Calling the Code, when enough is enough

[SWATdocMD]

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Thanks for taking the time to read my new thread. This is one of those questions that I have been thinking about for a while and just can't seem to come up with a great answer nor have I asked any of my attendings.

I have been using a lot of bedside cardiac echo to help me make the decision on when to call a code. I had a patient a not too long ago that had an approximate down time of maybe 20 - 30 minutes with continuous CPR. Low protoplasm at baseline. I thought I felt a faint femoral pulse when we stopped compressions for US and rhythm check, but in the back of my mind I told myself that the contraction that I was seeing was simply 2/2 to his pacer and NOT intrinsic cardiac function. Needless to say "we got him back" for a few days until he went into DIC up in my ICU (I was working the ICU at the time and went to the ED when the attending called me and let me know what was coming in). But, here is my question:

what do you do when your patient has a pacemaker and you see cardiac contractility on the US screen or your feel a pulse? Is the patient dead and what you are seeing/feeling is the pacer or is that intrinsic cardiac contractility?

 

[docB]

Good question.

Just as critical care technology in general a forced society to rethink its definition of death (brain dead vs. PVS vs. other) US is forcing us to try to figure out what to do with pulseless patients with cardiac movement.

Patients without a pulse are more straight forward. Once we are at the point of futility I quit using the US and call it as a refractory PEA which is what it is.

When you can get back a weak pulse it's tougher. In those cases if there is family I use the time that is essentially a break in CPR to try to get them to categorize the patient (which is the Vegas term for limit care). If there's no family I document futility and when they lose the pulse again I just call it.

 

[Tiger26]

Good question.

Just as critical care technology in general a forced society to rethink its definition of death (brain dead vs. PVS vs. other) US is forcing us to try to figure out what to do with pulseless patients with cardiac movement.

Patients without a pulse are more straight forward. Once we are at the point of futility I quit using the US and call it as a refractory PEA which is what it is.

When you can get back a weak pulse it's tougher. In those cases if there is family I use the time that is essentially a break in CPR to try to get them to categorize the patient (which is the Vegas term for limit care). If there's no family I document futility and when they lose the pulse again I just call it.

I do the same as DocB--I'm pretty aggressive but it's all based on futility even if you get a little flicker. If it's their day, then it's their day . . .

Mostly, I do some shared decision making if family present. If not, I look for consensus in the room and ask for alternative diagnoses among nursing and other staff and whether people are alright with calling the code. If yes in either situation, I document as such.

 

[southerndoc]

Can't feel a pulse after eliminating causes and trying your best to reverse them? Call it.

I don't fool with cardiac ultrasounds in codes or dopplers. If you can't feel a pulse, they aren't perfusing enough to perfuse their brain. To my knowledge, cardiac ultrasound has not been shown to improve survival to discharge in cardiac arrest patients. It's more for the practitioner's peace of mind than for patient care.

There are plenty of times that beating hearts are pronounced. It's called PEA.

 

[pseudoknot]

Yeah, I don't think there's any literature supporting the positive predictive value of movement on ultrasound, just negative. If you see nothing you can probably call it earlier but I don't see any need to go until "ultrasound death."

 

[docB]

I will say that calling PEA is one of those things you have to get used to as an attending. The first couple of times you do it with no one to defer to is a bit stressful.

It is also a special situation when it come to families. I've seen situations go really bad because families are confused by the monitor. If possible I try to get the family out if I foresee a PEA call coming. If they are there you've got to get the nurses to turn off the monitors ASAP after the call.

 

[Rendar5]

Yeah, I don't think there's any literature supporting the positive predictive value of movement on ultrasound, just negative. If you see nothing you can probably call it earlier but I don't see any need to go until "ultrasound death."

the last time I did ultrasound to confirm death, I did see cardiac standstill. Then we get a pulse back 30 seconds after I leave the room. and yes, he actually survived to discharge. so I no longer bother with u/s.

 

[deleted109597]

If you're thinking "what else can I do in this code?" then you've hit time to call it. Unless you're going super heroic on whatever young patient you have.

In the NH population, it's "what procedures can my residents do to learn" and then call it.

