Case summary:

An ALS crew responded to a 40s man who was reported to be in cardiac arrest.  The crew arrived on scene to find the patient pulseless on the floor with the family doing CPR.  They learned that the patient had gotten out of bed and suddenly collapsed in front of the family.  The crew continued chest compressions and placed the patient on the cardiac monitor  The patient was in ventricular fibrillation so the shocked the patient at 200J and obtained return of spontaneous circulation (ROSC).  The crew placed an IO while obtaining vitals:

Vitals: BP 152/100,  HR 139,  RR 12 via BVM,  Sat 95% on 15L,  glucose 112,  GCS 3

The crew also obtained the following 12-lead EKG

The crew noted that the QTc looked very long to them and the monitor read the QTc at 534.  The crew placed an IV and gave the patient 2 grams of magnesium sulfate over the next 20 minutes.

The crew then began to package the patient for extrication.  During this process, the patient became completely awake and alert.  Vitals remained stable in route to the receiving hospital with vitals just prior to arrival being:

Vitals: BP 177/72,  HR 65,  RR 19,  Sat 98% on RA, ETCO2 17mmHg, GCS 15

Highlights of the case:

Everything went right for this patient

This was a case where everything went right for the patient and due to this, the patient ended up having a neuro intact recovery.  This patient was young, had a witnessed cardiac arrest, got bystander CPR and got early defibrillation.  When all of these factors are present, the odds of the patient having a good outcome are much higher than for our usual out of hospital cardiac arrests.  The key for us when we respond in the field is we want to capitalize on these opportunities, which is exactly what this crew did.  Every minute that defibrillation is delayed increases the patients mortality by 6% showing how critical early defibrillation is.  The crew quickly identified a shockable rhythm and delivered electrical therapy to achieve ROSC.  This was perfect!

Once you get ROSC, slow down

Once you get ROSC, the key is to slow everything down.  The goal after ROSC is to prevent re-arrest since hypotension is horrible for the post-arrest brain and you can’t get more hypotensive than cardiac arrest.  We want to do everything we can to optimize the patient prior to extrication to minimize the risk of re-arrest.  This includes getting a second line since it is easy to lose the first during extrication and we do not want to lose are only point of access if the patient is starting to crash.  This also includes making push dose epinephrine or another pressor to be ready to go if the patient is getting hypotensive.  We also want to have a bag of fluids spiked and ready for this same reason.  If the patient doesn’t have an advanced airway and needs one, now would be the time to place this airway since it is very difficult if not impossible to effectively use a BVM to effectively bag a patient during extrication.  We also want to get a 12-lead EKG to look for STEMI since we would want to activate the cath lab at the receiving hospital as soon as possible or change our intended destination to a hospital that has the capability to perform emergent heart catheterizations.  We also want to look for abnormalities on the EKG that could explain why this patient went into cardiac arrest.  This crew obtained a 12-lead EKG that showed a very long QTc.  The QTc can be long for a multitude of reasons, but long QT can absolutely lead to sudden cardiac arrest and might have been the cause of this patient’s arrest.  The crew was absolutely correct to immediately treat this with magnesium sulfate.  While magnesium sulfate will not shorten the QTc, it will decrease the chance of going into torsade’s de pointes, which is what we are concerned about in patients with long QT.  This crew did a great job optimizing the patient as much as possible prior to any attempt to extricate the patient to minimize the chance of re-arrest.