TPA at the end of a code

[valianteffort]

Does anyone have any articles or good evidence they can share on giving TPA at the end of a code (especially in patients under 50 highly suspicious for PE)? How much time are you committed to performing CPR after giving TPA to give appropriate time for cycling of the medication through the venous system?

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[Mount Asclepius]

What's the Code Dose of tPA?

What is the code dose of tPA? Based on the the sparse literature, summarized by Dr. Bryan Hayes, it seems the answer is 50-100 mg.

www.aliem.com

 

[WildEMDoc]

If you have concern IMO you should be pushing TPA at the beginning. 15min is the generally circulation time with cont CPR.

If you are still asystole/PEA after 15-20min I'm likely reaching the conclusion of that code. If you decide to push it after 20min, and say you do get ROSC, the chances of good neurologic outcome is a lot smaller.

 

[GonnaBeADoc2222]

If you have concern IMO you should be pushing TPA at the beginning. 15min is the generally circulation time with cont CPR.

If you are still asystole/PEA after 15-20min I'm likely reaching the conclusion of that code. If you decide to push it after 20min, and say you do get ROSC, the chances of good neurologic outcome is a lot smaller.

Interesting. For some reason i was under the impression that after pushing tpa you were kinda committed to abother hour of CPR.

 

[BoardingDoc]

As @WildEMDoc said, I don't give tPA at the end of a code. I will give it up front at the beginning of a code if I suspect PE. I read the subject line and thought "tPA at the end of a code? Like, just to make absolutely sure that they're dead?"

 

[valianteffort]

As @WildEMDoc said, I don't give tPA at the end of a code. I will give it up front at the beginning of a code if I suspect PE. I read the subject line and thought "tPA at the end of a code? Like, just to make absolutely sure that they're dead?"

On the flip side for discussion, highly suspicious but also can not rule out for example aortic dissection or intracranial bleeding. Are you legally on the hook if you start with TPA and you were wrong about your suspicion? Of course, if someone is coding from any of the above they are likely dead from the start.

 

[Jabbed]

I was always taught that you need to continue compressions for at least 15 minutes after administration, so obviously something that you want to do up front.

Personally, once I see blood shooting out the ET tube I consider that to be my endpoint, which is often more like 5 minutes with good compressions.

 

[Siggy]

I’m going to echo the “if you’re going to give TPA, give it as soon as you think a PE is a reasonable cause.”

 

[Tenk]

On the flip side for discussion, highly suspicious but also can not rule out for example aortic dissection or intracranial bleeding. Are you legally on the hook if you start with TPA and you were wrong about your suspicion? Of course, if someone is coding from any of the above they are likely dead from the start.

You’re legally on the hook for giving Tylenol and amoxicillin. You’re always on the hook. You are basically one with the hook.

I’d only tpa if they had a known PE or mega high pretest with right heart strain. Lots of things can present like PE and PE can present like lots of things so just thinking it might be PE is a no go from me. I also agree with giving it immediately.

 

[PianoMedic]

My n of 3 with this (all during residency, not done yet in closing in on 2 years as an attending):

First time was a guy who collapsed in front of us, gray, was complaining of dyspnea and was hypoxic and tachycardic right before he collapsed. No pulse. Did usual stuff. Honestly thought it was ACS, but no shockable rhythm. My attending asked if there was anything else we could try, and me being the dumb intern threw out tpa. Sure as ***t we push 50 mg, and within 2 minutes have ROSC. Has a decent outcome.

One of my coresidents had a patient come in, walking boot on one leg and swollen calf. Started heparin while awaiting CTA, coded, they gave tpa and got them back. Came down a few days later and thanked him in the ED.

Those were atypical cases.

Final case came in as an OHCA, downtime for a few minutes. I was a senior in the department, came over to see if they needed a hand but second year had it under control. Attending was an ivory tower type though, and rhythm had been PEA whole time. He asked if there was anything else we could do. It’d been 15-20 minutes of working it by that point. He then threw tpa out, pt had terrible protoplasm so didn’t seem a good idea and I said so. He decided to give it anyway, worked it another 20-30 minutes and then called it. So 45 minutes of code time in the ED.

