CPR and Dopplerable Pulse

[thegenius]

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Just happened to me yesterday, 80 yo guy with unwitnessed cardiac arrest, EMS had asystole and were going to call it after 20 minutes of CPR but then had afib in the 70s with a pulse. I get him and he brady's down and we go in and out of CPR and Afib for another 30+ minutes.

For a few of those pulse checks, I'm like "that is a good EKG tracing. That should produce a pulse."
I US his heart, it is hypodynamic but should produce some cardiac output
Then US his femoral artery and there is a brisk waveform "Woosh Woosh Woosh" and I'm thinking the guy has a pulse.

Here's the problem. Are there any studies that show that a dopplerable pulse after or during CPR means you can stop CPR and assume you "have a pulse?"

I ended up putting in a central line and a-line, and initial BP was 80/40, pH 6.6, and he lingers there as I'm giving him more pressors and calcium and like 10 amps of bicarb over an hour and he eventually goes to the ICU.


You guys ever do this?

Before US, we would call this PEA. Now I don't know if this is PEA or a "thready pulse" or what

 

[thegenius]

Jeez I can't even spell "Dopplerable" -> Doop LOL

 

[Groove]

Nice job. This is one of those few times where I’ve argued the utility of a-lines in the ED. Sometimes I’ll have pts so clamped down that it’s difficult to get a BP and sometimes to even feel a pulse. Unfortunately, I can’t place them in the ED where I’m at as the monitors are incompatible or some such craziness. I fought a battle against it several years ago, got the supplies and the nurses could do it for about 2 months before the knowledge was lost forever and we went back to the dark ages.

 

[BoardingDoc]

Just happened to me yesterday, 80 yo guy with unwitnessed cardiac arrest, EMS had asystole and were going to call it after 20 minutes of CPR but then had afib in the 70s with a pulse. I get him and he brady's down and we go in and out of CPR and Afib for another 30+ minutes.

For a few of those pulse checks, I'm like "that is a good EKG tracing. That should produce a pulse."
I US his heart, it is hypodynamic but should produce some cardiac output
Then US his femoral artery and there is a brisk waveform "Woosh Woosh Woosh" and I'm thinking the guy has a pulse.

Here's the problem. Are there any studies that show that a dopplerable pulse after or during CPR means you can stop CPR and assume you "have a pulse?"

I ended up putting in a central line and a-line, and initial BP was 80/40, pH 6.6, and he lingers there as I'm giving him more pressors and calcium and like 10 amps of bicarb over an hour and he eventually goes to the ICU.


You guys ever do this?

Before US, we would call this PEA. Now I don't know if this is PEA or a "thready pulse" or what

Why were you giving bicarb? Has the pendulum started swinging back towards giving the stuff? Every study I've seen in the past several years all shows that it makes you feel better because it treats the pH but has no mortality benefit.

 

[bravotwozero]

I think the real question is, will it matter? He was in/out of cardiac arrest for at least 20+ minutes? Would be surprised if he's not brain dead already...

 

[TooMuchResearch]

If you think there is BP, don't do compressions. I'm not great at feeling thready pulses and have used US to stop compressions. In residency we occasionally dropped art lines when we weren't sure, I don't think all the places I work have art line kits in the hospital, maybe I could place one in the big hospital but haven't tried.

 

[thegenius]

Why were you giving bicarb? Has the pendulum started swinging back towards giving the stuff? Every study I've seen in the past several years all shows that it makes you feel better because it treats the pH but has no mortality benefit.

In CPR yes that is what I recall too. However he had been alive for about 45 mins and on max levo/vaso and I was hanging an epinephrine drip.

I gave maybe 2 amps of bicarb during CPR...I think one could argue that was wasteful. There was a recent podcast on Weingart's website where it was suggested that even epinephrine is not helpful and likely bad because if you do survive, you end up having poorer brain function.

However once he had a pulse, I gave maybe another 4 amps, and after talking to the intensivist, he wanted me to give another 4. His reasoning was that pressors don't work well in highly acidic environments.

