Without evidence of benefit, an intervention should not be presumed to be beneficial or safe.

- Rogue Medic

Not Successful Resuscitation

Here is another Normal Sinus Rhythm post. The topic this week is kids, so it should be interesting what different people write about, since this is one of the few calls that almost everyone in EMS dreads. Read the rest of the NSR Blog posts at NSR Week 7.

EE at Backboards and Band-Aids writes the messenger.

Her posts are usually very brief. Here she shows that she really knows how to write when she has a little more to communicate.

Telling someone that a loved one – spouse/parent/child/fiance/. . . – is dead is very difficult to do. I prefer to be the one to tell people, not because I do it so well, but because I have seen it done so badly.

I have always hated the phrase, “I’m sorry for your loss.” It sounds like a Hallmark card for a stranger you’ve never met. What happened? “Passed on,” “Sorry for my loss,” “No longer in pain,” “No longer with us,”. . . . We ask too much of the family member when we provide vague descriptions of what is going on. Unless we use the words “is dead,” or “has died,” we aren’t helping them to recognize what has happened. These are attempts to say the right thing, but they just seems so far from adequate, at least to me.

That does not mean that we rush to say, “She’s dead. Gotta go,” and leave. That is not at all the right approach.

I prefer to lead them to recognize death themselves. A more gradual approach, but I am not in a rush to get back in service. I just acquired a bunch of potential patients, who may not need anything medical from me. They may need someone to yell at, someone to hold, someone to just be a connection to reality in this unreal time. Until someone they feel more comfortable with shows up. No. I do not remove family from the room, unless they are interfering with care, which is extremely rare.

We are performing CPR. One hand compressions on the center of the sternum (breast bone), about 1/3 the depth of the chest. At least 100 per minute as the compression rate. Compressions on a child, you will probably be compressing too quickly, but try to get an idea of the rate. Compressions should produce a femoral pulse (felt by someone else), so if not maybe that is a clue about a reversible cause of cardiac arrest, or you aren’t compressing deeply enough, possibly out of fear of hurting the child. The child will let you know if you are causing physical pain, but that is not going to happen with a properly assessed cardiac arrest. Too deeply would be where you feel the sternum hitting the spine. Until the tube is in place, compressions are paused after every 15 compressions for 2 breaths. After the tube is in placed and confirmed to be in the right place, there is no reason to pause for breaths, just every couple of minutes for reassessment and/or defibrillation.

What does that mean to the family? They see it on TV and frequently the person on the receiving end of CPR survives. This is not typical, but appears to be more common with switching to compression only CPR.

So, we are performing CPR, after we obtain relevant medical information, we can explain why we do CPR.

This is part of the way through the treatment of the cardiac arrest (and cardiac arrest is not a term that is helpful for family).

RM – “Her heart is not beating on it’s own, so we are trying to keep blood moving to her brain and heart.”

Mom – “She was just in Emergency this morning and the doctor said she was fine.” (This is information we already knew, but it is her attempt to deny what is happening.)

RM – “She is not breathing on her own, so we are trying to keep some air moving to her lungs.”

Mom makes more statements of not comprehending what is happening.

The police want to talk with her because this is unusual. An otherwise healthy 7 year old, who attends a regular school, has no medical history, and was seen in the ED less than 12 hours ago. This child should not be dead. All medications in the home have been accounted for, she has not been out of the sight of her mother since going to the ED for a high fever, with weakness, nausea, and decreased appetite.

While Mom is talking with the police, I contact medical command at the ED where she was seen. The doctor who saw her has gone for the day and nobody there knows anything about her. I explain that the patient has no history prior to today/late last night and that when we arrived she was asystolic (flat line, no electrical activity of any kind in the heart), pulseless (no pulse), and apneic (no breathing). We follow the standard asystole treatments and there is no indication that she has any of the potentially reversible causes of cardiac arrest (the doctor is able to pull up her labs on the computer and everything is normal, including her potassium – hypokalemia, or low potassium, is one of the reversible causes of asystole; vomiting could cause this, but she has not been vomiting, nor has she been taking much in). The potentially reversible causes are listed at the end of the post.

Her blood sugar was very low, so some D25W (25% Dextrose in Water or concentrated sugar water) is given through an IV. Aspirate a little bit (pull back with the syringe to make sure blood returns, so that we are confident that the IV is in the vein and not leaking), push about 5 ml, look for signs of infiltration (a bulge under the skin that indicates the fluid is leaking out of the vein and under the skin), aspirate again, push D25W again, and repeat until 1 g/kg is in. Or use a length based resuscitation tape, which I wrote about in More Bad Airway Instruction. And everybody dead gets epi, so 0.01 mg/kg epinephrine, and repeat epinephrine every 3 – 5 minutes. Atropine would be appropriate – if she were an adult, but she is not.

I never get another chance to let her come to the realization her daughter has died, but it is unlikely she would, no matter how much time I spent trying to get her to see something she can’t yet accept.

We exhaust the asystole algorithm and medical command says to cease efforts. She had been febrile in the ED, but is cool to the touch when we arrive, not cold, just not really warm either. Mom never really does seem to understand what has happened, still keeps expecting her daughter to meet her, sick, but recovering, in the ED. Not an example of when I was able to persuade a family member to recognize the futility of a resuscitation attempt, but children are different. How do we react to the death of a child? Would we react any more logically if it were our child, or little brother/sister?

The potentially reversible causes of cardiac arrest use 5 H’s and 5 T’s to help remember them [this is how PALS (Pediatric Advanced Life Support) teaches memorizing this].

Hypovolemia.

Hypoxia.

Hydrogen ion (Acidosis).