So one good save, one I accidentally saved, and one of what I’d typically expect. I’m only thinking of it in young people with short downtime. I’m also wondering if it could be useful in shock refractory vfib… any data on that? You’d assume usually that would be ACS, so could be useful in that instance.

 

[Rockinacoustic]

Interesting. For some reason i was under the impression that after pushing tpa you were kinda committed to abother hour of CPR.

American guidelines say at least 15 minutes, European guidelines say 60-90 minutes.

Everything is based on low quality evidence, and if i recall correctly, the European rec is based on a case report of an inpatient code with confirmed PE.

 

[southerndoc]

On the flip side for discussion, highly suspicious but also can not rule out for example aortic dissection or intracranial bleeding. Are you legally on the hook if you start with TPA and you were wrong about your suspicion? Of course, if someone is coding from any of the above they are likely dead from the start.

If they have coded from a thoracic aortic dissection, then nothing you can do will bring them back. You have nothing to lose by giving tPA. If somebody sues you for that, please let me know because I will be an expert witness against the expert witness that testified that your actions contributed to their death.

A well respected cardiovascular surgeon who specialized in thoracic aortic repair told me if it ruptures in the OR prior to the patient being on the bypass machine, there is nothing he can do to save the patient's life. We shouldn't even do CPR on patients with a ruptured TAD.

I gave TPA in a code that I got back that was a PE. Syncope, came in hypoxemic, coded 5 mins after hitting the door. I did it before the CT of his head despite his age (70 something) and large head lac. It was a last ditch effort. I've given lytics to a guy coming in with chest pain ("steak stuck in my esophagus") who had a history of esophageal stricture. APP gave Reglan and he coded. I gave TPA wondering if it was a dissection, but figured if it was, nothing I would do would help him. If it's a PE, TPA could. My friend -- the local ME -- gave me a hard time for lysing a TAD. I also lysed someone who came in as a STEMI and coded immediately after his 12-lead was obtained. Had a ruptured wall. None of these led to litigation or peer review.

 

[JacobMcCandles]

American guidelines say at least 15 minutes, European guidelines say 60-90 minutes.

Everything is based on low quality evidence, and if i recall correctly, the European rec is based on a case report of an inpatient code with confirmed PE.

There's nothing like letting a case report directly influence your guidelines.

 

[thegenius]

Does anyone have any articles or good evidence they can share on giving TPA at the end of a code (especially in patients under 50 highly suspicious for PE)? How much time are you committed to performing CPR after giving TPA to give appropriate time for cycling of the medication through the venous system?

I remember in residency (2010-2014) that someone did an evidence detectives on giving tPA in undifferentiated cardiac arrest and it wasn't recommended. Didn't change outcomes.

Since being an attending for the past 9 years, I've probably given it twice in the same scenario with no good outcome. The only thing I remember about doing it is if you plan on giving tPA for undifferentiated cardiac arrest, do it early. No point after 20 minutes of PEA or fib when you should just do it early. If i were to do it again, do it early, and do compressions for like 5-10 minutes non-stop to allow the tPA to maximally circulate.

 

[thegenius]

On the flip side for discussion, highly suspicious but also can not rule out for example aortic dissection or intracranial bleeding. Are you legally on the hook if you start with TPA and you were wrong about your suspicion? Of course, if someone is coding from any of the above they are likely dead from the start.

likely?

They are dead!

 

[thegenius]

My n of 3 with this (all during residency, not done yet in closing in on 2 years as an attending):

First time was a guy who collapsed in front of us, gray, was complaining of dyspnea and was hypoxic and tachycardic right before he collapsed. No pulse. Did usual stuff. Honestly thought it was ACS, but no shockable rhythm. My attending asked if there was anything else we could try, and me being the dumb intern threw out tpa. Sure as ***t we push 50 mg, and within 2 minutes have ROSC. Has a decent outcome.