So imagine you had a patient who never had CPR, but was critically ill with a pH 6.8. Would you give bicarb? I would. I would probably intubate that patient and give 3 amps NaHCO3. Intubating so I can control the resultant respiratory acidosis. For instance, I had a critically ill DKA with a pH 6.8 the other day, she had surprisingly pretty good mental status. I did give her bicarb.

 

[thegenius]

I think the real question is, will it matter? He was in/out of cardiac arrest for at least 20+ minutes? Would be surprised if he's not brain dead already...

EEG the next day showed brain silence, and they made him comfort care.

I really want to know if using US in these cases makes a difference, because I don't want to prolong someone inevitable death just because I can dooperable a pulse.

Interesting you know how you can keep your finger on the pulse during CPR so you know where it is, and then when it's suspended can determine if they had a pulse? I think during those times I would have classified it as either "no pulse" or "extremely thready." Sometimes it's hard to tell

 

[GatorCHOMPions]

EEG the next day showed brain silence, and they made him comfort care.

I really want to know if using US in these cases makes a difference, because I don't want to prolong someone inevitable death just because I can dooperable a pulse.

Interesting you know how you can keep your finger on the pulse during CPR so you know where it is, and then when it's suspended can determine if they had a pulse? I think during those times I would have classified it as either "no pulse" or "extremely thready." Sometimes it's hard to tell

There have been small studies showing the sensitivity/specificity of digital pulse checks in CPR being pretty bad and this intuitively makes sense. It’s a high stress environment and patient-related factors like age and other comorbidities affecting vasculature are some of the main contributors to this. Last I checked the data there was nothing about the reliability doppler pulse checks. However I can’t count the number of times a pulse is not palpable (or even doppler-able) but art-line has a MAP well over 60 and/or the patient has what appears to be bounding cardiac activity on US.

In these situations as described above, if US shows some form of organized activity I place an art-line to get a reliable pressure. Prior to placement I have the nurses hang norepi or epi as an infusion in case they do have a MAP around 40+ and I just can’t feel it.

Not sure if any of the above makes a patient-centered difference, though.

 

[Hamhock]

Nice job. This is one of those few times where I’ve argued the utility of a-lines in the ED. Sometimes I’ll have pts so clamped down that it’s difficult to get a BP and sometimes to even feel a pulse. Unfortunately, I can’t place them in the ED where I’m at as the monitors are incompatible or some such craziness. I fought a battle against it several years ago, got the supplies and the nurses could do it for about 2 months before the knowledge was lost forever and we went back to the dark ages.

It's not hard to do yourself. It takes about two minutes.

CVP and A-Line Set-Up

Alternatively, you can encourage the charge nurses to be all trained...much easier than getting 100 shift working ED nurses to learn and remember something they "might" do once a year.

HH

 

[Arcan57]

As a question, has anyone seen someone come back intact from cardiac arrest when there has been a broken link in the chain of survival? I’ve had some super prolonged downtimes make it back, but none of them had any significant delay in CPR or (if applicable) cardioversion. I’m rolling up on 15 years and have never seen prolonged downtime in the field or briefly regained ROSC then comes into the ED in unrecognized arrest (“he had a pulse when we pulled in!”) make it out of the hospital under their own power.

 

[alpinism]

Here's my problem with these pseudo PEA patients though do you really think they're adequately perfusing their brain?

I personally think we're asking the wrong question. Its not whether they have a pulse but whether they have adequate perfusion.

IMO we should treat adults like children and perform compressions to assist with perfusion regardless of pulse status.

 

[alpinism]

Nice job. This is one of those few times where I’ve argued the utility of a-lines in the ED. Sometimes I’ll have pts so clamped down that it’s difficult to get a BP and sometimes to even feel a pulse. Unfortunately, I can’t place them in the ED where I’m at as the monitors are incompatible or some such craziness. I fought a battle against it several years ago, got the supplies and the nurses could do it for about 2 months before the knowledge was lost forever and we went back to the dark ages.

I've also started using a-lines during prolonged arrests as they're much more reliable than pulse checks and you don't need to stop compressions.

