Codes where they won't die, but won't stay alive

[engineeredout]

Had a run of these recently, and not sure quite what else to do with them:

Cardiac arrest brought in by EMS. At initial face value, this are at least viable codes. Young-ish people, reasonable onset of CPR, tubed in the field, have access. They of course have cardiac risk factors if not actual known CAD.

Work on them for a while, get them back. Post-ROSC vitals: P180s, BP 200/100, about what you'd expect from someone who just got a crap ton of epi. In the next few minutes however, start to slow down the HR. BP starts to drop. Get a pressor hanging at maximum, push bicarbonate, doesn't do it. Lose pulses. Start over again, 1-2 rounds CPR/epi, ROSC. Hypertensive/tachycardic again, but not for long. Pressor #2 goes up. Then #3. A line in at this point, watching them slow down and pressure drops out. Another round of ACLS, another ROSC. Good ETCO2, oxygenating, but can't maintain pulses. Bedside us: nothing helpful (no tamponade, no grossly dilated RV, no PTX), and around and around we go.

If they didn't come back rapidly, then we'd call it. If pulses maintained more than 5 minutes we'd have something to work with. In a future society this might be a perfect ECMO candidate. In the meantime, what do you do with these people who continue to show signs of life?

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[TeamZissou]

Have you gotten any lactates from the blood draws? Any trends? All not vs extremely vs started low on initial then trended up s/p each code? Any other labs show anomalies? ABG's?

 

[shoal]

tough cases. hopefully you get some history to guide possible causes, throw the kitchen sink at them and hope something sticks. no improvement youre kinda stick coding them until no signs of life or family tells you to stop

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[deleted245139]

At some point, the ability to get a meaningful Neuro outcome is nil.... So, there is an end to it. I've had a few of these as well. I've given tpa to a few, but had info to suggest a PE- dilated RV on US, PEA initial rhythem- and gotten ROSC. Theoretically, may help the yet undiagnosed MI as well.
Tough with a young person... Tough to say stop.

 

[alpinism]

Sigh.

Sounds typical of post code patients given **** tons of Epi during CPR.

That's what Epi does - It restarts the heart but trashes the brain. If the patient can't maintain adequate rates/pressures on their own they likely have severe brain damage and aren't worth saving. Unless they have a promising neuro exam the chances of a meaningful recovery are close to zero.

Sometimes you just have to stop the pressors and let them die.

(Obviously after excluding the reversible causes of cardiac arrest).

 

[Traumahawk]

This is never anyone's idea of a happy fun "nice save, yay team" resus. I've participated in a fair few of these, both OHCA brought to the department (either EMS transport or the dreaded "blue guy/gal in the back of a car" scenario), as well as one or two IHCA witnessed-on-TMS and simply unwitnessed. Most of the cases I've seen present a cardiogenic shock picture when you do get ROSC (garbage EF, global hypokinesis and misc other wall motion abnormalities on bedside US), and whatever rhythm you do get back usually has at least some ST abnormality if not actual STEMI criteria. We all can name off the PMH by heart - CAD, HTN, HLD, NIDDM, + smoking hx, +/- COPD and/or CRI.

As alpinism said, epi probably isn't your friend here - titrate it to a EtCO2 of 20 or a DBP of 40 mmHg (AHA consensus, Circ 2013) and consider using a drip (your nursing staff can mix this at bedside, 1 mg per 1000 mL NS and titrate for effect) instead of the 1 mg q3min "per protocol." There's some not entirely awful evidence and a lot of consensus recently out for sprinting these folks to the cath lab - if you have such a thing immediately available and if your interventional cards guys are willing to accept that this patient might die (repeatedly) on their table. Absent that, it's a crapshoot - lytics are no good, don't bother (Abu-Laban et al, NEJM 2002), maybe throw up some dobutamine as a temporizing measure (ECC 2015), and recognize that you're still flogging a mostly dead muscle. IABP was a not-awful bridge therapy in the SHOCK trial, but was more or less busted by SHOCK II, and also requires the presence of available control consoles, someone with the training to insert the balloon, and someone with the training to run the console in your ED - and if your shop boasts that trifecta, you probably have an ED ECMO* program anyway, which is a whole other discussion. And of course, there's the role of expectation management - at some point you just aren't going to recover anything cardiologically or neurologically viable.

