the difference between winning and losing. This is where precious seconds can be lost or gained. Good communication is what leads to coordination and problem solving. Lack of communication leads to errors and loss of situational awareness.

Best Practices

Doing something because "that's the way it's always been done" or because "that's how a real pit crew operates" is short-sighted if the end result is losing the race. A good pit crew learns from its mistakes (and the mistakes of others) and will not hesitate to amend its procedures when another pit crew demonstrates a way to do it better. The outcome drives the process. Not tradition. Not ego.

Rehearsal

A good pit crew doesn't "make it up the day of the race" and neither does any other high-performance team (Navy SEALs, surgical team at Johns Hopkins, NFL football team). It takes practice. Lots of practice. It also takes a commitment to excellence which is the motivation. It has to start with the desire to win and be the best.

Applying these lessons

Firefighters with Hilton Head Island Fire & Rescue discuss
the "lessons learned" from a recent cardaic arrest.

Are you familiar with the latest evidence based guidelines for the care of cardiac arrest patients?

Have you bothered to find out how the top EMS systems in the country are doing it?

When's the last time you practiced working a cardiac arrest with a fully clothed 175 pound mannequin found face-down between a toilet and a bathtub?

When's the last time you practiced using your own real equipment (as opposed to the equipment laid out on the table at your last ACLS class)?

When's the last time you sat down with your crew and choreographed exactly who would do what during a cardiac arrest?

Are you like a "pit crew" when you arrive on scene? Or do you "do the best you can" and hope for the best?

Who would you want showing up to save a member of your family?

Photo credit: Wake County EMS blog

See also:

Why you need to strengthen your community's chain-of-survival

Tom Bouthillet and Jamie Davis discuss cardiac arrest and the chain-of-survival

Cardiac arrest – Anatomy of a System Failure

Cardiac arrest – Are you ready to save one of our own?

65 year old male CC: Cardiac arrest on the tennis court

57 year old male CC: Cardiac arrest

Posted by on January 27, 2011 • Filed under: ems-topics, patient-management • Tagged: , , , , , , , , , , ,

Regionalization in EMS (End-of-year column at EMS1.com)

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My “End-of-Year” column is up at EMS1.com.

Trends in 2010: Regionalization in EMS

Enjoy!

Posted by on December 22, 2010 • Filed under: ems-topics, patient-management • Tagged: , , , , , , , , , , , ,

Cardiac Arrest – Anatomy of a System Failure

6 comments


Dave Statter (STATter911.com) recently posted a story about a cardiac arrest that occurred in Ocean City, MD. It’s a sad story with an unhappy ending. In fact, there’s only one redeeming quality about this story. It’s a perfect example of a system failure.

  • The dispatcher who answered the 9-1-1 call “froze” and was unable to effectively process the call.
  • There was an unacceptable delay in dispatching the call: approximately 4 minutes and 26 seconds.
  • Total response time for the first responder from call received (17:21:38) to patient’s side (17:27:50) was documented as 6 minutes and 12 seconds on the run sheet, even though the news story suggests that a fire station was only a mile and a half away.
  • Even this documentation is suspect considering that a Critical Incident Report from the Ocean City Department of EMS indicates that 7 minutes and 10 seconds into the call they switched dispatchers to handle CPR instruction. If first responders were at the patient’s side in 6 minutes and 12 seconds, why would they need to give CPR instructions?
  • Internal documents discussing the case attempt to gloss over the issue by suggesting that there’s no evidence based standard for call processing or response time intervals.
  • The dispatcher was unable to distinguish between agonal respirations and effective breathing, even though the caller stressed that the breathing was abnormal.
  • The dispatcher asked the caller to take the patient out of the boat prior to starting CPR.
  • The pre-arrival instructions, when they were finally given, were antiquated (mouth-to-mouth rescue breathing as opposed to “hands only” CPR for untrained lay rescuers).
  • The dispatcher sounds annoyed with the caller (stating “she’s screamin’ in my ear!”) as if the caller wasn’t completely justified in becoming impatient.
  • Internal documents refer to the caller as “panic stricken” in an apparent effort to stigmatize the caller and avoid responsibility.
  • Once paramedics arrived, the automatic CPR device malfunctioned.
  • The manufacturer of the automatic CPR device was able to determine that the equipment had not been properly maintained.
  • The EMS Incident Report is poorly written (I tried to figure out when or if the patient was shocked but I gave up) and suggests there was a problem with the patient’s airway en route to the hospital (tracheal tube replaced with a King).