 

[alpinism]

As a question, has anyone seen someone come back intact from cardiac arrest when there has been a broken link in the chain of survival? I’ve had some super prolonged downtimes make it back, but none of them had any significant delay in CPR or (if applicable) cardioversion. I’m rolling up on 15 years and have never seen prolonged downtime in the field or briefly regained ROSC then comes into the ED in unrecognized arrest (“he had a pulse when we pulled in!”) make it out of the hospital under their own power.

Never with the exception of severe hypothermia patients.

 

[Birdstrike]

It's reasonable to run codes a little longer than you might think necessary. Nobody wants to be the doc is this article:

'Dead' woman found alive in South Africa morgue fridge

 

[anbuitachi]

ACLS algorithm is designed to standardize care since it improves outcome overall and also because our brain tends to become dumb in periods of high stress situations, it doesn't mean every case needs to follow the ACLS algorithm. I think the whole pulse check is a bit outdated, but still useful in situations where thats all you have, but ive seen several instances of people following these algorithms to the dot without really thinking. Several times i was called to a code for airway, and they stop to do pulse check and i point at the A line that says 220/120 with an obvious pulse wave, and i'm like theres no need to feel for a pulse.

I think just do what you think is correct in these cases, because there's a lack of data. Also i think EKG waveform is not reliable (unless its obvious like V fib), ive seen perfect sinus rhythms and the patient is dead as a rock with no perfusion.

Also i agree with using bicarb to temporize the situation. I use it in the OR all the time because yes pressors do not work well at all when the pH is very low. I see quick affects after correcting the pH. In terms of the studies i take them with a grain of salt, and i think every case needs to be individualized.

One situation i got into last year was when to declare the patient DEAD when theres an arterial line in place, cause you see the pulse waves. How low do you wait for it to go? because if you were only feeling for a pulse, it disappears after about a systolic of 60s or so. I think we declared it when the A line showed like 45/30 despite having pulsatile waveforms.

 

[thegenius]

Here's my problem with these pseudo PEA patients though do you really think they're adequately perfusing their brain?

I personally think we're asking the wrong question. Its not whether they have a pulse but whether they have adequate perfusion.

And how would you measure that during CPR or just after? adequate perfusion? I agree that's a fine endpoint. if you have adequate perfusion, no CPR. If you have inadequate perfusion, then start CPR or add pressors.

I've also started using a-lines during prolonged arrests as they're much more reliable than pulse checks and you don't need to stop compressions.

Curious, if you had a a-line when would you start compressions? What MAP or SBP?
Say you get someone back from CPR and you pop in an a-line. Or you use normal sphingomanometry. Whatever. First pressure is 100/60. With that no CPR. Do you start compressions when it's 80/40? Or maybe you do push-dose pressures as the MAP falls slowly from 75 to 60 or what have ya. I don't know the answer to this.

 

[thegenius]

One situation i got into last year was when to declare the patient DEAD when theres an arterial line in place, cause you see the pulse waves. How low do you wait for it to go? because if you were only feeling for a pulse, it disappears after about a systolic of 60s or so. I think we declared it when the A line showed like 45/30 despite having pulsatile waveforms.

Good post.

Declaring DEAD I probably wouldn't do, but I would implore the family to make the patient comfort care, so the pulse of 50/35 would slowly go down and they would pass soon after.

 

[deleted547339]

There’s essentially no reason to give bicarb, ever. People are treating themselves, not the patients. It has no quality evidence to support its use in any anion gap metabolic acidosis and may be/likely is harmful. I don’t give it.

 

[Groove]

It's not hard to do yourself. It takes about two minutes.

CVP and A-Line Set-Up

Alternatively, you can encourage the charge nurses to be all trained...much easier than getting 100 shift working ED nurses to learn and remember something they "might" do once a year.

HH

The pressure line cables aren’t compatible with the ports on our monitors in the ED. So, we changed the monitors in 2 of our major medical bays but the problem is with nursing education. Turnover is too high for anyone to remember and we weren’t doing them frequently enough.

 

[Groove]

There’s essentially no reason to give bicarb, ever. People are treating themselves, not the patients. It has no quality evidence to support its use in any anion gap metabolic acidosis and may be/likely is harmful. I don’t give it.

