Do you terminate codes when patient is in PEA?

[iaskdumbquestions]

Recently witnessed a code in an ICU. It went on for about 45 minutes before it was called. Patient was in PEA, looked like maybe underlying sinus rhythm but no pulses with either palpation or doppler. Patient was very morbid, bad vascular disease, multiple amputations, on dialysis with sepsis from pressure ulcers from living in a nursing home and a baseline mental status of A&O x0. On 2 vasopressors at time of the arrest (distributive). No prior known cardiac history.

Anyways, after about 45 minutes the team called it despite rhythm still being PEA. Seemed weird to me but if you can't doppler a pulse maybe it's ok?

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[Rocher]

Yes, I can't quote you numbers off the top of my head but I feel like most codes I've ran ended with the patient in PEA. I don't remember much asystole (definitely severe sinus bradycardia) and it is rare to terminate a code with the patient in a persistent ventricular arrhythmia

 

[shouldigomd]

I think going 45 minutes on a patient that bad off is weird to me ... I would have called it after 15 minutes or so unless there was something reversible going on.

 

[Radetzky]

Patient was very morbid, bad vascular disease, multiple amputations, on dialysis with sepsis from pressure ulcers from living in a nursing home and a baseline mental status of A&O x0. On 2 vasopressors at time of the arrest (distributive). No prior known cardiac history.

One doesn’t know whether to laugh or cry.

 

[aafisahar]

I think going 45 minutes on a patient that bad off is weird to me ... I would have called it after 15 minutes or so unless there was something reversible going on.

yea, best case scenario, you bring the patient back to just before they coded.

Working on any patient for 45 minutes is basically criminal especially the patient described in the OP.

 

[iaskdumbquestions]

All fair points.

Let's say it had been 10 minutes. 15? I don't know where the cutoff is. I agree also it's ridiculous to code this person, they should probably never be admitted to an ICU in the first place. But at least in the US, we need a dramatic cultural paradigm shift vis-a-vis end of life, expectations etc, before we can condemn the team for following the families (and patient's - based on their last known wishes, at least according to the family) explicit wishes. It is a mess though, no doubt.

Be that as it may, would you call an arrest after X amount of time for a patient in PEA? I guess it's just awkward (for me anyway) to see an organized rhythm and do nothing.

 

[Radetzky]

All fair points.

Let's say it had been 10 minutes. 15? I don't know where the cutoff is. I agree also it's ridiculous to code this person, they should probably never be admitted to an ICU in the first place. But at least in the US, we need a dramatic cultural paradigm shift vis-a-vis end of life, expectations etc, before we can condemn the team for following the families (and patient's - based on their last known wishes, at least according to the family) explicit wishes. It is a mess though, no doubt.

Be that as it may, would you call an arrest after X amount of time for a patient in PEA? I guess it's just awkward (for me anyway) to see an organized rhythm and do nothing.

It depends on the circumstances. I would code an immersion hypothermic PEA arrest for over an hour. I wouldn’t code this patient at all. PEA just means you are doing good enough CPR to keep enough coronary blood flow to keep the sinus node or AV node or ventricles generating an electrical impulse. It implies nothing about the reversibility of the condition.

 

[aafisahar]

All fair points.

Let's say it had been 10 minutes. 15? I don't know where the cutoff is. I agree also it's ridiculous to code this person, they should probably never be admitted to an ICU in the first place. But at least in the US, we need a dramatic cultural paradigm shift vis-a-vis end of life, expectations etc, before we can condemn the team for following the families (and patient's - based on their last known wishes, at least according to the family) explicit wishes. It is a mess though, no doubt.

Be that as it may, would you call an arrest after X amount of time for a patient in PEA? I guess it's just awkward (for me anyway) to see an organized rhythm and do nothing.

If it's a patient that's going to have a bad outcome, I will do 2 rounds CPR, max.

 

[iaskdumbquestions]

PEA just means you are doing good enough CPR to keep enough coronary blood flow to keep the sinus node or AV node or ventricles generating an electrical impulse. It implies nothing about the reversibility of the condition.

This is really helpful. I'm still trying to develop an understanding of what I'm seeing instead of just knowing it. Thank you for this

 

[PTPoeny]

It is appropriate to terminate the code when it is clearly futile with no chance of reversibility. The time you call the code isn't necessarily the time of death.

 

[aafisahar]

It is appropriate to terminate the code when it is clearly futile with no chance of reversibility. The time you call the code isn't necessarily the time of death.

Just because you can get ROSC doesn't mean you should.

 

[aafisahar]

This is really helpful. I'm still trying to develop an understanding of what I'm seeing instead of just knowing it. Thank you for this

PEA = electricity but no contraction. So things that interfere with this pathway eg hypovolemia (eg if you can't stretch the myocytes, you can't generate a contraction), hypoxia (if no oxygen, can't generate ATP, can't move the myocytes), thrombosis (same deal, if you have an acute prox LAD or left main, then you can't get nutrients to the myocytes to generate a contraction), tension pneumo (same deal as acute thrombosis or hypovolemia), etc etc. Electricity and having that electricity generate a contraction are two separate things. You can see electricity on the monitor and you observe the contraction by noting a BP.