In reading (and listening) to this story one is left with the sick feeling that the chain-of-survival is horribly broken in Ocean City, MD. Worse than that, one senses that officials in Ocean City, MD are oblivious to their duty to protect the public.

Imagine that your wife, husband, mother, father, sister, brother, daughter, or son will experience a sudden cardiac arrest in your jurisdiction sometime in the next 365 days. Then design a system to save their life.

Spare the bereaved families of the dead your lame excuses. They pay your salary and they deserve a heck of a lot better than that. I don’t think they expect perfection. Just an honest effort.

At the very least, the surviving spouse in this case deserves what she tearfully asks for in her interview with the news media: acknowledgement.

See also:

Left waiting: Alexandria man in cardiac arrest waits for EMTs in Ocean City

Posted by on November 23, 2010 • Filed under: ems-topics, patient-management • Tagged: , , ,

Another soccer player experiences sudden cardiac arrest on camera

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h/t Dr. Wes

You might recall a previous post that showed Belgian soccer player Anthony Van Loo collapsing on camera and receiving a shock from his ICD.

In this video Salamanca soccer player Miguel Garcia experiences a sudden cardiac arrest on camera.

Electrophysiology Fellow makes the point that sudden syncope is almost always cardiac! You will note that the victim makes no effort to protect his face when he falls.

See also:

Miguel Garcia ‘continues to improve’ after suffering heart-attack during Spanish league game

Incredible video of soccer player saved by ICD (VIDEO)

Scientist shocked by ICD at Copenhagen Summit (VIDEO)

Cardiac arrest – are you ready to save one of our own? (VIDEO)

Posted by on November 16, 2010 • Filed under: ems-topics, patient-management • Tagged: , , , , , , , ,

Tom Bouthillet and Jamie Davis discuss cardiac arrest and the chain-of-survival

4 comments

Part I – Jamie Davis and Tom Bouthillet discuss the 2010 AHA ECC Guidelines with Monica Kleinman, M.D., incoming Chair of the AHA’s ECC Committee.

Part II – Jamie Davis and Tom Bouthillet discuss the 2010 AHA ECC Guidelines with Monica Kleinman, M.D., incoming Chair of the AHA’s ECC Committee.

Part III – Jamie Davis and Tom Bouthillet discuss cardiac arrest and the chain-of-survival.

Posted by on November 1, 2010 • Filed under: ems-topics, patient-management • Tagged: , , , , , ,

Must-see JEMS.com webcast!

1 comment

I came across an outstanding webcast the other day. It’s hosted by JEMS.com and sponsored by Physio-Control. It’s called Connecting Care Teams and Collecting Data: How it helps both you and your patient—The Houston Experience

It’s dated February 18, 2010 so I’m not sure how I missed it the first time around. It will be available until September 20, 2010 at 11:30 a.m.

In other words, you have less than 48 hours!

The presenter is Chris Souders, MD, Associate Medical Director of Houston Fire Department.

This webcast is divided into two parts. The first part is about STEMI and the second part is about cardiac arrest.

The first part features an interesting discussion about the problem of false positives and the value of prehospital ECG transmission. It shows this interesting ECG.

The second part addresses quality assurance of cardiac arrest using the most modern technology available. I was impressed, particularly because my fire department just purchased the new LIFENET technology and CODE-STAT.

Here they use the impedance channel to review chest compressions.

Take a look at the webcast while you can! It’s pretty amazing.

Posted by on September 18, 2010 • Filed under: ems-topics, patient-management • Tagged: , , ,

69 year old male CC: “Indigestion”

17 comments

Here’s a case from a faithful reader who wishes to remain anonymous.

In his own words:

Presenting Complaint – Chest Pain

History of Present Complaint – 69 year old male, nil cardiac history, none smoker, social drinker.
Complaining of indigestion last 2-3 weeks with noticably increase in belching.
This a.m acute onset of burning heavy central chest pain radiating to neck.

