81-year-old male mowing his lawn, develops crushing chest pain and collapses.

Narrative History Text:

Called for a male with chest pain after mowing the lawn. EMS states that pt was explaining how he was feeling and became unresponsive. Pt was moved to the ground and CPR was initiated.  Lucas device was immediately placed and compressions were continued with Lucas. Monitor pads applied and found pt in V-Fib. Pt was defibrillated and compressions continued. IO was established and Epi 1 mg IO. BVM used while preparing to intubate.  Pt intubated using King Vision and a 7.0 tube. + lung sounds on the right side but diminished in the left. The tube was pulled back a few centimeters and lung sounds became equal bilat. Vitals est. Pt with + pulse on recheck. Lucas was discontinued. Cardiac rhythm changed to an SVT at a rate between 180-200 bpm. Monitor was switched to SYNC and pt was cardioverted. Pt began having occasional breaths on his own. Pt was packaged and moved to squad. 4 & 12 lead ECG taken. Pt's HR lowered 90 bpm at this time. Rhythm was showing Sinus rhythm with inferior ST elevation MI criteria. Report was called to UH Ahuja. Pt was given 4,000 units Heparin IO. ASA and Brilinta were not given due to inability to swallow. Vitals reassessed. Upon arrival at Ahuja, care and report given to ED staff.

The patient who has Parkinson’s and known heart disease was breathing on his own at arrival to the emergency department.  He was taken to cardiac cath lab and noted to have severe multi-vessel disease with heavy calcifications making passing a wire impossible.  He was moved and prepared for emergency bypass surgery.  This is an outstanding case of how to respond to not just cardiac arrest but ROSC.  Getting ROSC is critical, and the two critical pre-hospital factors associated with survival is Bystander CPR and early defibrillation.  Both occurred for this patient.  The other take home lesson is that 70% of cardiac arrests occur due to a STEMI, so any ROSC in a viable patient needs to be taken directly to a cardiac cath center.

The above strip demonstrating V-fib required immediate defibrillation, then noted SVT with EMS doing a great synchronized defibrillation and converting the patient to atrial fib with demonstrating ST elevation in II, III, and AVF with anterior lateral reciprocal changes confirming acute MI.  The need to synchronize cardiovert out of atrial fibrillation RVR can be considered in the unstable patient, but with capnography stabilizing and the patient’s vitals being carefully addressed, this can be decided within the hospital setting.

Thanks for taking a minute to review the case of the week.  Teamwork makes the dream work.  Well Done.