Definitive airway in cardiac arrest

This forum made possible through the generous support of SDN members, donors, and sponsors. Thank you.
engineeredout said:
Soooo you want to completely wreck your neuro exam in the post-arrest patient by giving a longer acting paralytic so you don't have to titrate sedation? Then you really have to idea if you should be doing therapeutic hypothermia or not.

As for post arrest cath, that requires the stars to be aligned, the interventionalist has just gotten laid, and the quarter to land on heads.

In the glorious state of Pennsylvania, they publicly report post-cath mortality for the cardiologists, but fail to make a distinction between the outpatient cath for an abnormal stress test and the post-code 80yo who arrested 8 times. Since most of these OHCA patients will do poorly through no fault of the cardiologist, they essentially do nothing now for fear of having their metrics jacked up. Even for those who need it.

Metrics!!
Click to expand...

I think you misunderstand me. I get a neuro exam and attempt sedation. If I can reasonably get them down with sedation and not tank their pressure, then we're done and off to icu. I make a decision for a paralytic fairly quickly post rosc though and if paralysis is needed I prefer roc. I'm not saying I avoid sedation and am not using a paralytic as a pressor from attempted under sedation.


Sent from my iPhone using Tapatalk
Members don't see this ad.
 
Well it depends on the case but ETT has the advantage of being able to suction and put them on a ventilator. This frees up a pair of hands in case you get another code .

Do those 10 - 20 seconds really matter ? IDK that is a question for the ages.
 
Spectre of Ockham said:
Well it depends on the case but ETT has the advantage of being able to suction and put them on a ventilator. This frees up a pair of hands in case you get another code .

Do those 10 - 20 seconds really matter ? IDK that is a question for the ages.
Click to expand...

Can vent through an LMA or King
 
  • Like
Reactions: 1 user
Members don't see this ad :)
migm said:
Can vent through an LMA or King
Click to expand...

Ohmygodyesss.... I remember now. Anesthesia did LMA cases on the vent back when I did my anes month way back in residency.

Did they? I'm thinking they did. My shift ended at 6am... I might just be hallucinating that. Zzzz.
 
if you're being sarcastic, there's no need. I was responding to the individual stating they were worried about not having an extra set of hands.

https://www.ncbi.nlm.nih.gov/pubmed/28118660

Seems to point towards early ETT (in adults) and a recent similar paper in kids is not the best way to go in arrest.
 
How many of you guys actually place the patient on a vent during the arrest? We always bag until we get rosc
 
yeah i don't. don't see why you can't though, except the vent might be extra alarmy in the setting of someone pushing on the chest
 
migm said:
if you're being sarcastic, there's no need. I was responding to the individual stating they were worried about not having an extra set of hands.

https://www.ncbi.nlm.nih.gov/pubmed/28118660

Seems to point towards early ETT (in adults) and a recent similar paper in kids is not the best way to go in arrest.
Click to expand...

No sarcasm intended. It honestly never occurred to me before why we dont regularly vent thru an LMA while *other**** gets done* if there's few hands on deck.

My shift finished at 6am. I left the hospital at 8am after mad critical care time and the single worst COPD'er this year. I was trying to account for the fact that I might have it all wrong, and it was a dream, or something.
 
RustedFox said:
No sarcasm intended. It honestly never occurred to me before why we dont regularly vent thru an LMA while *other**** gets done* if there's few hands on deck.

My shift finished at 6am. I left the hospital at 8am after mad critical care time and the single worst COPD'er this year. I was trying to account for the fact that I might have it all wrong, and it was a dream, or something.
Click to expand...
no worries. hope you got some rest :)
 
Apollyon said:
Well, in the OR, with an already-tubed patient, if they code, the gas guys disconnect the vent and bag by hand.
Click to expand...

I would suspect that's more of a feature of eliminating the vent from the list of possible reasons why your previously perfectly normal NPO >8 hr patient has suddenly developed a case of the deathies
 
Members don't see this ad :)
migm said:
I would suspect that's more of a feature of eliminating the vent from the list of possible reasons why your previously perfectly normal NPO >8 hr patient has suddenly developed a case of the deathies
Click to expand...

That, plus the tactile feedback of feeling the bag's resistance gives you useful information.
 
migm said:
yeah i don't. don't see why you can't though, except the vent might be extra alarmy in the setting of someone pushing on the chest
Click to expand...
You can code someone on the vent, but you'd have to change your settings during the code and afterwards if you get ROSC. Otherwise, it's my understanding that the elevated pressures from compressions would cause the vent to deliver no breaths. I've never seen anyone try it, though.
 