* imagine the sexy "ECMO" voice-over from countless episodes of EM:RAP

 

[deleted547339]

I don't believe in bicarb for one.

If you have any history suggestive of coronary etiology, I think lytics are fine - just make sure you give enough time of continued CPR to circulate the meds.

Also, good ETCO2 and can't keep a pulse don't seem to go together.

At some point, I tell everyone in the room that if they code again I am not going attempt further resuscitation as we are likely not viable. Make sure everyone in the room is OK with this - they are usually are relieved.

 

[GeneralVeers]

tough cases. hopefully you get some history to guide possible causes, throw the kitchen sink at them and hope something sticks. no improvement youre kinda stick coding them until no signs of life or family tells you to stop

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I disagree with this. You potentially would be coding this patient every 30 minutes for hours, and tying up nursing staff, and yourself for a futile effort. I will resuscitate until I determine medical futility. (usually after the 3rd code). I tell family that they are no longer responding meaningfully to the meds and discontinue efforts. You do not need family's permission.

 

[bravotwozero]

At what point would you expect permanent brain death? 30 minutes? 10 minutes with no rosc? 50 minutes with on and off rosc? That's what I find hard to figure out, and I wouldnt want to make a premature determination..


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[GeneralVeers]

At what point would you expect permanent brain death? 30 minutes? 10 minutes with no rosc? 50 minutes with on and off rosc? That's what I find hard to figure out, and I wouldnt want to make a premature determination..


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It's your job to make that determination. Part of the tough decision-making that we have to do. Whatever your cutoff is, as long as you have a reasonable justification then it's fine.

 

[Siggy]

At what point would you expect permanent brain death? 30 minutes? 10 minutes with no rosc? 50 minutes with on and off rosc? That's what I find hard to figure out, and I wouldnt want to make a premature determination..


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The problem is that it depends. One of the patient's on the floor at my hospital went into electrical storm and we ended up coding him for 40 minutes with 10 or 11 defibrillations. He'd go back into sinus, and then after about 90 seconds go back into v-fib or v-tach. We finally got him to stay in a sinus rhythm... and he ended up walking out of the hospital neurologically intact. Granted, this is more than a little different than the person who goes into brady-asystole or PEA.

 

[Traumahawk]

At what point would you expect permanent brain death? 30 minutes? 10 minutes with no rosc? 50 minutes with on and off rosc? That's what I find hard to figure out, and I wouldnt want to make a premature determination..


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For traumatic arrest, it's pretty cut and dried: 10 minutes in blunt trauma or 15 minutes in penetrating trauma with no signs of life and no cardiac activity on US = dead (ROSC rate of 0 in multiple trials). For medical arrests, the data become murkier (OHCA? IHCA? Witnessed? How long down? Bystander CPR? Early defib? Reversible causes?), but in your typical adult I'd start dropping strong hints of futility at the 30-min mark, especially with a negative prognostic EtCO2 (persistently under 10 w/ high quality CPR = dead, again in multiple trials) and non-reassuring US findings (no cardiac activity and no reversible cause generally = dead).

On/off ROSC, as has been under discussion, requires a judgment call. Have the episodes of ROSC been long enough to achieve reasonable cerebral perfusion? Does the patient have any measurable neuro function? Are there reversible causes you can address during the "uptime"? If none of the above, I think a reasonable argument for futility can be made... but that judgment is ultimately yours.


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[gamerEMdoc]

These are the cases I like to pull the family into the room on. In the end, when they see what all is being done, and how many times you have to do CPR, and that their loved one isn't waking up, they often make the decision easy and ask to terminate.

 

[canigetawhatwhat]

Im a big proponent of TPA if you get back a PEA one with no obvious cause.
Most of the Hs and Ts I can treat and screen for in 30s-1m.
PE is super common and you cant make dead deader.

 

[Birdstrike]

Had a run of these recently, and not sure quite what else to do with them:

Cardiac arrest brought in by EMS. At initial face value, this are at least viable codes. Young-ish people, reasonable onset of CPR, tubed in the field, have access. They of course have cardiac risk factors if not actual known CAD.

