While participating in run review with Dr. Hill, Firefighter / Paramedic Chris Fredmonsky suffered cardiac arrest.

“It stared like any normal day”

Although Chris has had sleep apnea and bradycardia, he was otherwise healthy. That day he felt more tired than usual, he attributed that to a busy weekend and the first day back to the firehouse. While rounding out the run review, there was a thud as Chris went to the floor from his seated position.

Initial Presentation

Chris initially presented with seizure-like activity.  This was a result of the lack of perfusion to his brain. Seizure-like activity is a major sign/symptom of the onset of “sudden” cardiac arrest of presumed cardiac etiology, particularly in patients with shockable initial rhythms. Such activity is significantly associated with neurologically favorable outcomes.

Immediate Action

Once it was realized that this was resultant from cardiac arrest, CPR was started. Early recognition and CPR is one of the key components of survival neurologically intact. Often early recognition, CPR, and defibrillation alone yield ROSC. In this case, the full ACLS gamut was necessary to return circulation.

Refractory V-FIB

Chris’ presenting (and sustained) rhythm was V-FIB.

Shock refractory V-FIB requires the addition of medications to optimize the heart’s electrical system and hemodynamics to accept and hopefully convert to a perfusing rhythm. Amiodarone was used in this case. The first 300 mg was eventually followed by a defibrillation that eventually restored perfusion. 6 Defibrillations were required to achieve ROSC on Chris. In most cases, each defibrillation yielded brief return of an organized rhythm that quickly degraded back to V-FIB.

Online Medical Control vs Offline Medical Control vs Medical Control Present

While most providers are used to our traditional offline protocols and the concept of online medical control when they need additional insight, orders, or ideas, rarely the situation presents itself where the medical control doctor is present. In these cases, where the Physician is an active participant in the case, certain latitudes can be afforded to the resuscitation team. Being present the Physician can modify real time the direction of the arrest. In this case, medications that were not part of a typical resuscitation of this type were used in an order that is also not typical of standard EMS care. The presence of the Medical Director changed some of the course of this resuscitation.

This change in course, does not mean that standard of care EMS protocols are ineffective, or in any way less effective. This is simply the decided upon course for MOST common situations as deliberated by the medical directors. Providers should always feel free to identify interventions and treatments that may benefit the patient, and if not protocolized, engage medical control. Even though protocols are written for the most common presentations, it is permitted to be smarter that the protocols.

Sodium Bicarbonate

Since Dr. Hill was participating in the resuscitation, he chose to utilize Sodium Bicarbonate early in the resuscitation. Although not protocol, he determined that there was value in correcting acidosis early in this case. Sodium Bicarbonate is part of routine protocol if the patient is a dialysis patient.

Calcium

Also, since Dr. Hill was calling the shots he chose early calcium administration. Calcium theoretically increases myocardial contraction and improve the possibility of defibrillation. Sodium Bicarbonate is part of routine protocol if the patient is a dialysis patient.

Epinephrine

Epinephrine hydrochloride produces beneficial effects in patients during cardiac arrest, primarily because of its α-adrenergic receptor–stimulating properties. The adrenergic effects of epinephrine increase myocardial and cerebral blood flow during CPR. The value and safety of the β-adrenergic effects of epinephrine are controversial because they may increase myocardial work and reduce subendocardial perfusion.

Waking up

Shortly after beginning transport and the 6th and final defibrillation, there was ROSC. After this Chris recalls waking up, and at one point even purposfully gestering to the crew letting them know he understood what was happeing. After this, Dr. Hill ordered ketamine be given for analgesia, sedation, and to promote amnesia for Chris. Chris does not recall any of his ED or the beginning of his ICU stay after this. The protocol dosing for this use is 1 - 2 mg / kg. In this particular case, Dr. Hill ordered a flat 250 mg dose.

Hospital Course

During transport, Dr. Hill called ahead and activated the cath lab. Chris was taken to the lab after stopping in the ED for additional assessment and stabilization. His cardiac vessels were clear. 

Later in his ICU stay Chris would receive an implantable pacemaker / AICD 

The above rhythm strip is defibrillation #5 of the resuscitation. At this point the patient had received epinephrine, bicarbonate, epinephrine, bicarbonate, calcium chloride, amiodarone. The strip shows ventricular fibrillation while charging, 360J of energy being delivered, and the post-shock rhythm being more organized then converting into ventricular fibrillation.

The above rhythm strip is defibrillation #6 of the resuscitation. The strip shows ventricular fibrillation while charging, 360J of energy being delivered, the post-shock rhythm being a organized sinus rhythm with a pulse which mean the patient achieved return of spontaneous circulation (ROSC).