BAM! said:
Didn't the AHA change it from A-B-C to C-A-B?

Just glidescope a tube in while doing compressions. Or throw one in during a rhythm/pulse check (though you may have to rely on your best nurse to look at the rhythm ~ or take a quick look at the strip after the tube is in).

If they're already dead, throw a tube in, do 1 more round and then call it. Even though we know it's not right, don't open yourself up to litigation due to upset family members feeling you didn't do "everything" or didn't do a basic airway.
Click to expand...
Is not tubing your patient who dies during resus a potential issue that can be litigated?
 
Druggernaut said:
You can code someone on the vent, but you'd have to change your settings during the code and afterwards if you get ROSC. Otherwise, it's my understanding that the elevated pressures from compressions would cause the vent to deliver no breaths. I've never seen anyone try it, though.
Click to expand...

I told RT to take a patient off the vent and bag during a code (which to me is standard care) and they looked at me like I had 13 heads.

As an aside, I get sideways glances and underhanded comments from RT when I do apneic oxygenation during a tube.

It's 2017 people, let's get with it.
 
  • Like
Reactions: 1 user
GonnaBeADoc2222 said:
I told RT to take a patient off the vent and bag during a code (which to me is standard care) and they looked at me like I had 13 heads.

As an aside, I get sideways glances and underhanded comments from RT when I do apneic oxygenation during a tube.

It's 2017 people, let's get with it.
Click to expand...

+1.

I ran the whole "delayed sequence intubation" program during my last tube. RN staff had to complain to my director about what "Dr. Rustedfox is doing".

The same fat, (barely) literate RN goonsquad complained about my use of atropine during PEA (psst.... it was pseudo-PEA, bedside cardiac ultrasound FTW) because it wasn't "in the ACLS protocol anymore".

Swear to Christ, they learned one thing, once, and they're sure of it.

Once.

Now and forever. And Ever.

Amen.

Pffft.
 
  • Like
Reactions: 4 users
RustedFox said:
(psst.... it was pseudo-PEA, bedside cardiac ultrasound FTW)
Click to expand...
An aside. Did they have a pulse? If not, it's PEA. That's the definition. It doesn't mean contractionless electrical activity. At least, not today. Maybe another version will come out and changes the order to UCAB, but until then, it's still PEA.
Also, they should know ACLS are guidelines, not protocols. Otherwise, we wouldn't have to be there. The goonsquad could run it. I'm sure they talk about how good they would do on facebook already.
 
Dr.McNinja said:
An aside. Did they have a pulse? If not, it's PEA. That's the definition. It doesn't mean contractionless electrical activity. At least, not today. Maybe another version will come out and changes the order to UCAB, but until then, it's still PEA.
Also, they should know ACLS are guidelines, not protocols. Otherwise, we wouldn't have to be there. The goonsquad could run it. I'm sure they talk about how good they would do on facebook already.
Click to expand...

I used to think that "no pulses = PEA" as well. What if the pulse is there, but we just can't find it?

http://lifeinthefastlane.com/ccc/pulseless-electrical-activity-pea/

https://www.ncbi.nlm.nih.gov/pubmed/25891961

http://edecmo.org/pseudo-pea-emd-and-such/
 
I'm curious as to what degree of contractility you require for it to not be PEA then? Are just eyeballing the kinesis? Measuring EFs?
I mean, I get it, but at the same time, PEA means no carotid or femoral pulses. If they're so fat you can't find these, well they're likely to die anyway. And probably too fat for my ultrasound to find their heart.

At the same time, is there an atropine indication for low blood pressure? I mean, if I can't feel their pulses, and they've got a slow rate, they're getting epi. And then more epi.
 
  • Like
Reactions: 1 users
RustedFox said:
I used to think that "no pulses = PEA" as well. What if the pulse is there, but we just can't find it?

http://lifeinthefastlane.com/ccc/pulseless-electrical-activity-pea/

https://www.ncbi.nlm.nih.gov/pubmed/25891961

http://edecmo.org/pseudo-pea-emd-and-such/
Click to expand...