Hyperkalemia in an acidotic pt? Or do you mean as a generalization for codes?

 

[RustedFox]

There’s essentially no reason to give bicarb, ever. People are treating themselves, not the patients. It has no quality evidence to support its use in any anion gap metabolic acidosis and may be/likely is harmful. I don’t give it.

Please.

(1.) Call my hospital.
(2.) Ask to talk with my intensivist. No, not the old white guy - the young turk straight out of fellowship who talks like he's Bangalore's Bruce Willis.
(3.) Tell him that he's wrong. I've been telling him that for awhile, but all it gets me is ridicule and derision. Even when I send him literature, the response that I get is "that's not how we did it at *big fellowship program*. Tell him to untuck his shirt from his briefs, too.
(4.) Ask him who he took to his prom. Watch as he cries and tells a lie, but knows deep down that he either didn't go, paid a girl from another school district to go with him, or took his cousin.
(5.) Tell us how this goes.

 

[Brigade4Radiant]

I do give bicarb in codes but the problem is if you give calcium chloride right after it can precipitate. Also I would say bicarb can be given in aspirin toxicity, acidodic hyperkalemia but other than that probably little use.

Nephrology loves it though as well as kayexalate but I don't put in kayexalate even though they ask me to.

 

[RoyBasch]

Here's my problem with these pseudo PEA patients though do you really think they're adequately perfusing their brain?

I personally think we're asking the wrong question. Its not whether they have a pulse but whether they have adequate perfusion.

IMO we should treat adults like children and perform compressions to assist with perfusion regardless of pulse status.

This is the key question.

Just to elaborate a little bit more, I guess if you suspect pseudo-PEA, then that implies the answer is more pressors and that you can maybe start/uptitrate aggressively, or you could start/uptitrate while trying to bridge off of CPR.

That being said, if it really is pseudo-PEA (patient not truly asystolic but rather profoundly hypotensive) and you treat it just like PEA, that means you will be giving a full dose of epi pretty soon (q3-5mins) following ACLS. I would think 1000mcg of epi IV would boost a very hypotensive blood pressure pretty fast assuming thats really the actual problem. So making the distinction between PEA vs. pseudo-PEA is perhaps not super clinically important.

"Pseduo-PEA" that is not responding to multiple rounds of IV epi still not generating a palpable pulse might be pretty much equivalent to just PEA.

 

[deleted547339]

Hyperkalemia in an acidotic pt? Or do you mean as a generalization for codes?

I mean as a generalization for everything. Bicarbonate can be used to treat certain medical conditions, but anion gap acidosis is not one of those medical conditions.

 

[TooMuchResearch]

I do give bicarb in codes but the problem is if you give calcium chloride right after it can precipitate. Also I would say bicarb can be given in aspirin toxicity, acidodic hyperkalemia but other than that probably little use.

Nephrology loves it though as well as kayexalate but I don't put in kayexalate even though they ask me to.

Well there's your problem. Consulting nephrology during a code. (internet sarcasm)

 

[Groove]

I think we all try to be as evidence based as possible but tell me there's not a little bit of "voodoo" in much of what we do during codes. Many times after those long "threw the kitchen sink" codes, I feel a little bit like this guy...

 

[Radetzky]

There is not much evidence to give bicarbonate however equally there is not much evidence to not give it. I think the harms are being overstated, and the recent BICAR-ICU trial showed no particular harms with aggressive bicarb therapy.

A lot of what is done for critically ill patients has no evidence based mortality benefit behind it and I think that is a combination of underpowered studies, and heterogenous patients. At what pH is bicarb being given? What are your end points for stopping bicarb therapy? The answers will be wildly different among clinicians and clinical situations and this makes it a fraught thing to study and come to definitive conclusions.

 

[TooMuchResearch]

Or this guy?

 

[RustedFox]

In 18 years, we will revisit this topic and say to each other; "do you remember when we bickered over bicarbonate?! Like it mattered, at all."

 

[GeneralVeers]

The nurses will think you are a good doctor if you give it......so give it.

