The patient is a 62-year-old female with a past medical history of diabetes, chronic renal failure, hypertension, and hyperlipidemia.  She is nearly complete with her 4-hour dialysis treatment.  She suddenly has a syncopal event.  Staff recognizes an emergency event and calls 911.  They clamp her access needles and leave the needles in place.

EMS arrives and the patient is alert and oriented with a complaint of feeling weakness.  They report good blood pressure, but the patient is very tachycardic.  Moving her to the ambulance and proceeding to the hospital, they complete the following EKG:

Unfortunately, they did not get access and while the patient continued to the ED, they arrived at the ED, with the patient still speaking but she lost her radial pulse.

The ED placed defibrillator patches on, and the patient was still in V-tach.

The patient was immediately converted to rate controlled atrial fibrillation.  At that time the ED recognizing no renal dosing is required, started Amiodarone at 150mg IV over 10 minutes and then a standard drip of 1mg/min for 6 hours and 0.5 mg/min for 18 hours.

Patient did very well, so let’s take some time to discuss EMS options.

Access in a difficult access CRF patient.  

Can you use the AV Fistula?  Although we do ask that you avoid using AV fistulas as an access point for standard access, you are allowed to place an IV in an AV fistula during a resuscitation.  This was on the edge of resuscitation.  When the patient had a radial pulse and blood pressure, Amiodarone 150mg IV over 10 minutes would have been the treatment of choice.  The AVF could have been used, but there were still these clamped needles in place so access here could have been very tricky if not dangerous due to requiring proper pressure removal of AV fistula needles.  The better choice would be IV or even IO.

When is the patient too unstable for chemical therapy?  Hypotension, decrease mental status, low capnography all are excellent markers, that you as the provider must intervene.  That means have the patches ready, remember the synch button and provide electrical therapy for rapid control of unstable rhythms. She was larger so I went right to 100J synchronized shock with an excellent result.

When should you call medical control?  Call early and talk to the EMS online ED physician.  They can start rapid teamwork that can save lives and reduce morbidity and mortality. 

CRF patients, sudden bad rhythms have a much larger differential diagnosis.  Remember to consider Torsade’s Hyperkalemia. And toxidromes.  Be prepared to treat each appropriately. 

As always, we are all in this together, and together we can save lives. 

Sincerely,

Don Spaner MD CMO UH EMS Institute.