On Arrival – Semi-recumbent in bed

On examination:
Alert, orientated and communicable (GCS 15)
Pallor
Diaphoretic

Nil SOB, clear bi-lateral air entry – nil adventitious breath sounds
R/R 16, SpO2 98%

H/R 90 and irregular, Hypertensive 168/110

Temp 36.5 C (97.7 F)
B.M 9.0

C/O chest pain..
O – Acute
P – Nothing makes pain better. Not affected by breathing
Q – Heavy in chest, burning in throat
R – Retrosternal and radiating to neck
S – Pain score 10/10
T – 15 mins
I – No pain intervention sought.

Nil nausea, nil vomit

The cardiac monitor is attached.

A 12-lead ECG is captured.

What is your impression?

*** UPDATE ***

The patient lost consciousness and the monitor showed ventricular fibrillation. A shock was delivered at 200J.

The patient experienced return of spontaneous circulation.

A few minutes later the heart rhythm returned to baseline.

Emergent cath revealed 100% occlusion of the LAD.

Posted by on July 17, 2010 • Filed under: ems-topics, patient-management • Tagged: , , , , , , , , , , ,

57 yom CC: Cardiac arrest

26 comments

Here’s another interesting case submitted by a reader who wishes to remain anonymous.

While we’re on the subject, I’d like to thank my readers for the interesting case studies that have been coming in!

This is what the Web 2.0 experience is all about! We’re learning a lot from each other and that’s the difference between editing a blog and writing a book.

EMS is called to a seizure patient. According to the patient’s girlfriend, he had been feeling weak and vomiting about an hour earlier. She states that he had a “short seizure” after which he was unresponsive. She didn’t call 9-1-1 right away because the patient has a history of seizures.

After the patient was unresponsivee for longer than usual she contacted 9-1-1. When asked by EMS personnel, she estimates that the patient had not been breathing for 3-5 minutes prior to EMS arrival. She did not attempt CPR.

The patient is a 57 year old male.

Past medical history: CVA, NIDDM, and seizures

Medications: Tylenol, Trileptol

Pulselessness was confirmed and chest compressions were initiated.

The combo-pads were attached.

Here is the initial rhythm (with CPR artifact).

It was confirmed as asystole a short time later.

CPR was continued. The airway was managed with an OPA and BVM. An 18 ga IV was established in the LAC and run w/o. Epinephrine and atropine were administered.

A rhythm change was noted on the monitor.

A weak carotid pulse was palpated although radial pulses were absent and a BP could not be auscultated.

The patient was relocated to the ambulance. The patient was intubated with an ETCO2 in the mid 50s.

A 12-lead ECG was captured.

The paramedics left the scene en route to a PCI-hospital.

At this point the patient had radial pulses but for some reason the paramedics were still unable to auscultate a blood pressure.

The rhythm continued to be irregular and polymorphic.

Another 12-lead ECG was captured.

Some significant asystolic pauses were noted on the monitor.

As the last 12-lead ECG was captured the patient lost pulses.

By now the ambulance was arriving at the PCI hospital. CPR was resumed. Another round of epinephrine was given and the patient re-gained pulses.

The ED staff identified the prehospital 12-lead ECGs as showing “STEMI”.

Do you agree? Why or why not?

Should it matter at this point? In other words, should the patient be cathed anyway (assuming the patient is stable enough for a cath)?

Posted by on February 23, 2010 • Filed under: ems-topics, patient-management • Tagged: , , , , , , , , , ,

Cardiac arrest – Are you ready to save one of our own?

18 comments

Firegeezer posted a recent story about a firefighter from Lynn, MA who experienced cardiac arrest on the fireground and was resuscitated at the scene.

Coverage from Firefighter Close Calls is here.

According to the post, the firefighter had “just come out of the house” when he suddenly collapsed and firefighters began CPR immediately.

A news helicopter captured dramatic footage of the resuscitation, which you can see here.

It was not immediately clear whether or not he’s going to be okay, and our prayers are with firefighter Mark Ducharme and his family.

Anyone who reads NIOSH reports knows that heart attacks are the leading cause of LODDs in the United States, and perhaps the world, but how many of us are really prepared to work a cardiac arrest at a fire scene or even on the training ground?

Emergencies are stressful, especially when it’s one of our own.

Is an AED a part of your RIC/RIT kit?

As an ALS unit standing by at every fire scene?

