An ALS crew was dispatched to a middle-aged woman who was unresponsive but breathing.  They found her to be on the floor with agonal respirations and pulseless.  They started chest compressions, ventilated the patient and placed the pads on the patient.  During the first pulse and rhythm check, patient was found to have a pulse but was in ventricular tachycardia.  The crew cardioverted the patient which converted into a bradycardic rhythm at 20-30 beats per min.  The crew then initiated transcutaneous pacing ad obtained mechanical capture.  Initial blood pressure with pacing was 56/36 mmHg so the crew mixed push dose epinephrine and gave frequent 10 mcg pushes to support the blood pressure.  They checked a glucose level which was found to be normal and trailed Narcan given patient was still hypoventilating.  Patient began to vomit so they suctioned the airway and attempted to intubate but were unsuccessful.  The crew managed the airway with suctioning and bagging, and they were able to maintain oxygen saturations in the 90s.  The crew transported the patient to the hospital for further evaluation and care.

Highlights of the case:

Unstable patients with tachy or brady arrythmias should be treated with electricity.

If patients are unstable, they need the treatment that is most effective first.  In the case of tachyarrhythmias and bradyarrhythmias, we want to cardiovert or pace respectively.  Both rhythms were causing cardiogenic shock in this patient, and electricity works much faster and is often more effective than medications.  While the crew did not have a BP on the patient when she was found to be in ventricular tachycardia (VT), she was just in arrest so we should assume the rhythm is unstable.  This crew’s use of electrical cardioversion for unstable VT and pacing for an unstable bradycardia was perfect.

Treat post arrest hypoxia and hypotension aggressively.

One organ that we particular worry about in cardiac arrest is the brain.  The reason is that the brain uses a ton of energy and cannot tolerate any decrease in either oxygen or glucose for long before neurons start to die.  Once we get return of spontaneous circulation (ROSC), we want to ensure that there is no further insult to the already injured brain.  We do this by working as hard as possible to prevent any hypotension and hypoxia as well as shooting for a normal ETCO2 to prevent against hypo or hyperventilation.  While getting ROSC is needed for survival from cardiac arrest, are real goal is a neuro intact recovery.  Preventing further injury to the brain in the post arrest period is critical for this.  The crew in this case treated post arrest electrical instability quickly with pacing as well as cardioversion as well as used frequent doses of push dose epi to support the blood pressure.  They also managed the patient’s airway as best they could to support good oxygenation.  This was fantastic post-cardiac arrest care!