Work on them for a while, get them back. Post-ROSC vitals: P180s, BP 200/100, about what you'd expect from someone who just got a crap ton of epi. In the next few minutes however, start to slow down the HR. BP starts to drop. Get a pressor hanging at maximum, push bicarbonate, doesn't do it. Lose pulses. Start over again, 1-2 rounds CPR/epi, ROSC. Hypertensive/tachycardic again, but not for long. Pressor #2 goes up. Then #3. A line in at this point, watching them slow down and pressure drops out. Another round of ACLS, another ROSC. Good ETCO2, oxygenating, but can't maintain pulses. Bedside us: nothing helpful (no tamponade, no grossly dilated RV, no PTX), and around and around we go.

If they didn't come back rapidly, then we'd call it. If pulses maintained more than 5 minutes we'd have something to work with. In a future society this might be a perfect ECMO candidate. In the meantime, what do you do with these people who continue to show signs of life?

You know what happens with "Codes where they won't die, and won't stay alive"?

They die.

 

[The White Coat Investor]

You know what happens with "Codes where they won't die, and won't stay alive"?

They die.

Yup. They're dead when you say they're dead. Turn the monitor off.

 

[Traumahawk]

Agreed, and I don't think too many people have a problem ending the ballgame when it's your typical walking smorgasbord of comorbidities that just keels over at 52 rather than at 79. (Though I will state that the worst staff violence incident we've had in our shop in the last several years was the result of just such a case.) Really young folks who up and die, I think, might pose a bit more of an emotional challenge - from staff counter-transference if nothing else. Nobody wants to consider that someone just like you (or your spouse, children, etc) might end up dead on your resus bay stretcher.

The Laws of the House of God apply quite aptly here: "At a code, the first step is to take your own pulse."

Do you know, in your heart of hearts, that you've done everything in your power for that patient, and yet you still came up with a negative outcome? (Forget superheroics like ECMO or whatnot.) If that answer is yes, call the time and shut off the monitor. That patient was never going to be anything other than dead; it just took a little longer than the average and psyched everyone out in the process. GamerEMdoc is absolutely right, too, in pointing to family presence as a potential benefit in this situation (which is a big part of why we on the nursing side push for it). Families are all for the "do everything, don't let them die" approach until they see what we actually have to do to their loved one to obtain a very poor facsimile of life - and then they almost invariably say "no more" (plus or minus any resignations to any given deity).

There are live people out there that need the help more. Move on.

 

[GeneralVeers]

GamerEMdoc is absolutely right, too, in pointing to family presence as a potential benefit in this situation (which is a big part of why we on the nursing side push for it). Families are all for the "do everything, don't let them die" approach until they see what we actually have to do to their loved one to obtain a very poor facsimile of life - and then they almost invariably say "no more" (plus or minus any resignations to any given deity).

There are live people out there that need the help more. Move on.

I don't involve families in the decision making process. They don't get to decide if I waste another hour doing a futile resuscitation of a dead patient. I will explain to them the situation, and let them watch the last few minutes of our efforts. I tell them that "Your grandma's heart has stopped responding to the medication. We've done everything we can, but unfortunately there's nothing more we can do".

 

[engineeredout]

I'm all for a shot of tPa when I have a reasonable history suggestive of PE (anyone ever get the patient who rolls in coding with the surgical boot on?) or us findings consistent with such. Or in the case of STEMI that I can't stabilize to get to a cath lab. The rest of the time, it just seems like an expensive way of making a bloody mess

 

[Tenk]

Unless you have something to treat: Ie STEMI, PE, etc, it's usually best to call it in these situations. If it were you on that table would you want to be coded for 1-2 hours on 3 pressors with no definitive end in sight? Sometimes dead is better. Sucks but true.

 

[RustedFox]

I don't involve families in the decision making process. They don't get to decide if I waste another hour doing a futile resuscitation of a dead patient. I will explain to them the situation, and let them watch the last few minutes of our efforts. I tell them that "Your grandma's heart has stopped responding to the medication. We've done everything we can, but unfortunately there's nothing more we can do".

Ahhhh, Veers. We've missed you.

 

[engineeredout]

Unless you have something to treat: Ie STEMI, PE, etc, it's usually best to call it in these situations. If it were you on that table would you want to be coded for 1-2 hours on 3 pressors with no definitive end in sight? Sometimes dead is better. Sucks but true.

Always wonder though. In theory if CPR was started immediately, and you have high quality compressions, good ETCO2, you could possibly be providing a halfway decent cerebral perfusion pressure, at least enough to keep some of those neurons alive. It's easy when it's the found in the bathroom, unknown downtime, no CPR until EMS arrived.