Hypo/Hyperkalemia.

Hypoglycemia.

Hypothermia.

Toxins (Drugs).

Tamponade, cardiac.

Tension pneumothorax.

Thrombosis (coronary or pulmonary – AMI or PE).

Trauma.

This list is supposed to make it easier to remember the potentially reversible causes when under stress. I recommend memorizing them in a way that works for you. The H and T list does not work for me. Once I get up to three or more items, it becomes hard to remember how many I have covered. I also recommend carrying a cheat sheet that includes cardiac arrest algorithms, especially pediatric, until you feel that you have run enough of these codes, without errors, that you no longer need the cheat sheet.

I have changed this from what I originally wrote. My, borrowed from Jeff B of JB on the Rocks, mnemonic (memory aid) for the potentially reversible causes of cardiac arrest is now two words – COLD PATCHeD. There are others, but this is what I intend to use from now on – at least until somebody convinces me that there is a better mnemonic. Find what works for you, modify it as necessary, and use it regularly. Teaching helps to drill this into my head.

C – COLD reminds you that the C is for hypothermia – being very cold, sometimes we forget the obvious in resuscitation attempts, so it doesn’t hurt to put extra reminders in a mnemonic.

O – Oxygen deficit or hypoxia.

L – Lytes. This works better as a mnemonic for the in hospital crowd, but there is nothing wrong with getting EMS to think more about electroLytes. Hypokalemia and Hyperkalemia – too little and too much potassium.

D – Drugs (OverDose, poison, wrong drug, wrong dose, . . .).

P – PE (Pulmonary Embolus).

A – Acidosis and AMI (Acute Myocardial Infarction).

T – Tension Pneumothorax.

C – Cardiac Tamponade.

H – Here it is now much less confusing, only 2 Hypos.

HypoVolemia and HypoGlycemia.

e – Everybody dead gets Epi. Just a reminder to continue CPR and other treatments – don’t forget the basics.

D – Distributive Shock.

I will have to write a post on why these categories matter, what the treatments are, and other ways to approach them, rather than the order of the mnemonic. This is a lot for one post and a not at all cheerful one.

All of the treatments listed are following the current recommendations of the AHA (American Heart Association) . These are links to the free full text of all of the current AHA guidelines.

Circulation, Volume 112, Issue 24 Supplement; December 13, 2005.

Part 11: Pediatric Basic Life Support.

Part 12: Pediatric Advanced Life Support.

Figure 1. PALS Pulseless Arrest Algorithm image.

TABLE 1. Medications for Pediatric Resuscitation and Arrhythmias.

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Comments

  1. Did you ever find out the cause of death? Or was it just the low blood sugar?Is TCP not in the asystole treatment for PEDS?It's been >2 years since I have done ACLS but in those days everyone in asystole got a "cup of T.E.A":TCPEpiAtropineI haven't done PALS *hangs head in shame* so I am curious…

  2. Albinoblackbear,No. I never did find out the cause. There was a lot of fear of legal action with that, so people were very careful about what they revealed. We never were called in for meningitis prophylaxis or anything similar.

    TCP (TransCutaneous Pacing) is no longer even in the adult asystole algorithm. It was something that they figured should be given a try. Not much to lose. Unfortunately, there has not been improvement in outcome with pacing of asystole. AHA quote at the end.

    Only epi is used in pediatric asystole. My mistake listing the ten times dose. I have corrected that in the post. Only the standard dose is currently in the algorithm. Adults get both epi and atropine. Only living people get pacing.

    Asystole resuscitation seems to be about quickly identifying a reversible cause. Unless you are in a fancy hospital, some of the reversible causes are only wishful thinking.

    PALS, PEPP, or any other pediatric emergency course is a good idea. You have an opportunity to practice with the equipment – something that comes in handy when everybody is afraid to use the IO. They get you to practice a rapid assessment and make decisions based on the limited, but focused information you obtain.

    Here is what AHA wrote about pacing for asystole in adult patients:

    Pacing is not recommended for patients in asystolic cardiac arrest. Pacing can be considered in patients with symptomatic bradycardia.

    Three randomized controlled trials (LOE 2)140–142 of fair quality and additional studies (LOE 3 to 7)143–149 indicate no improvement in the rate of admission to hospital or survival to hospital discharge when paramedics or physicians attempted to provide pacing in asystolic patients in the prehospital or hospital (emergency department) setting.

    2005 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care: Part 5: Electrical Therapies: Automated External Defibrillators, Defibrillation, Cardioversion, and Pacing – Pacing

  3. Here she shows that she really knows how to write when she has a little more to communicate.🙂 Thanks.Interesting case.

  4. Rogue–thanks for the reply. I feel terrible at being out of date with my certs but since I am a one-woman-traveling-nursing-road-show right now I have to pay for everything myself. Currently a new road bike takes priority over PALS cert in my Maslow hierarchy of needs. I know…I am a terrible person. ;)In the meantime I’ll get free medical education and protocol updates from your site. =P

  5. e – Everybody dead gets Epi. Just a reminder to continue CPR and other treatments.I love that one.

  6. EE,It is a great, although painful post. You’re welcome.

  7. AlbinoBlackBear,I am not able to give any kind of certificate for recognition of the amount of material covered. Some of the organizations might actually want you to get more CEs to counter what I write. 🙂

  8. Brick City Medic,How many codes have you been on where somebody forgets to resume compressions or bagging or both.I try to remind people that without the basics, all of the fancy stuff is useless. When it comes to resuscitation, except for the reversible causes of cardiac arrest, all of the fancy stuff (drugs, tubes, IVs) is useless, in my opinion.

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