Since we are already off topic... hypokalemic arrest. How fast and how much potassium are you giving? Had this one time where I got an istat showing k of 2.0 and me and pharmacist just kind of looked at each other
 
Probably speaking to my inexperience but I have not seen a hypokalemic arrest in my 4 years as an MD, or at least have not gotten labs during such a possible arrest to know it. My feeling is that hypokalemia of 2.0 likely isn't your source unless there was an R on T from QT prolongation, in which case 100 mEq of K should raise the serum K by 1.0 mg/dl. I'd probably give Mg as well.
 
RustedFox said:
+1.

I ran the whole "delayed sequence intubation" program during my last tube. RN staff had to complain to my director about what "Dr. Rustedfox is doing".

The same fat, (barely) literate RN goonsquad complained about my use of atropine during PEA (psst.... it was pseudo-PEA, bedside cardiac ultrasound FTW) because it wasn't "in the ACLS protocol anymore".

Swear to Christ, they learned one thing, once, and they're sure of it.

Once.

Now and forever. And Ever.

Amen.

Pffft.
Click to expand...

Yup. Tried this (delayed sequence intubation) once as an intern with an attending who was a badass. However, know-all RNs not up on the literature put the kibosh on it even though attending explained the entire procedure at the beginning. As a result, pt starting O2 sat prior to induction was 75%. Attending to intern Dr. GonnaBeADoc: "You have one shot." Was my second tube attempt in residency and I missed it.

Another favorite: RN pushes RSI sedative. Me: "Did you push the paralytic?" RN: "No, did you want that?" Me: Facepalm

Or even better, RN pushes RSI paralytic with no sedative first. Can't do DSI, but we can sure torture the poor patient with paralysis without sedation.
 
Dr.McNinja said:
I'm curious as to what degree of contractility you require for it to not be PEA then? Are just eyeballing the kinesis? Measuring EFs?
I mean, I get it, but at the same time, PEA means no carotid or femoral pulses. If they're so fat you can't find these, well they're likely to die anyway. And probably too fat for my ultrasound to find their heart.

At the same time, is there an atropine indication for low blood pressure? I mean, if I can't feel their pulses, and they've got a slow rate, they're getting epi. And then more epi.
Click to expand...

Short answer: I'm eyeballing the kinesis. If it looks like it should result in a pulse, then that's useful data.

Sometimes they're too fat.
Sometimes, they're vasculopathic and been stented and CEA'd and all that.
Sometimes, they've got a pacer, so the rhythm strip is worthless.
But all those sometimes are becoming more and more common.
 
  • Like
Reactions: 2 users
Eyeballing the EF is probably your best option during an arrest.

Another option is just to slide the probe up and look at the carotid.

If its pulsating then they've got perfusion and are not technically in PEA (aka PREM)
If its not pulsating then they've got no perfusion and are technically in PEA (aka PRES)

As an aside our ability to detect pulses during an arrest is horrible. If you look at the literature its somewhere around 55% and probably even worse in your overweight patients...
 
  • Like
Reactions: 1 users
GonnaBeADoc2222 said:
Probably speaking to my inexperience but I have not seen a hypokalemic arrest in my 4 years as an MD, or at least have not gotten labs during such a possible arrest to know it. My feeling is that hypokalemia of 2.0 likely isn't your source unless there was an R on T from QT prolongation, in which case 100 mEq of K should raise the serum K by 1.0 mg/dl. I'd probably give Mg as well.
Click to expand...

I really hope you're not saying to give 100 meq of IV push K. You need to know how to raise potassium acutely in someone who is dying from sequlae of profound hypok, what's the answer?
 
migm said:
I really hope you're not saying to give 100 meq of IV push K. You need to know how to raise potassium acutely in someone who is dying from sequlae of profound hypok, what's the answer?
Click to expand...

My apologies. Was mixing up maximal PO dosing and IV dosing in my head. In a code/peri-code situation, would likely give max ~40 mEq / hr IV. Thanks for pointing out my mistake.
 
GonnaBeADoc2222 said:
My apologies. Was mixing up maximal PO dosing and IV dosing in my head. In a code/peri-code situation, would likely give max ~40 mEq / hr IV. Thanks for pointing out my mistake.
Click to expand...
Totally reasonable via central line, in a code situation, i'd push 10 meq IV over a few minutes then another 10 a few minutes later if still dying. Mag is a must
 
  • Like
Reactions: 1 users
A hypokalemic arrest? Never seen one, and been out for 9 years. Not that it doesn't happen, but I've never caught one, so it's much lower on my list of badness.
HYPERkalemic? That's more like it.