 

[TeamZissou]

Always wonder though. In theory if CPR was started immediately, and you have high quality compressions, good ETCO2, you could possibly be providing a halfway decent cerebral perfusion pressure, at least enough to keep some of those neurons alive. It's easy when it's the found in the bathroom, unknown downtime, no CPR until EMS arrived.

That's why I asked about the lactate on arrival. Not like it does anything for you at the time but when I look back at frustrating codes where supposedly prehospital care was done really well but the initial lactate is 10+... There was probably something left out of the story aside from perfect CPR etc

 

[Tenk]

Always wonder though. In theory if CPR was started immediately, and you have high quality compressions, good ETCO2, you could possibly be providing a halfway decent cerebral perfusion pressure, at least enough to keep some of those neurons alive. It's easy when it's the found in the bathroom, unknown downtime, no CPR until EMS arrived.

That situation occurs in a hospital setting or once in several hundred. The question you should always ask is: how can we fix this? STEMI? Cath. PE? tPA. Hypothermia? Rewarm. If your answer is: I don't know, they are probably dead. Pressors and supportive care are only temporizing measures. If you don't have an end goal in sight the only place you'll end up is the morgue. This isn't even me being pessimistic, more compassionate if anything. No worse way to die than slowly over 1-2 weeks in an ICU.

 

[gro2001]

Had a run of these recently, and not sure quite what else to do with them:

Cardiac arrest brought in by EMS. At initial face value, this are at least viable codes. Young-ish people, reasonable onset of CPR, tubed in the field, have access. They of course have cardiac risk factors if not actual known CAD.

Work on them for a while, get them back. Post-ROSC vitals: P180s, BP 200/100, about what you'd expect from someone who just got a crap ton of epi. In the next few minutes however, start to slow down the HR. BP starts to drop. Get a pressor hanging at maximum, push bicarbonate, doesn't do it. Lose pulses. Start over again, 1-2 rounds CPR/epi, ROSC. Hypertensive/tachycardic again, but not for long. Pressor #2 goes up. Then #3. A line in at this point, watching them slow down and pressure drops out. Another round of ACLS, another ROSC. Good ETCO2, oxygenating, but can't maintain pulses. Bedside us: nothing helpful (no tamponade, no grossly dilated RV, no PTX), and around and around we go.

If they didn't come back rapidly, then we'd call it. If pulses maintained more than 5 minutes we'd have something to work with. In a future society this might be a perfect ECMO candidate. In the meantime, what do you do with these people who continue to show signs of life?

As above poster has said, "Good ETCO2" and "keeps dying" don't go together.

You probably know this, in which case forgive me, but I've seen a lot of well trained people fail to cognitively make the distinction between two related pieces of equipment we commonly use:

1) Calorimetric end tidal CO2 detector: the little plastic thingie that we put on endotracheal tubes, they turn purple -> yellow in the presence of CO2 (gold is good!) and help confirm endotracheal intubation. These are a QUALITATIVE tool only.

2) Continuous wave form capnographers: provide a continuous reading of end tidal CO2 in both numeric as well as a waveform. These (in the presence of a 4 stage waveform only!) allow to independently confirm endotracheal intubation, as well as for a lot of other uses such as being indirect measures of the quality of CPR, ROSC, etc. These are QUALITATIVE and QUANTITATIVE tools.

One possible source of error is to stick the calorimetric end tidal CO2 detector on a coding/intubated patient, see it turn yellow, and conclude that "there is good ETCO2". This would be wrong, because the ETCO2 could be very low, and still trigger one of these things. Furthermore, while they sometimes initially change back to purple, leading some people astray in thinking that you can use them in some sort of continuous way, this is also completely unreliable. In fact, these little things should be always taken with a sizable grain of salt, according to the NAP4 experience (http://www.nationalauditprojects.org.uk/NAP4_home).

So if he TRULY had "good ETCO2", meaning a continuous waveform capnographer connected to the ETT circuit displayed a distinct 4 stage waveform (very important) and the numeric reading was >20 mm Hg, yet this patient kept dying, I would be looking for something I was missing that allowed the patient to keep grasping at life despite my best efforts. My first concern would be reassessing ABCs, particularly unexpected airway issues (did the tube get blocked/dislodged? how do I know?) or equipment trying to fool me (is the BVM plugged in? Into the oxygen outlet? that is turned on? and working? and connected to this patient? and isn't broken?).

