Case summary:

An ALS crew responded to a 90s woman with shortness of breath.  The crew arrived to find her unresponsive, with agonal respirations and weak radial pulses.  The family informed the crew that the patient became unresponsive about 10 minutes prior ot arrival.  The crew immediately started bag valve mask ventilations (BVM), obtained vitals and placed the patient on the cardiac monitor.  The first set of vitals were:

Vitals: BP 60/40,  HR 65,  RR 12,  Sat 60%,  glucose 155,  GCS 3

The crew drilled an interosseous line for access and pressure bagged fluids in to try and support the blood pressure.  Given how hypotensive the patient was, the also administered dose of push dose epinephrine to try and support the blood pressure more.  The patient became more bradycardic with a HR in the 40s so the crew started transcutaneous pacing and were able to achieve mechanical capture.  Shortly after starting to pace the patient, she went into cardiac arrest.  The crew-initiated compressions with a mechanical compression device and was able to get return of spontaneous circulation (ROSC) by the first pulse check, however, they lost pulses 2 minutes later.  The crew continued CPR care and intubated the patient with an endotracheal tube.  They learned from family on scene that the patient had a history of kidney disease, so they gave calcium and bicarb.  The continued cardiac arrest care for another 35 minutes giving 6 doses of epinephrine.  The patient remained in the bradycardic PEA rhythm the entire time.  The crew called online medical control to discuss, and the decision was made to terminate resuscitation on scene.

Highlights of the case:

Despite the patient dying, this crew provided amazing EMS care

While this patient ultimately expired on scene, this crew gave this woman her absolute best chance at survival.  The crew provided immediate and aggressive resuscitation and to try and correct her hypotension, hypoxia and bradycardia.  When patients are this sick, seconds matter, so we want to initiate the resuscitation prior to extrication.  That is exactly what this crew did.  This patient died due to being too sick prior to the crew arriving.  This crew can hold their heads high knowing that they gave her the best chance she could possible have.

For profound shock, consider giving both fluids and push dose epinephrine at the same time

This patient was profoundly hypotensive when the crew arrived.  Fluids can certainly help, but it often takes time to administer fluids.  Sometimes patients will arrest before we can get enough fluids in to support the blood pressure.  For patients with mean arterial pressures (MAP) under 65 mmHg, consider giving push dose epinephrine simultaneously with fluids.  This is because push dose epinephrine works almost immediately and can bridge patients while we are getting fluids on board.  In addition, sometimes patients are so hypotensive that fluids alone will not be sufficient and the simply will need both push dose epi and fluids to maintain a perfusing blood pressure.  The crew did a great job using both push dose epinephrine and fluids right away with this patient.

Look for reversible causes in cardiac arrest

Often, we are not able to find a reversible cause in cardiac arrest patients.  If we find evidence of a potential thing we can fix, we should jump on this.  In the case of this patient, the crew learned that the patient had a history of kidney disease.  This concerned them that hyperkalemia could have caused her arrest so the correctly treated this with calcium and bicarbonate.  This was very reasonable here and a smart choice by this crew.  We should not give calcium and bicarb to all cardiac arrest patients, but if there is evidence that this could be the cause, we should absolutely attempt to treat it.

 If meaningful recovery seems unlikely, consider field termination of resuscitation (TOR)

Even though this was an EMS witnessed cardiac arrest and there was transient ROSC, field TOR was a reasonable choice here.  This crew had thrown the kitchen sink at this patient and did everything possible to prevent the cardiac arrest and then treat the cardiac arrest after it occurred.  Emergency departments provide the same ACLS care that this crew has already provided on scene.  Often times, if high quality ACLS care in the field is unable to achieve ROSC, transport to the hospital to get more of the same care is unlikely to achieve a better outcome.  If you think that there is a benefit to the patient to transport them to the hospital while in cardiac arrest, then by all means transport the patient.  However, if you feel you have done everything possible and the likelihood of neuro intact recovery is very unlikely, then consider calling medical control to discuss field TOR.  Given that this crew had already provided amazing ACLS care, field TOR was a reasonable choice.