 

[anbuitachi]

Some people rely on evidence WAY too much. its fine to use the evidence in that particular scenario but to use it and extrapolate it to ALL scenarios is ridiculous. No evidence of benefit doesnt mean no benefit, it only means theres no evidence as of today. Before there is any evidence, there is always no evidence. And i would say our level of evidence in many areas of medicine today is still pretty awful.

 

[TheComebacKid]

Correct me if I'm wrong, but I do believe there are guidelines that support the use of bicarb drips for patients the are severaly acidotic i.e. <7.0. Whether this is associated with mortality benefit or not is unclear, since there really haven't been many studies to support its use in these patients, but regardless, it's still recommended by certain groups such as the ADA for management of DKA. Should we do it "just because?" No. But people who suggest it's use aren't completely crazy and there are many experts who believe, although likely anecdotally and theoretically, that it's beneficial.

With respect to PEA arrest, you are often throwing the kitchen sink at these patients, and assuming they could have some electrolyte derangement such as hyperkalemia, in which case, what's the downside to throwing some bicarb and calcium at that them?

 

[thegenius]

Please.

(1.) Call my hospital.
(2.) Ask to talk with my intensivist. No, not the old white guy - the young turk straight out of fellowship who talks like he's Bangalore's Bruce Willis.
(3.) Tell him that he's wrong. I've been telling him that for awhile, but all it gets me is ridicule and derision. Even when I send him literature, the response that I get is "that's not how we did it at *big fellowship program*. Tell him to untuck his shirt from his briefs, too.
(4.) Ask him who he took to his prom. Watch as he cries and tells a lie, but knows deep down that he either didn't go, paid a girl from another school district to go with him, or took his cousin.
(5.) Tell us how this goes.

I think your intensivist works at my hospital too, and works the morning AND evening shifts because I see him all the time. And I get his answer too. I stopped arguing with him. I'm just a dumb ER doc.

 

[thegenius]

Correct me if I'm wrong, but I do believe there are guidelines that support the use of bicarb drips for patients the are severaly acidotic i.e. <7.0. Whether this is associated with mortality benefit or not is unclear, since there really haven't been many studies to support its use in these patients, but regardless, it's still recommended by certain groups such as the ADA for management of DKA. Should we do it "just because?" No. But people who suggest it's use aren't completely crazy and there are many experts who believe, although likely anecdotally and theoretically, that it's beneficial.

With respect to PEA arrest, you are often throwing the kitchen sink at these patients, and assuming they could have some electrolyte derangement such as hyperkalemia, in which case, what's the downside to throwing some bicarb and calcium at that them?

The main thing I think about is how to deal with the CO2 that results from giving HCO3-. So if someone is obtunded and doesn't have a good minute ventilation, then I may think twice about giving it. For instance the severe DKA's and the aspirin overdoses (I've never had a severe ASA overdose though). But for your routine sepsis I don't give it.

But I f*&#$ing hate it when I have a septic patient on two pressors and the f&#$&ing intensivist says give bicarb! Then I don't and it's a fight. F@#^#ing hate it.


Just recall that we do a lot of things in medicine that probably don't help
We should make a thread and list all of them

 

[thegenius]

This is from UpToDate:

Acute metabolic acidosis — We initiate bicarbonate therapy when acute metabolic acidosis has generated severe acidemia (ie, pH less than 7.1). We also generally suggest bicarbonate therapy for patients with less severe acidemia (eg, pH 7.1 to 7.2) who have severe acute kidney injury (ie, a twofold or greater increase in serum creatinine or oliguria); bicarbonate therapy in such patients can potentially prevent the need for dialysis and may improve survival [30].

The clinical impact and treatment of severe acute metabolic acidosis remain controversial. Experts disagree about the indications for the use of sodium bicarbonate or other buffering agents. Some studies indicate that myocardial depression, decreased catecholamine efficacy, and arrhythmias develop when the pH falls below 7.1. However, these data come mainly from animal or tissue experiments. Human studies of the cardiovascular effects of severe acidemia have generally not supported the results reported from animal and tissue experiments. As an example, transient decreases in pH to 6.8 in individuals with diabetic ketoacidosis are not associated with depressed cardiac function [31]. In addition, raising the pH may have adverse consequences including intracellular acidification, increased lactate production, and myocardial depression. It is, however, important to recognize that, at a pH below 7.1, small changes in pCO2 or HCO3 can have very large pH effects. Thus, most clinicians initiate treatment of metabolic acidosis when the bicarbonate is very low and the pH is below 7.1.