(A Fat RN? Are you sure it wasn't masquerading as TTP?)
(Yeah, that's the wine typing... which that nurse probably desperately wanted by then...)
 
  • Like
Reactions: 1 user
GonnaBeADoc2222 said:
Yup. Tried this (delayed sequence intubation) once as an intern with an attending who was a badass. However, know-all RNs not up on the literature put the kibosh on it even though attending explained the entire procedure at the beginning. As a result, pt starting O2 sat prior to induction was 75%. Attending to intern Dr. GonnaBeADoc: "You have one shot." Was my second tube attempt in residency and I missed it.

Another favorite: RN pushes RSI sedative. Me: "Did you push the paralytic?" RN: "No, did you want that?" Me: Facepalm

Or even better, RN pushes RSI paralytic with no sedative first. Can't do DSI, but we can sure torture the poor patient with paralysis without sedation.
Click to expand...

What is their major issue? Where I am at in residency the nurses are all mostly pretty great and never question the things we do (unless it is a legitimate question for learning purposes) so I haven't had issues with DSI. They just have issues with giving ketamine first and waiting a bit while you oxygenate the patient? Don't you guys sometimes use ketamine or ketofol for procedural sedation without the need to intubate someone? What exactly is their concern?
 
How can you get a BMP back that fast?
 
I took more than 5 minutes to walk to the lab. Guess stat means stat now.
 
RustedFox said:
Short answer: I'm eyeballing the kinesis. If it looks like it should result in a pulse, then that's useful data.

Sometimes they're too fat.
Sometimes, they're vasculopathic and been stented and CEA'd and all that.
Sometimes, they've got a pacer, so the rhythm strip is worthless.
But all those sometimes are becoming more and more common.
Click to expand...

Agreed with this. All "PEA" is not equal and ultrasound is changing it. How many times have you gone to feel for a pulse on an awake talking patient and you're having trouble locating it? Do you really trust your code situation pulse checks?

Now I'm not advocating the quiver that you might see the walls do because you've given 18 rounds of code dose epi, but if I see some reasonable contractile effort (and no sorry I don't have specific objective cutoffs for this - I'm not measuring a specific EF nor do I care to), it changes things.

Money is if you can obtain an A-line in these patients, especially if they keep recoding or you have this heart thats moving but can't find a definitive pulse. Arterial line transducers will only be functioning if there is some sort of cardiac output. Even if it is crappy.

Something else I've seen recently that people tend to forget about - Pulse oximeter. Modern day pulse Ox functions because the two infrared lights which measure the absorbance of oxy and deoxy hemoglobin are looking for flow (moving blood) so they don't get confused by all the other surrounding tissues. If you see a pulse oximetry waveform on your monitor, no matter what the number is, you by definition have to have ROSC. The SpO2 itself might not be accurate in the pinkey post-arrest after infinity-epinephrine, but some forward flow has to be occurring for you to have a waveform.
 
  • Like
Reactions: 2 users
RustedFox said:
+1.

I ran the whole "delayed sequence intubation" program during my last tube. RN staff had to complain to my director about what "Dr. Rustedfox is doing".

The same fat, (barely) literate RN goonsquad complained about my use of atropine during PEA (psst.... it was pseudo-PEA, bedside cardiac ultrasound FTW) because it wasn't "in the ACLS protocol anymore".

Swear to Christ, they learned one thing, once, and they're sure of it.

Once.

Now and forever. And Ever.

Amen.

Pffft.
Click to expand...
What is the result of complaints like this? Do they actually result in you having to justify your actions to anyone? This sounds ridiculous. As someone about to start my EM residency, presuming the upcoming match week goes as it should, I am pretty sure I will be pretty frustrated when this type of stuff happens to me. I guess it is bound to happen to everyone at some point though, so I won't be surprised.
 
GonnaBeADoc2222 said:
Yup. Tried this (delayed sequence intubation) once as an intern with an attending who was a badass. However, know-all RNs not up on the literature put the kibosh on it even though attending explained the entire procedure at the beginning. As a result, pt starting O2 sat prior to induction was 75%. Attending to intern Dr. GonnaBeADoc: "You have one shot." Was my second tube attempt in residency and I missed it.

Another favorite: RN pushes RSI sedative. Me: "Did you push the paralytic?" RN: "No, did you want that?" Me: Facepalm

Or even better, RN pushes RSI paralytic with no sedative first. Can't do DSI, but we can sure torture the poor patient with paralysis without sedation.
Click to expand...
Similar to my response to rustedfox, is this type of interaction normal? I get the whole teamwork idea and realize you have to listen to everyone on the team, but this is just dumb.

