Calling A Code With A Beating Heart

[The White Coat Investor]

I had a tough code the other night. A 47 year old female, overweight but not huge, with only PMH being HTN. No PE risk factors. She'd gone to the gym and done some lifting, then came home. She had some chest pain, took some TUMS, and took a shower. She got out of the shower and dropped dead. Spouse heard her, saw she wasn't responsive and foaming at the mouth (no seizure activity) and called 911. 911 directed him to do CPR, medics arrived and found her in "fine V-fib." They started compressions, shocked 5 times at one point getting V-tach, started an IO and gave at least one dose of epi and a dose of amiodarone, and placed a King airway. They arrived at the ED about 15 minutes after their arrival on scene, with a presumed 5-10 minute response time. Current status- easily bagged with good BS, no pulse, slow, somewhat wide, "agonal" rhythm on the monitor, perhaps 20-30, pupils fixed and dilated.

She's 47, we went full bore on this one. Good compressions, given epi, calcium, bicarb, atropine. Placed an ETT and a couple of IVs and gave a couple of liters of fluid on squeezers. Managed at times to have a narrowish rhythm without any definite p waves at a rate of up to 120. Shocked her once when it looked kind of wide. Started maxed out Dopamine. Started Levophed. Never had a pulse. No pericardial effusion on US but the heart appears to be beating strongly. Actually got some labs back and she had a gap of 31 but normal K. After 30 minutes, a 2nd code arrived. We're double coverage at that time of day, and luckily had plenty of staff especially with the medics standing around, so we split up without any noticeable loss of efficient CPR. After 45 minutes, her heart was still beating on US. Her husband came in and wanted us to stop, so we did. She promptly turned blue, bradyed down, and died for good.

Should we have stopped sooner? Any other Hail Mary you would have tried on this one? Do you hate calling a code with a beating heart as much as I do?

---

Members don't see this ad.

 

[Apollyon]

No palpable pulse, even with max dose dopamine, and "leave 'em dead", and wide rhythm on the monitor, 20-30? Dying heart, period. There is no salvage.

What if you had no ultrasound? You wouldn't even know that there was no squeeze.

I would not have stopped sooner, as I have done the same as you in the past.

But I hear ya. Pulling the plug with electricity on the monitor seems wrong, intrinsically, in some way, even though that patient is on a one way trip, and just isn't there yet.

Now, I am waiting for some other grizzled posters to say something concrete and antiseptic, and say they would have stopped after 5 minutes or whatever. Then again, I picture a couple of these academic guys calling decedent care with the patient saying "but I'm not dead yet!"

 

[Birdstrike]

Some questions defy the realm of textbooks and these are perfect examples.

Should we have stopped sooner?

No.

Any other Hail Mary you would have tried on this one?

No.

Do you hate calling a code with a beating heart as much as I do?

Yes.



You did what you thought was right. You did what the husband thought was right. You did what everyone in the room thought was right. You did the right thing, but it still hurts, because you're human.

I've been there.

 

[Arcan57]

Should we have stopped sooner? Any other Hail Mary you would have tried on this one? Do you hate calling a code with a beating heart as much as I do?

47 yo with a quick response and transport time? That's worth the time to try and save. I'm a little confused at good heart squeeze without a pulse in a setting that doesn't suggest neurogenic or hypovolemic shock. I would have considered tPA (I don't have ECMO and we just had a meeting with cardiology where they complained WE were taking to many patients with poor prognosis to the lab screwing up their metrics) playing the odds on cause of arrest, but I almost never give it in these scenarios.

I try and justify calling it with PEA by thinking that the patient came in dead and you're not killing them, just deciding when there's no hope of bringing them back.

 

[dchristismi]

At 47, I really give it all I've got. I think you totally did the right thing, and yes, I'd have done the same.
Family telling you to stop is when I know I've done everything I could, and usually what gets me to call someone that young.

 

[Foster23]

47 yo with a quick response and transport time? That's worth the time to try and save. I'm a little confused at good heart squeeze without a pulse in a setting that doesn't suggest neurogenic or hypovolemic shock. I would have considered tPA (I don't have ECMO and we just had a meeting with cardiology where they complained WE were taking to many patients with poor prognosis to the lab screwing up their metrics) playing the odds on cause of arrest, but I almost never give it in these scenarios.

I try and justify calling it with PEA by thinking that the patient came in dead and you're not killing them, just deciding when there's no hope of bringing them back.