One of my coresidents had a patient come in, walking boot on one leg and swollen calf. Started heparin while awaiting CTA, coded, they gave tpa and got them back. Came down a few days later and thanked him in the ED.

Those were atypical cases.

Final case came in as an OHCA, downtime for a few minutes. I was a senior in the department, came over to see if they needed a hand but second year had it under control. Attending was an ivory tower type though, and rhythm had been PEA whole time. He asked if there was anything else we could do. It’d been 15-20 minutes of working it by that point. He then threw tpa out, pt had terrible protoplasm so didn’t seem a good idea and I said so. He decided to give it anyway, worked it another 20-30 minutes and then called it. So 45 minutes of code time in the ED.

So one good save, one I accidentally saved, and one of what I’d typically expect. I’m only thinking of it in young people with short downtime. I’m also wondering if it could be useful in shock refractory vfib… any data on that? You’d assume usually that would be ACS, so could be useful in that instance.

Both of those cases were witnessed cardiac arrest, much different than EMS bringing in someone already doing CPR. I would be much more enthusiastic about pushing thrombolytics in those cases above

 

[Siggy]

There's nothing like letting a case report directly influence your guidelines.

To be fair, if that's the totality of the evidence, then that's the evidence. That sounds like a guideline that should be written as "It may be reasonable to do ___ (low quality evidence)."

 

[JacobMcCandles]

To be fair, if that's the totality of the evidence, then that's the evidence. That sounds like a guideline that should be written as "It may be reasonable to do ___ (low quality evidence)."

I think the absurdity of it lies mainly in the fact that they would recommend an additional 60-90 minutes of CPR after the administration of it. If they wanted to say that's the evidence then they need to include all the other codes that received tPA that went on to be terminated.

 

[Rekt]

Sounds like I do it more often than most. I have had variable success although it’s hard to tell if that’s the direct reason. I absolutely don’t do 60 minutes. I do 15 minutes. Repeat tpa + 15 mins if I decide to run longer. But I always make the decision very early. Essentially intubate, give a round of Epi, Ca, Bicarb back to back to back. Usually already on IVF and given D50 in the field. Then immediately do a echo and look at RV. If there’s a good story for it, or they’re young. Even if I think it’s recent pure cardiac lesion I’ll do it. With that said I don’t do it on any unknown downtime and they have to present pretty quickly. Don’t do it on gomers or dialysis pts.

 

[JacobMcCandles]

Sounds like I do it more often than most. I have had variable success although it’s hard to tell if that’s the direct reason. I absolutely don’t do 60 minutes. I do 15 minutes. Repeat tpa + 15 mins if I decide to run longer. But I always make the decision very early. Essentially intubate, give a round of Epi, Ca, Bicarb back to back to back. Usually already on IVF and given D50 in the field. Then immediately do a echo and look at RV. If there’s a good story for it, or they’re young. Even if I think it’s recent pure cardiac lesion I’ll do it. With that said I don’t do it on any unknown downtime and they have to present pretty quickly. Don’t do it on gomers or dialysis pts.

You’re giving calcium and sodium bicarb to all your codes?

 

[Rekt]

You’re giving calcium and sodium bicarb to all your codes?

For the most part. X1. Unless obvious response or tox/dialysis pt etc. Won’t make them anymore dead. My ems systems in my area usually call codes in the field often. So if they come in they’re typically young or short downtime etc etc. If one falls through the crack and it’s some rigid 90 year old I call it before they’re even transferred from ems stretcher.

It also takes less than 10 seconds to push all three since the code cart is already cracked and I’m already about to do my echo. I personally don’t run any codes without an ultrasound so we don’t sit there wasting time looking for a pulse. It also helps me call it earlier sometime too.