Having said all that, if there was no particular clinical history to guide you on specific rescue measures, I would echo what White Coat said. You are a physician and you get to decide what dead means in that clinical scenario. If you think there is zero chance of success, recap, ask your team for any other ideas, talk to the family if available, express that you've exhausted all relevant resources, and turn the monitor off.

 

[HLxDrummer]

You guys listen to the EMRAP recently where they discussed when to D/C CPR in the field? I imagine it would apply in the ED as well. Faintly remember them saying with good CPR, witnessed, etc. ,etc. that you should continue the code for around 40 mins (can someone back this up for me?). This was for PEA which surprised me. Seemed like good neuro outcomes, too. Not directly related to the original post but related.

 

[link2swim06]

You guys listen to the EMRAP recently where they discussed when to D/C CPR in the field? I imagine it would apply in the ED as well. Faintly remember them saying with good CPR, witnessed, etc. ,etc. that you should continue the code for around 40 mins (can someone back this up for me?). This was for PEA which surprised me. Seemed like good neuro outcomes, too. Not directly related to the original post but related.

I didn't listen to that but in our EMS system our medics can call into medical control and ask to terminate resuscitation efforts.

Generally they involve PEA or asystole codes with around 8 rounds of epi, successful intubation, and no obvious reversal causes.

You don't get very good CPR transporting a patient...if you couldn't get ROSC after 35 minutes of scene code time, spending 20 minutes of lesser quality CPR in transport probably isn't going to help, whatsoever.

These medic calls I just pronounce time of death over the radio and let the medics move on. No point in clogging up our ER with dead people.

 

[HLxDrummer]

I didn't listen to that but in our EMS system our medics can call into medical control and ask to terminate resuscitation efforts.

Generally they involve PEA or asystole codes with around 8 rounds of epi, successful intubation, and no obvious reversal causes.

You don't get very good CPR transporting a patient...if you couldn't get ROSC after 35 minutes of scene code time, spending 20 minutes of lesser quality CPR in transport probably isn't going to help, whatsoever.

These medic calls I just pronounce time of death over the radio and let the medics move on. No point in clogging up our ER with dead people.

Ya, the talk was actually regarding those calls and how to determine if they should keep trying. Good point regarding poor CPR in transit - didn't consider that factor.

 

[Traumahawk]

As above poster has said, "Good ETCO2" and "keeps dying" don't go together.

You probably know this, in which case forgive me, but I've seen a lot of well trained people fail to cognitively make the distinction between two related pieces of equipment we commonly use:

1) Calorimetric end tidal CO2 detector: the little plastic thingie that we put on endotracheal tubes, they turn purple -> yellow in the presence of CO2 (gold is good!) and help confirm endotracheal intubation. These are a QUALITATIVE tool only.

2) Continuous wave form capnographers: provide a continuous reading of end tidal CO2 in both numeric as well as a waveform. These (in the presence of a 4 stage waveform only!) allow to independently confirm endotracheal intubation, as well as for a lot of other uses such as being indirect measures of the quality of CPR, ROSC, etc. These are QUALITATIVE and QUANTITATIVE tools.

The one circumstance where you would have a "good" quantitative waveform ETCO2 and a repeatedly dead patient would be respiratory acidosis in the context of severe hypercarbia secondary to pulmonary disease. Much to the annoyance of our RTs, I've long been in the habit of putting an inline capnograph adapter on all my codes and all my COPDers on NIV, and then bringing all the newer nurses in to see the numbers. It's hilarious to see the looks on their faces when they see an awake, alert patient calmly blowing off 65-85 mmHg of ETCO2 per breath on the NIV. It's also a great way to get them to remember that the ETCO2 measurement is a floor. The real pCO2 might be at that number, a little above that number, or wildly above that number, but it'll never be below that number. That intra-arrest ETCO2 of 45 doesn't look so awesome when your blood gas comes back with a pH of 6.815 and a pCO2 of 128. At that point, the question becomes whether you can keep them not-quite-dead and kinda-sorta-perfusing long enough to blow down enough CO2 to mitigate the respiratory acidosis before lactic acidosis finishes the job.

Ya, the talk was actually regarding those calls and how to determine if they should keep trying. Good point regarding poor CPR in transit - didn't consider that factor.