So what solution did cardiology offer in regard to patients with poor prognosis with STEMI? With us, I activate Cath Lab on all STEMI, period. Once the interventional cardiologist call back, I give a perfectly honest presentation and let him cancel the activation if he chose to do so. Screwing up metrics or not, i can't imagine sitting on a STEMI and not activate the lab.

 

[WilcoWorld]

Tough case.

I'd like to think I'd have given tPA a try on that one - sounds like it could've been a massive PE. That being said, it would have been a loooong shot.

I agree that it's OK to call a code when there's still cardiac activity, especially if the patient's been down for 45 minutes at that point.

 

[Groove]

Tough one man. That's the kind of case that keeps you up at night. I would have probably done the exact same thing. +/- US to look for a dilated RV with +/- TPA just to say I gave it for presumed PE. That's assuming I saw a big dilated RV and with nothing else in the history. 99% of all providers would have probably done the exact same thing that you did. I would have def stopped per the husbands wishes. She probably had profound anoxic brain injury so even if you had gotten a rhythm, what's the result?

It reminds me of a brain dead/arrested neonate that showed up in a remote ED that I coded for 40 mins to get back on a massive epi infusion only to have a peds ICU doc make excuses for transport because he expected the kid to die any minute. I ended up talking a nurse into riding with me in the ambulance and kept the kids' vitals within range 45 mins to the PICU. He died on the table as soon as one of their nurses knocked the IV out during transfer from stretcher. I'm still not sure what I really accomplished during all of that. The end result would have been the same. I think sometimes we can do "too much" but I agree that your case wasn't so cut and dry. Heroic effort on your part. You did all you could.

 

[name?]

The only time I gave tPA during an arrest like this led to a much bloodier resuscitation effort. It went in early and we ended up with lots of blood in ETT, from nose, lines etc. It didn't help in that case, and made it look more horrific than it already was. That being said, I still entertain it if early and potentially salvageable.

Like Groove said, it's really hard to know when we're trying too hard when we have some great survival stories of a solid resuscitation with questionable outcome that ends up leaving intact. Most of them, though, end up exactly where you did and sometimes days and tens of thousands of dollars later. It's a tough call to make, but it sounds like you did everything right and even better that the husband was on board with cessation of efforts. Sorry for the tough case.

 

[Janders]

Had a very similar one a while ago. Witnessed collapse, immediate CPR, ALS crew on scene rapidly, fast transport, easy tube, easy access.

10 minutes in we're doing CPR, PEA on the monitor, in the ED. U/S shows some minimal attempts a squeeze. Go about 10-15 more minutes, get to the point where it might be time to give up, and suddenly they are in Vfib.

Shock/amio/shock/etc and suddenly we have a VERY weak pulse. Carotid only, prolly 55/35 if we had an A-line in. Didn't improve with levo, dopa, fluids. But stuck around for a long time.

Of course, this did not end well. Except, it kinda did... family gathered, religious leader came, and they got to hold a hand of a live-but-dying person and be with them at the end. So a silver lining.

U/S is great for codes, but it DOES complicate things a bit...

 

[Venko]

In my young folks who die without reason, I sometimes give intralipid as a "hail mary," and it has saved one person in my experience.

 

[TooMuchResearch]

In my young folks who die without reason, I sometimes give intralipid as a "hail mary," and it has saved one person in my experience.

Is there data on hail mary intralipid? If not, then it's hard to say if it helped or if you were about to get lucky anyway, and that is a good reason to write it up a case report. Get some anecdotes out there and let it gain traction so someone wants to study it.

 

[Venko]

There are cases of intralipid helping in cases of medicine toxicity. Especially lipophilic medicines.

 

[Birdstrike]

There are cases of intralipid helping in cases of medicine toxicity. Especially lipophilic medicines.

Bupivacaine cardiotoxicity.

 

[Daiphon]

Is there data on hail mary intralipid? If not, then it's hard to say if it helped or if you were about to get lucky anyway, and that is a good reason to write it up a case report. Get some anecdotes out there and let it gain traction so someone wants to study it.

"Hail Mary" - not exactly... but a LOT of literature building for its use.

Best example of a Hail Mary:
http://www.ncbi.nlm.nih.gov/m/pubmed/17766009/

Nice collection of studies:
www.lipidrescue.org

Pretty decent review:
http://www.ncbi.nlm.nih.gov/m/pubmed/19845549/

It gets called the HM because of the timing of its administration in most refractory codes; but given the right story, should probably be given sooner.