 

[JacobMcCandles]

For the most part. X1. Unless obvious response or tox/dialysis pt etc. Won’t make them anymore dead. My ems systems in my area usually call codes in the field often. So if they come in they’re typically young or short downtime etc etc. If one falls through the crack and it’s some rigid 90 year old I call it before they’re even transferred from ems stretcher.

It also takes less than 10 seconds to push all three since the code cart is already cracked and I’m already about to do my echo. I personally don’t run any codes without an ultrasound so we don’t sit there wasting time looking for a pulse. It also helps me call it earlier sometime too.

Interesting since neither of those are recommended unless it’s a specific scenario. If you use the reasoning of it won’t make them anymore dead then you should probably be giving a bunch more other drugs besides the calcium and sodium bicarb. If they took the calcium and sodium bicarb out of the code carts would you still use it? If something doesn’t have a benefit then all that’s left is no change or exposure to harm. I believe calcium does have an RCT that was stopped early because of harm shown in the calcium group.

I don’t want this to come off as a personal attack but I’m always surprised at what we do in medicine just because it ‘takes less than 10 seconds’ or because it makes us feel like we’re at least doing something.

 

[Rekt]

Interesting since neither of those are recommended unless it’s a specific scenario. If you use the reasoning of it won’t make them anymore dead then you should probably be giving a bunch more other drugs besides the calcium and sodium bicarb. If they took the calcium and sodium bicarb out of the code carts would you still use it? If something doesn’t have a benefit then all that’s left is no change or exposure to harm. I believe calcium does have an RCT that was stopped early because of harm shown in the calcium group.

I don’t want this to come off as a personal attack but I’m always surprised at what we do in medicine just because it ‘takes less than 10 seconds’ or because it makes us feel like we’re at least doing something.

I’m obviously aware. You automatically know every specific scenario when a patient comes in dead? I haven’t achieved your level of clairvoyance yet.

Most of medicine is based off piss poor studies, anecdotes. Most of what we do barely does anything. The affect we have on a patients medical course is realistically incredibly narrow.

 

[JacobMcCandles]

I’m obviously aware. You automatically know every specific scenario when a patient comes in dead? I haven’t achieved your level of clairvoyance yet.

Of course not…but I know the recommendations and use context clues to see if I’m dealing with a situation where those meds may benefit. Again, not a personal attack.

 

[Mount Asclepius]

I'll readily given thrombolytics for cases of cardiopulmonary arrest with higher suspicion for PE or ACS despite ambiguity and lack of diagnostic confirmation. Also usually in patients with projected higher likelihood of decent to good neurological outcome (caution advised as very subjective). I don't routinely give thrombolytics though in every cardiopulmonary arrest. I've given and achieved ROSC in a handful of patients subsequently confirmed to have massive PEs on CTA. Agree give early if high suspicion. Don't give as last ditch effort.

 

[Mount Asclepius]

I don't really ever understand the criticism of giving dead people medications. You can't make them more dead. The only bad thing that can happen is that they actually work and someone ends up in place for a week or two that is worse than dead - purgatory in the ICU prior to officially being dead.

However, I don't routinely give a cocktail of medications in cardiopulmonary arrest. I tailor it to the individual patient and situation. I do frequently given Bicarb and Calcium, but not always. Pressors will work better with improvement in acidosis. Severe acidosis though is a bad prognostic indicator and it's not necessarily always worth hammering in Bicarb to fix. Sometimes dead is dead. Sometimes people are just cold, because they are dead.

 

[JacobMcCandles]

I don't really ever understand the criticism of giving dead people medications. You can't make them more dead. The only bad thing that can happen is that they actually work and someone ends up in place for a week or two that is worse than dead - purgatory in the ICU prior to officially being dead.

It wasn't a criticism. I thought maybe there was going to be something behind it where we could all learn besides "because it's in the code cart". Dead is dead but in the case of calcium, there is some evidence that shows you have a lesser chance of ROSC by giving it. These people have the odds stacked against them but I think it's important we have rationale behind our decisions. If you're giving a medication that you feel like could potentially help them or increase their odds for ROSC, it's generally a good idea to make sure that it's not actually harming them or decreasing their odds of ROSC.