We do not generally use bicarbonate therapy in patients with less severe acidosis (pH 7.1 or greater), unless the patient also has severe acute kidney injury.

 

[SpacemanSpifff]

Here's my problem with these pseudo PEA patients though do you really think they're adequately perfusing their brain?

I personally think we're asking the wrong question. Its not whether they have a pulse but whether they have adequate perfusion.

IMO we should treat adults like children and perform compressions to assist with perfusion regardless of pulse status.

This would be ideal, but other than equating peripheral perfusion to cerebral perfusion, how would you monitor that end point? Some of the theoretical arguments behind the recent reexamination of epi in OHCA and PARAMEDIC2 are based on the notion the epinephrine may improve cardiac and peripheral perfusion, but impairs cerebral perfusion.

 

[anbuitachi]

The main thing I think about is how to deal with the CO2 that results from giving HCO3-. So if someone is obtunded and doesn't have a good minute ventilation, then I may think twice about giving it. For instance the severe DKA's and the aspirin overdoses (I've never had a severe ASA overdose though). But for your routine sepsis I don't give it.

But I f*&#$ing hate it when I have a septic patient on two pressors and the f&#$&ing intensivist says give bicarb! Then I don't and it's a fight. F@#^#ing hate it.


Just recall that we do a lot of things in medicine that probably don't help
We should make a thread and list all of them

I would not give bicarb in someone not tubed unless obviously breathing very well then a infusion is ok

 

[DrDrummer]

You can also always use vasopressin if you're worried that the epinephrine isn't going to work very well in a profoundly acidemic patient.

 

[deleted109597]

Remember, bicarb has 2000 mOsm/L. It's horrifically sclerosing and can also cause serious extravasation injury.
It's associated (retrospectively) with cerebral edema and increased lengths of stay for DKA in kids.

And for those that say no evidence doesn't mean it doesn't work, that's not true. It's been studied. There is plenty of evidence it doesn't work for this.

If you change your object from "bicarb" to "vaccine", see how you sound about evidence.
Use of Sodium Bicarbonate in Cardiac Arrest: Current Guidelines and Literature Review
Buffer therapy during out-of-hospital cardiopulmonary resuscitation. - PubMed - NCBI

2015 AHA guidelines state “sodium bicarbonate should not be used routinely in cardiac arrest”, unless you suspect arrest from TCA overdose or hyperkalemia

 

[anbuitachi]

Remember, bicarb has 2000 mOsm/L. It's horrifically sclerosing and can also cause serious extravasation injury.
It's associated (retrospectively) with cerebral edema and increased lengths of stay for DKA in kids.

And for those that say no evidence doesn't mean it doesn't work, that's not true. It's been studied. There is plenty of evidence it doesn't work for this.

If you change your object from "bicarb" to "vaccine", see how you sound about evidence.
Use of Sodium Bicarbonate in Cardiac Arrest: Current Guidelines and Literature Review
Buffer therapy during out-of-hospital cardiopulmonary resuscitation. - PubMed - NCBI

would not use bicarb in cardiac arrest except in very limited circumstances... i think above people were talking about acidotic patients who haven't arrested yet.

 

[scoKraz4]

Only thing I can think that bicarb would truly help is if the arrest is caused by suspected TCA or sodium channel blocker overdose..but we often don't have that info when they are rolled in.

 

[thegenius]

would not use bicarb in cardiac arrest except in very limited circumstances... i think above people were talking about acidotic patients who haven't arrested yet.

Yes...one thing is if the patient is alive and close to dying, and using bicarb. I'm confident it's indicated small, well-define cohort of people. The other situation is using it in dead people you are reviving. The evidence suggests it doesn't work, but no med actually works during CPR.