How about the training ground?

Have you ever tried to undress an unconscious firefighter in full gear, including SCBA?

I have. It’s not easy.

This is a drill that every firefighter in the country should attempt at least once.

A couple of observations:

If you think it’s a sudden cardiac arrest as opposed to an asphyxial arrest, just open the firefighter’s turnout coat, start chest compressions, place the combi-pads as soon as possible, and shock the firefighter prior to taking the firefighter’s SCBA and turnout coat off.

Undressing a firefighter in full gear is time consuming and defibrillation is too important.

If it’s an asphyxial arrest, then airway is more important, and you’ll have to address the airway immediately.

Before anyone asks, the BVM in the video had a broken stem so the oxygen tubing couldn’t be attached. It came out of a bin that is used to return equipment to the quartermaster, and I’m assuming that’s the reason it was in the bin.

But you know what? Emergency scenes can be chaotic. Equipment fails. That’s reality!

Obviously some time could have been saved by cutting off the SCBA mask and so on, but I can pretty much guarantee you that you can’t undress an unconscious firefighter as fast as you think you can!

See also:

Incredible video of soccer player saved by ICD (VIDEO)

Another soccer player experiences sudden cardiac arrest on camera (VIDEO)

Scientist shocked by ICD at Copenhagen Summit (VIDEO)

Posted by on January 6, 2010 • Filed under: ems-topics, patient-management • Tagged: , , , , , , , , , , ,

Why you need to strengthen your community’s chain-of-survival

10 comments

United Press International (UPI) is reporting that according to a study by the University of Michigan Health System, the chance of surviving an out-of-hospital cardiac arrest remains unchanged over the last 30 years.

The analysis of 79 studies involving 142,740 patients, published in Circulation: Cardiovascular Quality and Outcomes, found 23.8 percent of the patients survived to hospital admission and 7.6 percent lived to be discharged from the hospital.

While half of cardiac arrests were witnessed by a bystander, only 32 percent received bystander cardiopulmonary resuscitation.

“Increasing bystander CPR rates, increasing the awareness and use of devices to shock the heart and keeping paramedics on scene until they restore a person’s pulse needs to occur if we are ever going to change our dismal survival rate,” Dr. Comilla Sasson, the study’s lead author, said in a statement.

I find this study to be interesting because it shows that only about half of cardiac arrests are witnessed. Unwitnessed cardiac arrests have a very poor prognosis, which is not surprising when you consider that this is the most time sensitive of all emergencies.

Knowing how many cardiac arrests are witnessed by a bystander is important when estimating how many “savable” cardiac arrest patients a given EMS system interacts with in a given year.

According to the best data I could find, the incidence of out-of-hospital cardiac arrest in the general population is approximately 1/10 of 1% (or 1 out of 1000).

That means that each year, a community of 50,000 people can expect about 50 out-of-hospital cardiac arrests.

If half of them are witnessed, the number is down to 25.

It’s reasonable to assume that not all of those are VF/VT arrests. This isn’t evidence based, but let’s say that 20 of them are primary cardiac VF/VT arrests.

According to the Utstein template, the number of these patients that walk out of the hospital is a community’s save rate. If the save rate is 10% (generous) then a community of 50,000 can expect 2 patients to survive to hospital discharge each year.

It’s worth mentioning that most communities don’t measure their outcomes at all, so this is just speculation.

Let us assume for a moment that this same community started to save 35% of its cardiac arrest patients. Instead of saving 2 patients each year they would save 7 or an additional 5.

Five may not seem like a lot of patients, but in 30 years that’s 150 people, or enough to fill up a Boeing 737 (or Airbus A320).

Do you remember when Captain Sullenberger saved 150 passengers (plus the crew) on US Airways Flight 1549?

He was recognized as a hero, and justifiably so! Here’s New York City Mayor Michael Bloomberg showing off the “key to the city” that was specially made for Captain Sullenberger.

Stengthening a community’s “chain of survival” is a lot less dramatic than saving 150 people in a single afternoon, but we need to remember that these are real people, and they are loved just as much by their wives, husbands, daughters, sons, mothers, and fathers.

So what are we waiting for?