 

[DrDrummer]

However, I don't routinely give a cocktail of medications in cardiopulmonary arrest. I tailor it to the individual patient and situation.

As long as we're talking cocktails, is there anyone out there giving the VSE cocktail for arrests? It's one of the few with *some* evidence behind it-- it got some FOAMed traction back when the most well-known RCT came out, and I haven't heard much about it since, even after a larger multi-center RCT was released. A meta-analysis was recently published digging up and combining the studies, but garbage in / garbage out still applies. If I was throwing anything at a witnessed arrest other than tPA, this would probably be it. We do not keep vasopressin or methylpred in our code carts, but I have thought about trying to get it brought to all in-house codes.

 

[lucid_leprechaun]

As long as we're talking cocktails, is there anyone out there giving the VSE cocktail for arrests? It's one of the few with *some* evidence behind it-- it got some FOAMed traction back when the most well-known RCT came out, and I haven't heard much about it since, even after a larger multi-center RCT was released. A meta-analysis was recently published digging up and combining the studies, but garbage in / garbage out still applies. If I was throwing anything at a witnessed arrest other than tPA, this would probably be it. We do not keep vasopressin or methylpred in our code carts, but I have thought about trying to get it brought to all in-house codes.

The literature I’ve seen on vasopressin and methylpred did show increased ROSC but not neuro survival or survival to discharge.

 

[Siggy]

There are studies that suggest that empiric bicarb and empiric calcium does lead to less ROSC.

As long as we're talking cocktails, is there anyone out there giving the VSE cocktail for arrests? It's one of the few with *some* evidence behind it-- it got some FOAMed traction back when the most well-known RCT came out, and I haven't heard much about it since, even after a larger multi-center RCT was released. A meta-analysis was recently published digging up and combining the studies, but garbage in / garbage out still applies. If I was throwing anything at a witnessed arrest other than tPA, this would probably be it. We do not keep vasopressin or methylpred in our code carts, but I have thought about trying to get it brought to all in-house codes.

I don’t normally give it during the code, but I’ll start hydrocortisone at the drop of a hat if a post code patient is on pressors.

 

[DrDrummer]

The literature I’ve seen on vasopressin and methylpred did show increased ROSC but not neuro survival or survival to discharge.

Yeah. I think a lot of the effects on good CPC scores that an intervention might make often get washed out in these trials and it's really hard to show anything that will translate into that. But if you want to get to a good outcome, the first step is surviving the arrest, so for witnessed arrests in the ER (which is a different subgroup than those witnessed in the *hospital* which seems like they're probably already doing badly), I wonder if it might show even more of a signal there. Maybe Mike Donnino's next fellow will take that on...

 

[TrailRun]

I often give calcium and or bicarb. At my shop we don’t have istats so it allows me to at least (theoretically) address a couple of the Hs and Ts, while my bedside US shows no tamponade, PTX, the ETT or LMA addresses hypoxia, etc. Admittedly I don’t expect it to work, but neither does epi (for neuro intact survival) and we all still do that.

 

[thegenius]

It wasn't a criticism. I thought maybe there was going to be something behind it where we could all learn besides "because it's in the code cart". Dead is dead but in the case of calcium, there is some evidence that shows you have a lesser chance of ROSC by giving it. These people have the odds stacked against them but I think it's important we have rationale behind our decisions. If you're giving a medication that you feel like could potentially help them or increase their odds for ROSC, it's generally a good idea to make sure that it's not actually harming them or decreasing their odds of ROSC.

