Ever seen this one before?

[EM Junkie]

---

Members don't see this ad.

Working an asystolic cardiac arrest, witnessed by EMS, downtime 1 hour on arrival to ED. Multiple rounds of ACLS drugs without ROSC.

Paramedics thought there might be fine VF so shocked a couple of times - nothing. During CPR patient would bring his arms up to his chest (localizing?) and had rotary nystagmus. When we stopped for pulse check the movements ceased. There was questionable VERY low amplitude PEA in spurts. Ended up working him for another 45 mins because of this, and called it after no cardiac activity on echo either.

Because of the movements we kicked the family out after the code ended as I was afraid the movements would continue, but they did not.

Any thoughts? I'm 6 years out of residency and never seen anything like that before....

 

[Hamhock]

I seen a few similar activities...

?some odd spinal reflex

Kinda like the Lazarus effect.

I have also seen near full tidal volume breaths q20 seconds minutes after no cardiac motion on bedside ultrasound.

HH

 

[engineeredout]

Definitely had people moving while performing compressions on them. Like you, stopped compressions and checked for a pulse. Movement stopped, no pulse, resumed the code. Has happened several times to me in fact.

 

[RustedFox]

Yeah, I've had similar things happen. The young and healthy have some serious drive and will withstand hypoxemia for a long time. Something about the oxygen-dissociation curve and the unloading being "better" in times of localized tissue hypoxemia, I'm sure of it; I'm just not going to draw the sigmoid curve out right now.

 

[EM Junkie]

Thanks all. Reassuring that this is not unheard of.

 

[USCDiver]

You were perfusing a (partially) functioning brain. Did you consider thrombolytics?

I had the same thing a few months ago. Actually got a ROSC long enough to see ST elevation but couldn't get him to cath before he died for real.

 

[Arcan57]

I've had a patient fight me off (grabbing in closed fist and prying hands off chest) during chest compressions and lose all tone and responsiveness once I stopped. First two times he did it, everyone kinda freaked out. Afterwards it was business as usual.

 

[Birdstrike]

Working an asystolic cardiac arrest, witnessed by EMS, downtime 1 hour on arrival to ED. Multiple rounds of ACLS drugs without ROSC.

Paramedics thought there might be fine VF so shocked a couple of times - nothing. During CPR patient would bring his arms up to his chest (localizing?) and had rotary nystagmus. When we stopped for pulse check the movements ceased. There was questionable VERY low amplitude PEA in spurts. Ended up working him for another 45 mins because of this, and called it after no cardiac activity on echo either.

Because of the movements we kicked the family out after the code ended as I was afraid the movements would continue, but they did not.

Any thoughts? I'm 6 years out of residency and never seen anything like that before....

It sounds like decorticate posturing which could be from your trickle of blood flow during compressions giving just a flicker of life to the one remaining part of his brain that's still got live neurons, that is the brain stem, ie, a GCS 5 equivalent of sorts. I've seen similar, just not this many minutes out. Pulseless down-times are notoriously unreliable. I have a really cool post about a similar case that's been rattling around in my head for a few years now, but I just haven't gotten around to putting word to screen, yet.

 

[EM_Rebuilder]

I am an EMS Medical Director and my crews discuss having this happen in the field; I have seen some movements in the ER, but not as pronounced as you and others have described.

My opinion... I think some of our EMS services have recognized and are doing such EXCELLENT Chest Compressions that we are moving that blood, oxygenating it, and are getting some function of movements occurring. Is it a reflex? Is it (gasp) purposeful?

I surmise we don't see this in the ER all too often because our ER personal are traditionally terrible at doing High Quality CPR (which is shown to improve ROSC, and more importantly, OOHS).

 

[Arcan57]

I am an EMS Medical Director and my crews discuss having this happen in the field; I have seen some movements in the ER, but not as pronounced as you and others have described.

My opinion... I think some of our EMS services have recognized and are doing such EXCELLENT Chest Compressions that we are moving that blood, oxygenating it, and are getting some function of movements occurring. Is it a reflex? Is it (gasp) purposeful?

I surmise we don't see this in the ER all too often because our ER personal are traditionally terrible at doing High Quality CPR (which is shown to improve ROSC, and more importantly, OOHS).

That's one way to spin it. There's a counter argument to be made regarding time from onset of arrest to pt encounter.