Case summary:

An ALS crew and first responders were dispatched to 70s man who was reported to be in cardiac arrest.  The crews found the patient to be unresponsive, pulseless, and apneic, so they immediately started performing chest compressions.  The patient’s wife told the crews that he suddenly became unconscious a few minutes before they arrived and has a very significant cardiac and pulmonary history but could not give more details.  The crews provided bag valve mask ventilation (BVM) while also placing a mechanical CPR device on the patient along with placing the patient on the monitor.  The patient was found to be in ventricular fibrillation (VF), so they immediately provided defibrillation while continuing CPR.  They performed 3 more pulse and rhythm checks and found the patient to be in VF and polymorphic ventricular tachycardia.  They provided 3 more defibrillations with each of these rhythm checks.  

During this period, they also obtained interosseous access and gave multiple doses of epinephrine, two doses of amiodarone totaling to 450mg, and magnesium.  The patient was also intubated with an endotracheal tube.  Despite all of this, the rhythm remained in VF.  The crew was able to obtain a second monitor and attempted double sequential defibrillation 5 total times but was unable to convert the VF to a perfusing rhythm.  The crew then tried calling online medical control to get additional assistance.  Online medical control recommended a dose of lidocaine and one ampule of sodium bicarb.  These were given, but they failed to change the rhythm.  The patient’s wife then reported to the crew that she would like them to stop further resuscitation and that she did not feel he would have wanted more care.  At that time, the crew had been doing CPR for 35 minutes.  The crew stopped resuscitation and called medical control again for a time of death.

Highlights of the case:

Electrical Storm

This patient was in electrical storm.  This is defined as a state of cardiac electrical instability characterized by multiple episode of ventricular tachycardiac or ventricular fibrillation within a relatively short time frame.  While patients in cardiac arrest from a shockable rhythm often have a very good prognosis, patients who are in electrical storm and fail to convert after multiple shocks have a very poor prognosis since they are not responding to the standard treatments we have at our disposal.  The key is to shock these patients early and often as well as throw every adjunct therapy we have at them in an attempt to convert them to a perfusing rhythm as soon as possible.  That is exactly what this crew did, but despite heroic efforts, they were unable to obtain return of spontaneous circulation. 

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 continuing the mechanical compression device while they charged and shocked the patient.

Double sequential defibrillation.

Double sequential defibrillation involves the provision of rapid sequential shocks from two separate defibrillators with pads placed in separate planes.  The most common placement would be one set in the anterior-lateral position and the other in the anterior-posterior position.  This is a reasonable thing to consider when a patient is in cardiac arrest and is failing to convert to a perfusing rhythm after 3 shocks.  This does require two separate defibrillations which may limit who can receive this therapy in the field.  Another option to consider for patients who do not convert after 3 shocks is vector change.  If the first three shocks were given with pads in the anterior-lateral position, consider placing pads in the anterior-posterior position and giving the next shock from that vector.  If the first few shocks were in the anterior-posterior position, then switch to anterior-lateral.  This change in vector might be enough to convert the rhythm.  This crew happened to have two monitors on scene, so they attempted double sequential defibrillation.  This was a great idea, but sadly, it was not effective in converting this patient’s rhythm. 

Despite this patient not surviving, this crew provided amazing prehospital care and gave this man his best chance at survival.