In fact lots of these medicines make outcomes worse. For any one individual dead person, I guess you can't make them more dead. But when applied to a cohort of so-called dead people that roll into ER's every day around the nation, the number that survive with anything meaningful life is reduced when calcium or epi x >= 3 is administered. Some dead people get 8 rounds of epinephrine. That makes them even MORE dead. They might get a stiffy before (or while) dying because they have so much adrenaline in their bodies, but jeez who ever though 8 mg of epi is good for any cell in the body. We start epi drips at 0.05 -2 mcg/kg/min. So they are getting 5-10 mcg / min. And we give dead people 8 mg over 30 minutes.

 

[Rekt]

It wasn't a criticism. I thought maybe there was going to be something behind it where we could all learn besides "because it's in the code cart". Dead is dead but in the case of calcium, there is some evidence that shows you have a lesser chance of ROSC by giving it. These people have the odds stacked against them but I think it's important we have rationale behind our decisions. If you're giving a medication that you feel like could potentially help them or increase their odds for ROSC, it's generally a good idea to make sure that it's not actually harming them or decreasing their odds of ROSC.

Continue to not use your brain and pick what words you want. “Because it’s in the cart” is obviously not why I use it as Trailrun just addressed. Really not even worth wasting further time on your silly replies. I also said for the most part at the beginning and not 100% of the time, aka context. Also as to the above. I do it once unless it works and I also never give more than 4 epi including what EMS gave.

 

[wareagle726]

I seem to be pretty quick to give tPA to <40's seemingly healthy people OHCA. My N is probably 3-4 over the last 3 years. No luck so far. If I don't have a better explanation in OHCA then I'll give it. Down side seems pretty low. It could be me or my wife and I would hope they would give it. I know most are probably OD's but it seems like a low down-side treatment to potentially save someone. Oh, me and the wifey don't do drugs so it couldn't be us from that standpoint lol.

 

[Mount Asclepius]

Most things in medicine don’t work if given to everyone indiscriminately. Sometimes they still don’t work even if given discriminately based upon the evidence and guidelines. Sometimes they do though. The danger is in the black and white because some ‘evidence’ says you are doing it wrong for the patient in front of you. Right time and right place. You still won’t get thanked when they walk out of the hospital - and they likely won’t walk out of the hospital - but if they do you might be the one that made all of the difference.

 

[TooMuchResearch]

On the flip side for discussion, highly suspicious but also can not rule out for example aortic dissection or intracranial bleeding. Are you legally on the hook if you start with TPA and you were wrong about your suspicion? Of course, if someone is coding from any of the above they are likely dead from the start.

If they're in cardiac arrest from their dissection or ICH, they're dead no matter what you do. TPA isn't going to hurt.

 

[Dred Pirate]

There was a study- I can't find right now- that showed like a 80% survival rate of confirmed PE giving during arrest - I can't find it right now- but I have to call BS on that. The average time from arrest to administration of TPA was like 2 min and they all had CT confirmed PE's - so you are talking ideal situation where they wanted to give TPA and were already preparing it,

From my experience I have had TPA given in codes probably 40 or 50 times - I had 4 that survived to hospital discharge. One had a massive neurological injury, one seemed to recover from the arrest but had extensive liver mets (new diagnosis), one had a miraculous recovery as a 60 plus year old post femur fracture, and the other was a younger 20 something gal who had a complete recovery.

several got ROSC but ultimately passed away .

I generally say we have to do 20 min of CPR post TPA administration, and like others have said, if you are gonna pull the trigger, pull it early on.

 

[Dred Pirate]

If they're in cardiac arrest from their dissection or ICH, they're dead no matter what you do. TPA isn't going to hurt.

we had a long code that the doc almost gave TPA to due to suspected PE, we finally got ROSC to to CT - massive ICH - comfort care, died before leaving the ED. Doc "good thing we didn't give TPA" I responded "same outcome would have occured - just for $5k more"

 

[gutonc]

In fact lots of these medicines make outcomes worse. For any one individual dead person, I guess you can't make them more dead. But when applied to a cohort of so-called dead people that roll into ER's every day around the nation, the number that survive with anything meaningful life is reduced when calcium or epi x >= 3 is administered. Some dead people get 8 rounds of epinephrine. That makes them even MORE dead. They might get a stiffy before (or while) dying because they have so much adrenaline in their bodies, but jeez who ever though 8 mg of epi is good for any cell in the body. We start epi drips at 0.05 -2 mcg/kg/min. So they are getting 5-10 mcg / min. And we give dead people 8 mg over 30 minutes.