See also:

Essential Features of Designating Out-of-Hospital Cardiac Arrest as a Reportable Event

Cardiac Arrest Registry to Enhance Survival (CARES)



Posted by on December 9, 2009 • Filed under: ems-topics, patient-management • Tagged: , , , , , , , , , ,

No advantage seen with IV drugs in out-of-hospital cardiac arrest

11 comments

Heartwire is reporting a review of Olasveengen TM, Sunde K, Brunborg C, et al. Intravenous drug administration during out-of-hospital cardiac arrest: a randomized trial. JAMA 2009; 302:2222-2229.


Some highlights:

“[A] large randomized trial found that giving IV drugs like epinephrine and atropine in the setting of out-of-hospital cardiac arrest made it more likely that patients would be admitted to the hospital but little difference in whether they survived to discharge.

“That outcome was in spite of their undergoing resuscitation longer and receiving more defibrillations, and more often reattaining a spontaneous circulation, compared with another group that didn’t receive IV drugs during arrest.

“The trial is only the latest of several in recent years to reappraise the efficacy of major elements of conventional cardiopulmonary resuscitation.”

“The message for emergency providers is that, for now, the cornerstones of optimal cardiac resuscitation include high-quality cardiopulmonary resuscitation with minimal interruptions for anything, including any drug administration, and early defibrillation (emphasis added).”

“The quality of delivered cardiopulmonary resuscitation (including chest-compression rate, ventilation rate, and other factors), a prospectively defined secondary end point, was within guidelines and comparable in the two groups [...] So was the prevalence of therapeutic hypothermia as part of management, which exceeded 70%. (emphasis added).”

Posted by on November 24, 2009 • Filed under: ems-topics, patient-management • Tagged: , , , , , , , ,

CBS Exclusive: Back From the Dead

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56-Year-Old Man Brought Back To Life After 47 Minutes, 4,500 Chest Compressions And 8 Zaps With Defibrillator.



Click HERE for this amazing story with video.

“A specific procedure helped save Tiralosi’s life. Special cooling pads, not available in all emergency rooms, lowered his body temperature to 91 degrees, essential in preventing long-term neurological damage and preserving brain function. Placed in a medically induced coma, incredibly, he began to wake up three days later — without brain damage.”

Posted by on November 24, 2009 • Filed under: ems-topics, patient-management • Tagged: , , , , , , , ,

65 year old male CC: Cardiac arrest on the tennis court

13 comments

65 year old male collapses while playing tennis. The scene is less than 1 minute from the fire station.

On arrival, bystanders are providing rescue breaths but no chest compressions.

Medical history is unknown.

Initial rhythm:


First shock:


Return of spontaneous circulation (ROSC) noted.

Rhythm strip:

12 lead ECG:


The patient is still unconscious. LMA is placed and patient is ventilated 8/min. with 100% oxygen.

Vital signs:

  • RR: 0
  • Pulse: 82
  • NIBP: 112/82
  • SpO2: 100

What should happen next?

What is the patient's prognosis?

Posted by on November 16, 2009 • Filed under: ems-topics, patient-management • Tagged: , , , , , , , , , , , , , , , , ,

12-Lead ECGs for ROSC patients (was: ECG Grand Rounds)

4 comments

There’s an interesting case study posted over at Dr. Smith’s ECG blog called Right Bundle Branch Block with Acute ST Elevation Best Seen on Prehospital ECG.

Dr. Smith makes the point that RBBB should not distort the ST segment the way LBBB does. He’s right, but sometimes the ECG diagnosis of STEMI can be difficult with RBBB as his case study demonstrates.

The prehospital 12 lead ECG is a scanned copy, but you can easily make out ST segment elevation in leads V2-V6 and I and aVL. The ST segment elevation is concordant to the terminal deflection of the QRS complex in leads V2-V4.

The cardiac cath lab was activated by EMS while the patient was still in the field.

En route, the patient experienced VF a couple of times and was shocked by the treating paramedic. The patient was awake on arrival in the emergency department and a very interesting ECG was recorded that you can see here.

The S waves have retured in the precordial leads and the T waves are now appropriately discordant to the terminal deflection of the QRS complex. The ST segments are straight (non-concave) which is worrisome and still elevated in leads I and aVL, but as Dr. Smith says:

[W]ere it not for the arrest and the prehospital ECG, this would not be a slam dunk diagnosis.

