Return of pulse

[Dr.Evil1]

OK so I am on a medicine rotation as a sub-I and we are called to a code for a 84 yo female that was on telemetry who went into asystole (no idea of precipitating events/hx).

During code we were mostly in asystole/PEA with occasional ?V-fib. Multiple rounds of epi, maxed out atropine, multiple shocks (for the questionable v-fib), 1 amp bicarb (I don't know all the specifics). Finally after 18 min of downtime without pulse my senior calls the code. We actually end up calling the pt's attending and telling him that his pt expired. Fortunatly we hadn't yet called the patients family.

Techs are cleaning up the body when they notice an agonal respiration and then spontaneous return of bounding precordial pulse. Called back into the room to resume ACLS (despite my objections...why did they have to look at the body?). BP was 160/90 at this time and monitor showed sinus tach. ABG at this point (after 6-8 min of no ventilation) showed a pH of 7.12 and a pO2 of like 40, hyperkalemia. Gave 2 amps of bicarb, insulin and glucose, and ventilated the pt. BP declined and we needed multiple pressors but got the pt to the unit sort of alive.

My question is as follows: Is this common to have return of pulse after prolonged downtime like this? I know that this patients brain is toast and I did not want to resume ACLS after initially ending the resuscitation (but I'm just the sub-I) but is it unethical to not ventilate someone with a pulse and is full code? What are people's thoughts on this series of events (sorry I can't be more specific with the details of the code)?

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[spyderdoc]

OK so I am on a medicine rotation as a sub-I and we are called to a code for a 84 yo female that was on telemetry who went into asystole (no idea of precipitating events/hx).

During code we were mostly in asystole/PEA with occasional ?V-fib. Multiple rounds of epi, maxed out atropine, multiple shocks (for the questionable v-fib), 1 amp bicarb (I don't know all the specifics). Finally after 18 min of downtime without pulse my senior calls the code. We actually end up calling the pt's attending and telling him that his pt expired. Fortunatly we hadn't yet called the patients family.

Techs are cleaning up the body when they notice an agonal respiration and then spontaneous return of bounding precordial pulse. Called back into the room to resume ACLS (despite my objections...why did they have to look at the body?). BP was 160/90 at this time and monitor showed sinus tach. ABG at this point (after 6-8 min of no ventilation) showed a pH of 7.12 and a pO2 of like 40, hyperkalemia. Gave 2 amps of bicarb, insulin and glucose, and ventilated the pt. BP declined and we needed multiple pressors but got the pt to the unit sort of alive.

My question is as follows: Is this common to have return of pulse after prolonged downtime like this? I know that this patients brain is toast and I did not want to resume ACLS after initially ending the resuscitation (but I'm just the sub-I) but is it unethical to not ventilate someone with a pulse and is full code? What are people's thoughts on this series of events (sorry I can't be more specific with the details of the code)?

I've seen a few cases where the patient is ventilated so aggresively that air traps in the lungs and the intrathoracic pressure skyrockets and prevents blood return to the heart. After bagging is stopped, the air leave the lungs, intrathoracic pressure decreases, and blood (which is full of epi, etc) returns to the heart and kickstarts it again.......This is especially common in asthmatics and COPD patients....So, always pay attention to how aggressively the pt is being ventilated, shouldn't be more that 12-14 resp/min....In a code, all the adrenaline is pumping and you find that the pt is getting 28-32 FULL respirations per min, therefore the auto-peeping....
Just a thought....
Mark

 

[southerndoc]

I'm not sure I would've given the patient bicarb after you had a return of pulse. More than likely, the patient was acidotic from hypercarbia secondary to hypoventilation. By giving bicarb, you do indeed raise the pH, but you also increase the pCO2. By ventilating the patient, you would have corrected the CO2, which would have corrected the acidosis and made the administration of bicarb less likely to be needed.

That's my thought anyhow... take it for what it's worth (2 cents, 3.5 adjusted for inflation).

 

[Annette]

Spent two hours making a patient comfort care only. Patient starts agonal resps. During a particularly long apnic spell, the nurse tells the family the patient is dead. You guessed it, the patient take a breath, the family thinks it is a miracle and reverses the cco order to full code.

 

[deleted59964]

I've seen a few gas trapping induced PEA's as well, you really don't need to over do the ventilation much if they are severe asthmatics or post single lung transplant (untransplanted lung gas traps !). Real bummer when you've been busting your ass for 30min doing resus and then you disconnect the ETT and the BP comes back.

