Case summary:

An ALS crew was dispatched to a middle-aged man reportedly in cardiac arrest.  They arrived on scene and found the patient on the ground and his wife was doing chest compressions.  The patient was confirmed to be pulseless and breathing agonally so chest compressions were resumed.  The crew placed an IO while applying combo pads.  Crew performed their first pulse and rhythm check and found him to be in ventricular fibrillation.  Compressions were resumed and the device was charged to 200J.  Crew held compressions, defibrillated, and then placed the mechanical CPR device on the patient and then utilized this device for further compressions.  Before the next pulse and rhythm check, the patient began making purposeful movements, so compressions were held, and he was found to have a carotid pulse.  Patient was found to have a regular narrow complex tachycardia that looked like a supraventricular tachycardia (SVT) so they cardioverted the patient at 100J.  Patient converted to a sinus tachycardia and the first set of vitals were:

Vitals: BP 167/115,  HR 110,  RR 10,  Sat 95%,  glucose 186

The patient was awake with a GCS of 15 after return of spontaneous circulation (ROSC).  The crew obtained a 12-lead EKG to look for STEMI which was not present and obtained an IV for a second point of access prior to extrication.  Patient was transported to the receiving hospital without incident and the patient remained completely awake the entire time.

Highlights of the case:

In cardiac arrest care, we use C-A-B, not A-B-C

For patients in cardiac arrest, there many things we need to do in a short period of time.  Often there is only one medic on scene, so it is important to know what takes priority.  The order in which we do things is: chest compressions, pads to check rhythm, electricity (if indicated), IV/IO access for epi, advanced airway.  Historically we have focused on airway early hence why we have described this care as the A-B-Cs of resuscitation.  However, more recent studies have found that for most cardiac arrests, it should be the C-A-Bs of resuscitation meaning we prioritize support of the heart over airway.  Placing an advanced airway should almost never take priority over the other things listed ahead of it since BLS airway techniques are often sufficient while the more important interventions are being performed first.  If there is enough responders that all of this can be done simultaneously then that is completely fine.  This crew provided amazing cardiac arrest care and performed all key interventions in the proper order.

Continue chest compressions while the monitor is charging

The goal is to minimize pauses in compression during cardiac arrest.  The longest we should ever pause is 10s, but shorter pauses are better to minimize no flow time to the heart and brain.  This is also why we should NEVER hold compressions for placement of an endotracheal tube.  When we find a patient with a shockable rhythm, we should continue compressions while the device charges in order to minimize these pauses in compressions.  If we are doing manual compressions, we will then pause compression long enough to shock and then immediately get back on the chest without re-checking pulse or rhythm until the next check two minutes later.  If we are using a mechanical compression device, we only need to pause for the pulse and rhythm check.  We can turn the compression device back on for the charge and can defibrillate while compression are ongoing since this does not damage these devices.  This crew ensured the highest compression ratio by restarting manual compressions while their monitor charged.

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.  This crew did all of this which minimized the chance of this patient re-arresting in route to the hospital. 

Cardiovert for unstable tachycardia

Once the crew obtained ROSC, they noticed that the patient was in a regular, narrow complex tachycardia that looked like SVT.  This was the correct decision in this situation.  Given that the patient had just been in cardiac arrest, it is fair to say that this was an unstable tachyarrhythmia.  For all unstable tachyarrhythmias, the treatment is immediate cardioversion.  Medications are only indicated if the patient is completely stable.  There is a chance that this was sinus tachycardia, but if this was the case, cardioversion will not harm this patient.  If you cardiovert sinus tachycardia, the rhythm will not change.  However, if you fail to cardiovert an unstable tachyarrhythmia, the patient can die.  For this reason, if there is any doubt, it is best to cardiovert in these situations.