The bolded is my new favorite phrase. I don't work in the ED or the ICU, so I doubt I'll get the opportunity to use it much, but thank you for it.

 

[Dred Pirate]

In fact lots of these medicines make outcomes worse. For any one individual dead person, I guess you can't make them more dead. But when applied to a cohort of so-called dead people that roll into ER's every day around the nation, the number that survive with anything meaningful life is reduced when calcium or epi x >= 3 is administered. Some dead people get 8 rounds of epinephrine. That makes them even MORE dead. They might get a stiffy before (or while) dying because they have so much adrenaline in their bodies, but jeez who ever though 8 mg of epi is good for any cell in the body. We start epi drips at 0.05 -2 mcg/kg/min. So they are getting 5-10 mcg / min. And we give dead people 8 mg over 30 minutes.

Only 8 rounds? Those are rookie numbers. The most have seen given is 18. Ya. They were still dead.

 

[Druggernaut]

I've had ROSC on two patients with known PEs that I've given tPA. One was recently diagnosed with a PE but never took his anticoagulation after hospital discharge, one was an inpatient boarding in the ED and gradually declined over hours. Both got it within 5 minutes of presentation and took nearly 30 minutes for ROSC (my personal minimum to keep at it if I'm giving tPA). Both ultimately died anyways.

Never had one get ROSC after giving tPA based on echo or history but no confirmatory testing, but it's a total of probably 5 or less. I'd give it early or not at all.

 

[RustedFox]

For the most part. X1. Unless obvious response or tox/dialysis pt etc. Won’t make them anymore dead. My ems systems in my area usually call codes in the field often. So if they come in they’re typically young or short downtime etc etc. If one falls through the crack and it’s some rigid 90 year old I call it before they’re even transferred from ems stretcher.

It also takes less than 10 seconds to push all three since the code cart is already cracked and I’m already about to do my echo. I personally don’t run any codes without an ultrasound so we don’t sit there wasting time looking for a pulse. It also helps me call it earlier sometime too.

This. FTW.
Bro, lemme come work with you.

 

[Dantrolene FC]

Only 8 rounds? Those are rookie numbers. The most have seen given is 18. Ya. They were still dead.

Anesthesia resident here. I’ve been involved in a case in the OR where we lost track of how much epi we gave. We ran out of epi in the OR, so I grabbed the code tray, for which we ran out of epi in it. Then I went to the pharmacy and grabbed more epi to use.

It was this day that I discovered 30mg/30mL vials of epinephrine. I grabbed a handful of those and we went through 2 of those in addition to all the other epi. A conservative estimate would be 75 mg of epi was given.

 

[SpacemanSpifff]

Anesthesia resident here. I’ve been involved in a case in the OR where we lost track of how much epi we gave. We ran out of epi in the OR, so I grabbed the code tray, for which we ran out of epi in it. Then I went to the pharmacy and grabbed more epi to use.

It was this day that I discovered 30mg/30mL vials of epinephrine. I grabbed a handful of those and we went through 2 of those in addition to all the other epi. A conservative estimate would be 75 mg of epi was given.

That’s a desperate surgeon.

 

[DocEspana]

Sounds like I do it more often than most. I have had variable success although it’s hard to tell if that’s the direct reason. I absolutely don’t do 60 minutes. I do 15 minutes. Repeat tpa + 15 mins if I decide to run longer. But I always make the decision very early. Essentially intubate, give a round of Epi, Ca, Bicarb back to back to back. Usually already on IVF and given D50 in the field. Then immediately do a echo and look at RV. If there’s a good story for it, or they’re young. Even if I think it’s recent pure cardiac lesion I’ll do it. With that said I don’t do it on any unknown downtime and they have to present pretty quickly. Don’t do it on gomers or dialysis pts.