 

[mikecwru]

I've seen a few gas trapping induced PEA's as well, you really don't need to over do the ventilation much if they are severe asthmatics or post single lung transplant (untransplanted lung gas traps !). Real bummer when you've been busting your ass for 30min doing resus and then you disconnect the ETT and the BP comes back.

Another tip---don't call the code right after a round of drugs.

mike

 

[WilcoWorld]

...are quite interesting & have taught me more than most of my M4 year has.

 

[southerndoc]

Do any of you routinely "decompress" the chest of asthmatics or COPD'ers after you intubate them?

I was saw this as a medical student and liked the idea. Basically it's a manual decompression (not involving any invasive procedures) of squeezing the air out of the chest with your hands symmetrically squeezing the chest. I've tried it a few times, and it definitely makes patients easier to bag.

 

[docB]

I've had this exact thing hppen a few times. I think the strongest stimulant of myocardium is the phrase "Let's call it."

 

[margaritaboy]

I don't think it is common, to answer the OPs question.

I do wonder about the lead placement for the cardiac monitor during the code and the asystole vs. possible runs of vfib. The most common cause of asystole is incorrect lead placement, and it would be rather remarkable if this patient did have asystole for 18 minutes, called the code, and then resume with a pH of only 7.1.

It wouldn't surprise me if she did in fact have some sort of perfusing rhythm during the code, otherwise I would expect a pH far worse the one obtained. This is just speculation though.


Good case.

 

[spyderdoc]

I use the ultrasound a lot during my codes, esp the PEA's to see if there is any cardiac activity. Also helps for ruling out pericardial effusion/tamponade.

If your dept doesn't have u/s machine, you can use an "old fashioned" handheld doppler over the carotids to see if there is any blood moving through them....

 

[Dr.Evil1]

Just an update...pt expired a few hours after the code. I doubt air trapping as a cause...we pretty much pulverized this ladys sternum and rib cage, in fact the only reason anyone checked a pulse after the code was that you could see the patients heartbeat through the rib cage. I don't think lead placement was an issue either because we had both pads and chest leads and both showed the same thing, after the code restarted we had sinus rhythm from the same leads. The code was run on a medical floor so we didn't have a US machine but we did have a dopler and did try to use this to find a pulse over the carotids and femoral during the code to no avail.

The patient did have a medical alert tag on her neck saying she had an IVC filter in place. If she threw a large thrombis to her filter and occluded her IVC (don't know if this is possible) then all the meds that we were giving her during the code through a femoral central line (they always do femorals at this hospital) might not have even gotten to her heart. Anyway thanks for the many replies, I think that I learned alot from being involved in this case.

 

[Doczilla]

OK so I am on a medicine rotation as a sub-I...
<snip>

My question is as follows: Is this common to have return of pulse after prolonged downtime like this? I know that this patients brain is toast and I did not want to resume ACLS after initially ending the resuscitation (but I'm just the sub-I) but is it unethical to not ventilate someone with a pulse and is full code? What are people's thoughts on this series of events (sorry I can't be more specific with the details of the code)?

Ethically... If the patient has a pulse, they're not coding. Unless there is an order not to intubate or to use "comfort measures only", then the patient with a pulse deserves all the care you can give, including ventilation if indicated. Yes, the code had been called, but circumstances changed radically since then, and resuming ACLS measures was the appropriate thing to do.

("I'm not dead yet!" "Yes you are, you just don't know it." -Monty Python)

U/S and doppler are good ways to confirm cardiac activity. Heart sounds are another tool for this. Overall, who knows why your patient did what she did. It's not unheard of. It seems that I'm frequently hearing stories about prehospital patients who are declared dead, only to come alive in the body bag. Prehospital personnel don't have quite as many nifty tools for confirming myocardial standstill as we do in the hospital, but I refuse to believe that none of the crews involved in these cases knows how to check a pulse.

As far as the bicarb is concerned, was there a suspicion for a metabolic acidosis? Southerndoc is correct in that the hypercarbia alone may lead to a significant acidosis. Current thinking on this is simply to ventilate, which should correct the respiratory acidosis. Any acidosis will cause some amount of hyperkalemia because cells take up H+ to raise the pH of the blood. In order to prevent alterations in membrane potential, the cells will get rid of K+ (which provides the driving force to take up the H+), causing serum K+ to increase.

If the (coding) patient has a good reason to be hyperkalemic (renal failure, crush injury, rhabdomyolysis, potassium sparing diuretics), then calcium chloride should be given first to stabilize the cardiac membranes, then bicarb.


'zilla