 

[Venko]

Daiphon, thank you for providing some of the backing for intralipid. I was referring to it as a hail mary when there is no indication that it would be needed. If there is a history of overdose etc then I agree it should be given promptly when indicated. Wrong or right, I sometimes give it in codes that aren't going well with young people or people who would not otherwise code even without any known overdose or medication exposure. In this case, because it is highly unlikely to work, I consider it a "hail mary," which may be the wrong use of the term but it seems akin to throwing the 60 yard pass on the last play. Regardless of the term, I think you've provided some of the evidence for considering it in sick patients.

 

[TooMuchResearch]

"Hail Mary" - not exactly... but a LOT of literature building for its use.

Best example of a Hail Mary:
http://www.ncbi.nlm.nih.gov/m/pubmed/17766009/

Nice collection of studies:
www.lipidrescue.org

Pretty decent review:
http://www.ncbi.nlm.nih.gov/m/pubmed/19845549/

It gets called the HM because of the timing of its administration in most refractory codes; but given the right story, should probably be given sooner.

Thanks!

 

[msgsk]

Sorry to resuscitate an old thread, but do you guys routinely give dopamine/norepi even if there's no pulse? I've never done that or read that strategy before anywhere - looked it up and can't find any evidence supporting it. Link? Anecdotal evidence?

 

[Birdstrike]

Sorry to resuscitate an old thread, but do you guys routinely give dopamine/norepi even if there's no pulse? I've never done that or read that strategy before anywhere - looked it up and can't find any evidence supporting it. Link? Anecdotal evidence?

Apology accepted. However, I will not accept your necessary apology for working the word "resuscitate" into your post for the pun effect. "Resuscitate" a thread, in a thread about "resuscitating" people? How insensitive.







(Lol. JK)


Sent from my iPhone using SDN Mobile

 

[fergustsi]

i see the majority of you guys use levo and dopamine, does anyone else besides me use epi gtt first and then let the icu titrate and switch?

 

[alpinism]

In my young folks who die without reason, I sometimes give intralipid as a "hail mary," and it has saved one person in my experience.

Beat me to it.

Another hail mary: Steroids +/- vasopressin.

http://www.scancrit.com/2013/08/20/cpr-steroids/#more-5683

 

[deleted109597]

It gets called the HM because of the timing of its administration in most refractory codes; but given the right story, should probably be given sooner.

Sure. Maybe.
http://www.thepoisonreview.com/2014...ulsion-for-overdose-causation-or-coincidence/
I agree that it wasn't given soon enough on those, but we certainly need to keep studying it.

 

[Birdstrike]

Steroids in Cardiac Arrest: Just Blowing Smoke?


Compared to other ACLS drugs, steroids are pretty darn benign in general, to begin with. Since acute adrenal insufficiency can cause cardiovascular collapse, and often arrest patients come in with zero known history, in theory it's always in the differential anyways, albeit low on the list. It certainly is tough, if not impossible, to get good level I evidence for resuscitation for obvious reasons. But hey, steroids in cardiac arrest, why not? Are you going to hurt someone who you are 5 minutes from calling "dead," with a dose of IV hydrocortisone?

I really doubt it.

If my family member was coding and you wanted to throw in a dose of steroid as part of typical ACLS protocol, without getting in the way of typical ACLS protocol, I'm cool with it. Like most other things in these end of the line scenarios it's very tough to get good data. It would be very hard to argue a dose of steroids would cause harm in a patient with whom you are already following standard protocols. These often are "kitchen sink" situations anyways that don't always follow a pretty or controlled timeline or pathway. It certainly seems like a better idea than "blowing smoke up someone's a-s," during a code, which some of your predecessors have been known to do. Literally.


Lancet:

"Tobacco smoke enemas...Ghislaine Lawrence a The notion of reviving victims of drowning accidents with tobacco smoke enemas seems, to say the least, a little odd. But to 18th-century physicians, this approach was entirely rational. The mainstay of treating the “apparently dead” was warmth and stimulation. Rubbing the skin was one method of stimulation, but injecting tobacco smoke into the rectum was generally thought more powerful. Since its introduction from the New World by Sir Walter Raleigh (1552—1618), tobacco has had a place in the p ..."

We rock!

http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(02)08339-3/fulltext