 

[deleted92121]

the last time I did ultrasound to confirm death, I did see cardiac standstill. Then we get a pulse back 30 seconds after I leave the room. and yes, he actually survived to discharge. so I no longer bother with u/s.

I've seen our attendings use u/s to confirm cardiac standstill frequently. I am just curious what exactly would cause standstill long enough to confirm death but then restart spontaneously and survive to dc?

 

[goodoldalky]

I've seen our attendings use u/s to confirm cardiac standstill frequently. I am just curious what exactly would cause standstill long enough to confirm death but then restart spontaneously and survive to dc?

Acidosis or hyperkalemia most likely. Maybe got some bicarbonate or calcium and came back, far fetched as that is.. Standstill can also be misinterpreted easily. You can miss a subtle contraction or fibrillation if you don't use m-mode. That's the most likely explanation.

 

[deleted92121]

Acidosis or hyperkalemia most likely. Maybe got some bicarbonate or calcium and came back, far fetched as that is.. Standstill can also be misinterpreted easily. You can miss a subtle contraction or fibrillation if you don't use m-mode. That's the most likely explanation.

I appreciate the reply. The pre-hospital units are supposedly getting u/s for use in the field at my ED. I suppose it is useful but I am one of those medics who thinks getting patients to definitive care is more important than playing around on-scence.

 

[docB]

I appreciate the reply. The pre-hospital units are supposedly getting u/s for use in the field at my ED. I suppose it is useful but I am one of those medics who thinks getting patients to definitive care is more important than playing around on-scence.

Now that's a whole different topic but a really interesting one. US in EMS. I think there is a role there but we're probably 10 years from really defining what it is and seeing it implemented.

Right now I think the best out of hospital arena would be aero med. In that setting you have highly trained and educated providers with prolonged transport times with sick patients. FAST has obvious utility. Another would be US guided lines. These providers get fewer lines than say an EP so they would benefit a lot by both pre procedure anatomic survey and real time US guidance. Another opportunity would be to use US to eval for PTX which is a big issue for aero.

 

[deleted92121]

Now that's a whole different topic but a really interesting one. US in EMS. I think there is a role there but we're probably 10 years from really defining what it is and seeing it implemented.

Right now I think the best out of hospital arena would be aero med. In that setting you have highly trained and educated providers with prolonged transport times with sick patients. FAST has obvious utility. Another would be US guided lines. These providers get fewer lines than say an EP so they would benefit a lot by both pre procedure anatomic survey and real time US guidance. Another opportunity would be to use US to eval for PTX which is a big issue for aero.

Did my time as a flight medic and I definitely see the use there. Have had more than one PTX slip by us for numerous reasons. But on the ground in most areas, u/s would be overkill. Unless you are in a rural area and hundreds of miles from an ED.

 

[docB]

Did my time as a flight medic and I definitely see the use there. Have had more than one PTX slip by us for numerous reasons. But on the ground in most areas, u/s would be overkill. Unless you are in a rural area and hundreds of miles from an ED.

I think there might be some utility to field EMS in a few situations. Imagine if you could use FAST to triage patients to ground transport vs. HEMS. Other possible targets would be evaluation of PTX or pericardial effusion.

The biggest problem with using it in these situations would be getting providers who are trained, experienced and get enough opportunities to stay current. I think it could work in a Super Medic type system that uses a single, highly trained medic responding to assist lower level first responder units.

 

[Birdstrike]

Remember: "cardiac standstill" on ultrasound alone and out of context means nothing. V-fib on ultrasound can show "cardiac standstill" and that's the most viable, quickly reversible, otherwise fatal arrhythmia there is. Yet, on the other hand, a PEA with vigorous cardiac motion, ie freshly-pulseless massive blunt trauma, is equally as hopeless as the heart is vigorously contractile.

Unfortunately, calling a code can at times require some judgement and experience. "Dead" isn't always dead (especially if it's not warm and dead).

And remember, it's better to be the guy that runs a code a couple minutes too long, than it is to be the guy whose patient was found to still be breathing at the morgue.