Is there any recourse for the RN refusing to do it? Seems like an RN pushing back or refusing to implement medication orders when a patient needs intubated should be a pretty serious concern to all parties involved. Would it have been reasonable as a resident (I suppose probably not as resident) or attending to bring this up after the fact and perhaps discuss with nursing admin in an effort to ensure drugs during intubation are given in a timely manner as ordered by the physician?

I hope this kind of stuff isn't the norm. I kind of expected everyone to question my decisions as a medical student. That's why med students aren't responsible for making important decisions. That makes sense. But I didn't know this happens so much to attendings. I've seen several RNs avoid giving basic meds as ordered and am not surprised anymore when it happens. Everyone has to pick their battles, and if the med isn't crucial at that moment, it's usually not a battle worth having. But the situation you described seems much worse. What do others think? If an RN refuses to give medications during a code or intubation setting is this a battle worth having? Or would you let it slide? As someone who hasn't made it far enough in my training or career to experience this specific scenario, I'm curious what others would do or have done.
 
littlejuan said:
What is their major issue? Where I am at in residency the nurses are all mostly pretty great and never question the things we do (unless it is a legitimate question for learning purposes) so I haven't had issues with DSI. They just have issues with giving ketamine first and waiting a bit while you oxygenate the patient? Don't you guys sometimes use ketamine or ketofol for procedural sedation without the need to intubate someone? What exactly is their concern?
Click to expand...
it may be from their experience with benzos in these copders. for some reason they always ask due to intolerance of the bipap facemask and my answer is always no if im not trying to tube.

Sent from my Pixel using Tapatalk
 
Most times when you get pushback from nursing over issues like this it's a communication issue. Whenever I do something that isn't "normal" I give a brief reason for why we are doing it that way and then after the case go into more detail with the nurses about my reasoning/physiology/etc. Most nurses are eager to learn and willing to work with you but communication is a must vs just being a dictator
 
FutureDOdr said:
I hope this kind of stuff isn't the norm. I kind of expected everyone to question my decisions as a medical student. That's why med students aren't responsible for making important decisions. That makes sense. But I didn't know this happens so much to attendings. I've seen several RNs avoid giving basic meds as ordered and am not surprised anymore when it happens. Everyone has to pick their battles, and if the med isn't crucial at that moment, it's usually not a battle worth having. But the situation you described seems much worse. What do others think? If an RN refuses to give medications during a code or intubation setting is this a battle worth having? Or would you let it slide? As someone who hasn't made it far enough in my training or career to experience this specific scenario, I'm curious what others would do or have done.
Click to expand...

If you're ever having difficulty deciding what to let slide and what to hill to die on, the best rule of thumb is "Was the patient's health endangered?" Not giving code meds (if you believe they work) would be a firm yes. Now it's still possible to be right and end up as the bad guy so if you can get through the situation without throwing things or screaming insults at the nurse, that's ideal.
 
  • Like
Reactions: 2 users
Arcan57 said:
If you're ever having difficulty deciding what to let slide and what to hill to die on, the best rule of thumb is "Was the patient's health endangered?" Not giving code meds (if you believe they work) would be a firm yes. Now it's still possible to be right and end up as the bad guy so if you can get through the situation without throwing things or screaming insults at the nurse, that's ideal.
Click to expand...

I feel like we each legitimately get one thing. One issue we can be stubborn on and push to change the system in our departments around. Any more than one, and you become "that guy".
 
  • Like
Reactions: 1 user
You must log in or register to reply here.
Next unread thread

Similar threads

Dr Mantis Toboggan
Bills player with cardiac arrest. Commotio?
2
Replies
84
Views
4K
bravotwozero
bravotwozero
Angry Birds
Pediatric Airway review, tips, and resources
Replies
14
Views
1K
Apollyon
A
EctopicFetus
Usacs leader arrested for ……
Replies
20
Views
3K
Birdstrike
Birdstrike
thegenius
Billing and Coding: Cardiac Arrest
Replies
4
Views
6K
RoyBasch
R
SpacemanSpifff
Tandem resuscitative hysterotomy and thoracotomy in peripartum cardiomyopathy-mediated cardiac arrest
Replies
17
Views
2K
deleted109597
D
Top