He finishes with this teaching point:

[T]he prehospital ECG is critical, as was early prehospital cath lab activation. Were it not for this prehospital ECG and the cardiac arrest, the diagnosis may have been significantly delayed. Had this happened, the artery may have re-occluded prior to angiography, with resultant recurrent cardiac arrest and/or shock and death.

Thanks for sharing, Dr. Smith!

You can also see Dr. Smith’s recent post on hyperacute T waves here.

Next there is a recent post at Peter Canning’s Street Watch: Notes of a Paramedic called 12-Lead ECG in ROSC.

This is also the title of an article in JEMS by Keith Wesley MD in which he reviews:

Müller D, Schnitzer L, Brandt J, et al, The accuracy of an out-of-hospital 12-lead ECG for the detection of ST-elevation myocardial infarction immediately after resuscitation. Annals of Emergency Medicine. 52(6):658-64, 2008.

Peter explores the issue of performing a prehospital 12 lead ECG on cardiac arrest patients after they experience return of spontaneous circulation.

It’s definitely a good idea! See #8 in my recent blog post Prehospital 12 Lead ECG – What Are the Indications?

Here are some interesting ECGs from the first cardiac arrest I worked according to the “new” science (i.e., 2 minutes of CPR prior to the first shock and minimizing interruptions to chest compressions).


Here’s the 12 lead ECG we captured after ROSC:


As a side note, what is the cardiac rhythm? If you know, leave a comment.

Capturing a 12 lead ECG is particularly important if you need to justify transporting a cardiac arrest patient with ROSC to an interventional facility (PCI-hospital).

In reference to the study, Keith Wesley MD concludes:

One last interesting note on this article is that the physicians used 1 mm of ST elevation in the inferior leads but 2 mm in the precordial leads for diagnosis of infarction. Studies have shown that using 1 mm for both increases the sensitivity but captures a significant number of additional STEMIs. It would be interesting to know how this would’ve impacted the 77 patients in this study.

With respect to Keith Wesley MD, I actually agree with using 2 mm of ST-segment elevation in the right precordial leads as the standard, particularly for younger male patients, for whom 1 mm of ST segment elevation in leads V1-V3 is a normal finding (not a normal variant).

*** UPDATE ***

The American Heart Association published a policy statement on out-of-hospital cardiac arrest in January 2010.

Regional systems of care for out-of-hospital cardiac arrest: A policy statement from the American Heart Association. Circulation. 2010 Feb 9;121(5):709-29. Epub 2010 Jan 14

This part is particularly relevant to our discussion:

“Up to 71% of patients with cardiac arrest have coronary artery disease, and nearly half have an acute coronary occlusion. There is a high incidence (97%) of coronary artery disease in patients resuscitated from OOHCA who undergo immediate angiography and a 50% incidence of acute coronary occlusion. However, the absence of ST elevation on a surface 12-lead electrocardiogram after resuscitation of circulation from cardiac arrest is not strongly predictive of the absence of coronary occlusion on acute angiography. A case series of patients with unsuccessful field resuscitation suggested that in such patients, VF is more likely to be due to coronary disease than is asystole or pulseless electric activity…these studies suggest that patients who are resuscitated from out-of-hospital VF have a high likelihood of having an acute coronary occlusion.

“The feasibility and efficacy of primary PCI in patients who survive cardiac arrest with STEMI have been well established. The combination of mild therapeutic hypothermia with primary PCI is feasible, may not delay time to start of primary PCI in well-organized hospitals, and is associated with a good 6-month survival rate and neurological outcome…

“Patients resuscitated from OOHCA with STEMI should undergo immediate angiography and receive PCI as needed. Immediate coronary angiography is reasonable for patients resuscitated from VF and may be considered in patients resuscitated from other initial rhythms who do not have a clear noncardiac cause of cardiac arrest…Because emergent coronary angiography is not widely available, patients resuscitated from out-of-hospital VF or from OOHCA with STEMI should be transported as soon as it is feasible to a facility that is capable of performing these procedures. Field providers treating such patients should bypass referral hospitals and go directly to a cardiac resuscitation receiving hospital so that these patients can receive angiography within 90 minutes…”

Posted by on February 26, 2009 • Filed under: ems-topics, patient-management • Tagged: , , , , , , , , , , , , , , ,