 

[Rendar5]

Honestly not sure about my guy, was an alcoholic who fell and hit his head, then v-fibbed in the ambulance and diverted, worke dhim for a good 10+minutes, but asystole the entire time on monitor (don't ask me why they didn't immediately shock), got fancy and u/s'd definite standstill, not even a quiver. Anyway, checked on his charts a month later, the alcoholic druggy guy had full neuro recovery s/p hypothermia protocol and of course refused treatment and walked out AMA as soon as that recovery happens. can't keep one of those types down, of course.

 

[RustedFox]

Honestly not sure about my guy, was an alcoholic who fell and hit his head, then v-fibbed in the ambulance and diverted, worke dhim for a good 10+minutes, but asystole the entire time on monitor (don't ask me why they didn't immediately shock), got fancy and u/s'd definite standstill, not even a quiver. Anyway, checked on his charts a month later, the alcoholic druggy guy had full neuro recovery s/p hypothermia protocol and of course refused treatment and walked out AMA as soon as that recovery happens. can't keep one of those types down, of course.

Not clear on what you're saying, amigo. Guy was asystole and cold dead, but got hypothermia and ... fully recovered ?

Its cool, its late. I make mistakes too.

 

[Rendar5]

Not clear on what you're saying, amigo. Guy was asystole and cold dead, but got hypothermia and ... fully recovered ?

Its cool, its late. I make mistakes too.

just explaining my case above since someone was saying it could've been v-fib that looked like asystole. The guy was full asystole, then got a pulse back 30 seconds after we stopped our efforts.

 

[jbar]

I think there might be some utility to field EMS in a few situations. Imagine if you could use FAST to triage patients to ground transport vs. HEMS. Other possible targets would be evaluation of PTX or pericardial effusion.

The biggest problem with using it in these situations would be getting providers who are trained, experienced and get enough opportunities to stay current. I think it could work in a Super Medic type system that uses a single, highly trained medic responding to assist lower level first responder units.

My biggest issue with prehospital US is that the ultrasound companies are really pushing it, because they are going to make a ton of money. So they want it, the medics want a new toy, so it's hard to step in and say "show me when this will be useful." I'm a bit skeptical.

FAST: How does it change your transport destination? If there was a big enough mechanism they called a chopper, they should be going to the trauma center. I don't see bypassing the ER and going directly to surgery based on a prehospital fast, so what does it change?

IV lines: maybe. But hard enough to do in the ER, let alone in a rig. If they are that sick they need a line right now, go IO.

Cardiac: Don't see a big need.

Pregnant: IUP or no, getting transported.

Chest: How many lung ultrasounds do you have to do to find one pneumothorax, and then how many of those need decompression?

etc etc


And I say this as someone who like ultrasound and uses it a lot in the ER. I think it might have a place with flights. But if we are trying to hold down healthcare costs putting an ultrasound on every ambulance is moving in the wrong direction.

Unless you have sonosite stock.

 

[docB]

My biggest issue with prehospital US is that the ultrasound companies are really pushing it, because they are going to make a ton of money. So they want it, the medics want a new toy, so it's hard to step in and say "show me when this will be useful." I'm a bit skeptical.

FAST: How does it change your transport destination? If there was a big enough mechanism they called a chopper, they should be going to the trauma center. I don't see bypassing the ER and going directly to surgery based on a prehospital fast, so what does it change?

IV lines: maybe. But hard enough to do in the ER, let alone in a rig. If they are that sick they need a line right now, go IO.

Cardiac: Don't see a big need.

Pregnant: IUP or no, getting transported.

Chest: How many lung ultrasounds do you have to do to find one pneumothorax, and then how many of those need decompression?

etc etc


And I say this as someone who like ultrasound and uses it a lot in the ER. I think it might have a place with flights. But if we are trying to hold down healthcare costs putting an ultrasound on every ambulance is moving in the wrong direction.

Unless you have sonosite stock.

Like I said I think this is way out in the future.

We overuse HEMS and it's dangerous and not cost effective. EMS FAST and if FF then HEMS. If no FF and stable vitals then ground transport. One HEMS trip avoided pays for the US.

I didn't mention lines for field EMS. I think there might be a role for aero med.

Have you ever gotten a patient who was needled because there might have been a PTX? Well there's one now and now he needs a chest tube.

I think there might be some use. It needs study.