An ALS crew responded to a 60s man who was having chest pain.  While in route, dispatch informed the crew that the patient had collapsed and CPR was in progress.  They arrived to find the patient lying on the floor in the kitchen with agonal respirations.  The patient was purple from the nipple line up and the crew confirmed that he was pulseless.  Chest compression were started immediately and the crew began ventilation via bag valve mask ventilation (BVM).  He was placed on the monitor and found to be in ventricular fibrillation (VF) and was immediately shocked.  The crew placed a supraglottic airway and confirmed proper placement with ETCO2.  The crew also placed an interosseous line for access and administered epinephrine.  After the second shock, they noticed he had a pulse.  The crew quickly attempted to get a blood pressure and 12-lead EKG, however, he went back into VF.  They shocked again and continued chest compressions.  The crew continued delivering shocks, gave two doses of amiodarone, and continued giving doses of epinephrine while transporting the patient to the hospital.  While in route, the patient began to move around and right the crew.  They paused compressions and found that he was still in VF and pulseless.  The crew gave a dose of ketamine to sedate the patient while they continued ACLS care.  Shortly after arriving at the hospital, they were able to achieve ROSC.

Highlights of the case:

Consider sedation for patients showing signs of awareness while in cardiac arrest

This crew provided amazing ACLS care for a patient in electrical storm most likely from a myocardial infarction.  This patient was getting such good oxygenation and chest compressions that his brain was being perfused enough for him to move around purposely.  If you ever notice this, the first thing you should do is see if you achieved ROSC.  In this case, the patient was still in VF and pulseless meaning it was the good CPR, not ROSC, that was causing the patient to move.  This is very rare, but when this occurs, it is sign of a good prognosis since we are likely perusing the brain enough to prevent significant anoxic brain injury.  In these situations, we should consider sedating the patient as soon as possible for two reasons.  The first is that this movement can inhibit our ability to render high quality resuscitation.  The other reason is that we do not want the patient to remember the resuscitation.  I can think of few things more traumatizing and painful than being aware while getting chest compressions and being intubated.  This crew quickly identified this patient had CPR induced awareness and properly sedated him with ketamine which is an ideal agent to use here.