If it is true that pressors are not as effective in an extremely acidotic milieu, then I don't really have any compunction about giving bicarb for someone who is very acidotic (e.g. < 7.0) already on multiple pressors.

 

[TooMuchResearch]

Only thing I can think that bicarb would truly help is if the arrest is caused by suspected TCA or sodium channel blocker overdose..but we often don't have that info when they are rolled in.

I'm not sure that's enough to bring them back once dead.
Anyone with any good outcomes reviving a pulseless sodium channel blockade patient?

 

[scoKraz4]

I'm not sure that's enough to bring them back once dead.
Anyone with any good outcomes reviving a pulseless sodium channel blockade patient?

I've done it but they went pulseless in the ED and it was suspected already.

 

[TooMuchResearch]

I've done it but they went pulseless in the ED and it was suspected already.

I stand corrected. Sounds like a good (sad) case.

 

[PianoMedic]

As a question, has anyone seen someone come back intact from cardiac arrest when there has been a broken link in the chain of survival? I’ve had some super prolonged downtimes make it back, but none of them had any significant delay in CPR or (if applicable) cardioversion. I’m rolling up on 15 years and have never seen prolonged downtime in the field or briefly regained ROSC then comes into the ED in unrecognized arrest (“he had a pulse when we pulled in!”) make it out of the hospital under their own power.

Anecdotes being inherently biased caveat up front, but yes I've seen one. Unknown downtime, found at home by family. They lived a "short" distance from the hospital. Family member that found patient immediately threw patient over his shoulder and ran to the hospital. We got called overhead for the "patient under the canopy" code. Got the patient on a bed and one of the smaller residents started compressions and rode on the bed doing compressions to the resus bay. Initial rhythm was v fib, two shocks with ROSC but no Neuro responses besides reactive pupils. Tubed, started TTM with Arctic sun. Ecg showed massive anterior stemi, went straight to cath lab. Stented the 100% LAD lesion, then to ICU. Day 10, no Neuro recovery. Day 11, family starts talking about withdrawal of care. Day 12, patient starts moving extremities spontaneously. Day 13, passes SBT, gets extubated. Day 14, asking how the local baseball team is doing. Day 15, walks out of hospital totally Neuro intact.

This case was the exception, but it does show that some people take awhile for neuro recovery. I would expect the vast majority of these to do poorly, as the first "link" never happened. Patient did get expedited transport to the ED, but who knows how long that transport actually took.

 

[RustedFox]

Anecdotes being inherently biased caveat up front, but yes I've seen one. Unknown downtime, found at home by family. They lived a "short" distance from the hospital. Family member that found patient immediately threw patient over his shoulder and ran to the hospital. We got called overhead for the "patient under the canopy" code. Got the patient on a bed and one of the smaller residents started compressions and rode on the bed doing compressions to the resus bay. Initial rhythm was v fib, two shocks with ROSC but no Neuro responses besides reactive pupils. Tubed, started TTM with Arctic sun. Ecg showed massive anterior stemi, went straight to cath lab. Stented the 100% LAD lesion, then to ICU. Day 10, no Neuro recovery. Day 11, family starts talking about withdrawal of care. Day 12, patient starts moving extremities spontaneously. Day 13, passes SBT, gets extubated. Day 14, asking how the local baseball team is doing. Day 15, walks out of hospital totally Neuro intact.

This case was the exception, but it does show that some people take awhile for neuro recovery. I would expect the vast majority of these to do poorly, as the first "link" never happened. Patient did get expedited transport to the ED, but who knows how long that transport actually took.

I've seen one of these, too.
Coded the guy for 40+ minutes. In and out of ROSC.
Cath lab.
No neuro responses for about a week.

I went to the pub a few weeks later, and a giant man slapped me on my shoulder.
"Are you Dr. RustedFox?"
"Maybe?"
"You saved my dad's life; he's over there at that booth. Thank you; he'd love to say hello."
Walking, talking, drinking a Guinness.

 

[Fox800]

No one is going to LOL with me at the title of this thread? Dooperable

 

[thegenius]

No one is going to LOL with me at the title of this thread? Dooperable

I am the OP and I already commented on post #2 that I can't spell

LOL