I listened to that episode as well, and yes, intra-transport compressions absolutely are of stinky quality (or any other S-word you might imagine). Bonus points for the invariable scenario of the FF/medic one-arming the chest as the cot rolls into Resus. Unless the patient is under 50 kilos and the compressor recently auditioned for the role of Incredible Hulk, I guarantee they aren't compressing 2" into the chest. More and more of our EMS agencies are investing in automated devices (AutoPulse or LUCAS) for just this reason. As for calling codes in the field, we generally have very short transit times for crews rolling Priority 1, so calls for medical control are vanishingly rare. However, most of our docs do use some variation on the protocol previously outlined. (Down > 40 min? PEA or asystole? No reversible causes? Time is XX:XX, thanks for the call, be safe out there.)

 

[Hamhock]

Medics.

HH
(former medic)

 

[TooMuchResearch]

Ya, the talk was actually regarding those calls and how to determine if they should keep trying. Good point regarding poor CPR in transit - didn't consider that factor.

Nearly all (all?) of our local services are LUCAS 2 equipped, so the en route CPR is fine.

 

[Zebra Hunter]

We recently had a 30-something year old otherwise healthy individual come in following a witnessed arrest by EMS. He was hanging out with some friends, felt severe chest pain, had them call EMS. He was exhibiting that peri-death anxiety you often see then went pulseless en route and demonstrated what looked to be V-fib on their monitor. He was shocked, then went into PEA. He had received 10+ minutes of compressions by the time he came in. We continued coding this guy for 1.5 hours with multiple episodes of achieving ROSC in between. Went into V-fib multiple times and was shocked multiple times. He got everything: epi, calcium, bi-carb, lidocaine, mag, pressors. Considered giving tPA, but ultimately decided not to. During these episodes of ROSC, the pt's rhythm would look normal on the monitor. His lab work was unremarkable other than the obvious elevated lactate and an elevated trop. The nurses were all giving passive aggressive comments about letting him die, talking about how it was probably drugs that did this (it wasn't). We finally got him perfusing long enough to go to cath lab after maybe the 4th episode of ROSC. The cath was clean. He was then sent to the ICU. Fast forward 3 weeks later, and this 30-something year old, married, father of two was able to walk himself out of the hospital completely neurologically intact. We never actually figured out why this patient arrested.

He was one of those rare candidates for the prolonged code: young, healthy, and witnessed arrest w/ immediate CPR administration. If they meet all 3 of those, I might consider coding them for 2 hours or more if I am actually achieving ROSC multiple times. These are the people that you can actually save.

 

[namethatsmell]

We recently had a 30-something year old otherwise healthy individual come in following a witnessed arrest by EMS. He was hanging out with some friends, felt severe chest pain, had them call EMS. He was exhibiting that peri-death anxiety you often see then went pulseless en route and demonstrated what looked to be V-fib on their monitor. He was shocked, then went into PEA. He had received 10+ minutes of compressions by the time he came in. We continued coding this guy for 1.5 hours with multiple episodes of achieving ROSC in between. Went into V-fib multiple times and was shocked multiple times. He got everything: epi, calcium, bi-carb, lidocaine, mag, pressors. Considered giving tPA, but ultimately decided not to. During these episodes of ROSC, the pt's rhythm would look normal on the monitor. His lab work was unremarkable other than the obvious elevated lactate and an elevated trop. The nurses were all giving passive aggressive comments about letting him die, talking about how it was probably drugs that did this (it wasn't). We finally got him perfusing long enough to go to cath lab after maybe the 4th episode of ROSC. The cath was clean. He was then sent to the ICU. Fast forward 3 weeks later, and this 30-something year old, married, father of two was able to walk himself out of the hospital completely neurologically intact. We never actually figured out why this patient arrested.

He was one of those rare candidates for the prolonged code: young, healthy, and witnessed arrest w/ immediate CPR administration. If they meet all 3 of those, I might consider coding them for 2 hours or more if I am actually achieving ROSC multiple times. These are the people that you can actually save.

Great save.

It's amazing how one person can suggest "it's probably drugs" and in 30 seconds it's morphed into "the guy did coke, pcp, and a bunch of ghb with sprinkles on top." M&Ms and practice committee are built on such phenomena.

 

[shoal]

zebra im with you 100%. that trifecta. young, witnessed arrest, and intermittent rosc... its hard if not impossible to stop unless prolonged coding... old,unwitnessed no rosc these are easier to call

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