You’re giving calcium and sodium bicarb to all your codes?

I'm more confused by the use of calcium regularly. One of my personal pet peeves. "Goal" is stabilizing against arrhythmias, "risk" is making them actively harder to bring back to ROSC. Unless I see an arrhythmia (at which point I'm also using anti-arrhythmics which are almost certainly more effective anyway), calcium is just lowering my chance of bringing them back from "real low" to "slightly lower than that."

I get that bicarb "doesnt work" on someone without a native respiratory drive, but I also feel like that's a more standardly accepted "hail mary" move with little/no downside.

 

[DocEspana]

btw this whole argument is rather irrelevant for me as my EMS transports out of hospital asystoles as long as:
1. they spend less than 20 minutes at the scene (they can pronounce IF they CHOOSE to stay there 20 minutes), ambulance time doesnt count, only at-the-scene time
2. there is no evidence of rigor mortis
3. end tidal CO2 is >5. Thats not a typo.

so we are getting everyone except those who are essentially cold and dead for a long time. Aint none of these guys coming back at my site unless their name is lazarus and my god complex is *literally* deserved.

 

[Rekt]

I'm more confused by the use of calcium regularly. One of my personal pet peeves. "Goal" is stabilizing against arrhythmias, "risk" is making them actively harder to bring back to ROSC. Unless I see an arrhythmia (at which point I'm also using anti-arrhythmics which are almost certainly more effective anyway), calcium is just lowering my chance of bringing them back from "real low" to "slightly lower than that."

I get that bicarb "doesnt work" on someone without a native respiratory drive, but I also feel like that's a more standardly accepted "hail mary" move with little/no downside.

Again not all. Mega gomer, no. Asystole, no. Grannny didn’t want to be complicit with her oxygen and arrested, no. Etc PEA and young, Sure. And obviously not for ventricular dysthymia’s wtf.

 

[hopeful22213]

If they have coded from a thoracic aortic dissection, then nothing you can do will bring them back. You have nothing to lose by giving tPA. If somebody sues you for that, please let me know because I will be an expert witness against the expert witness that testified that your actions contributed to their death.

A well respected cardiovascular surgeon who specialized in thoracic aortic repair told me if it ruptures in the OR prior to the patient being on the bypass machine, there is nothing he can do to save the patient's life. We shouldn't even do CPR on patients with a ruptured TAD.

I gave TPA in a code that I got back that was a PE. Syncope, came in hypoxemic, coded 5 mins after hitting the door. I did it before the CT of his head despite his age (70 something) and large head lac. It was a last ditch effort. I've given lytics to a guy coming in with chest pain ("steak stuck in my esophagus") who had a history of esophageal stricture. APP gave Reglan and he coded. I gave TPA wondering if it was a dissection, but figured if it was, nothing I would do would help him. If it's a PE, TPA could. My friend -- the local ME -- gave me a hard time for lysing a TAD. I also lysed someone who came in as a STEMI and coded immediately after his 12-lead was obtained. Had a ruptured wall. None of these led to litigation or peer review.

Not to digress too much, but wasn't a thoracic aortic aneurysm one of the cases in "The L Word" podcast? The ER doc did seemingly everything right but the patient was transferred, ruptured and died basically immediately upon arrival to the receiving facility and the initial doc was sued. As I recall it, he settled after the plaintiff's attorney threatened to go after his house and garnish future wages.

 

[TooMuchResearch]

Not to digress too much, but wasn't a thoracic aortic aneurysm one of the cases in "The L Word" podcast? The ER doc did seemingly everything right but the patient was transferred, ruptured and died basically immediately upon arrival to the receiving facility and the initial doc was sued. As I recall it, he settled after the plaintiff's attorney threatened to go after his house and garnish future wages.

Don't work in whatever state that happened.