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

- Rogue Medic

Excited Delirium Strikes without Warning – Part I

In the February issue of JEMS, Dr. Keith Wesley has a very important article about excited delirium and in custody deaths.

According to the U.S. Department of Justice, 47 states and the District of Columbia reported 1,095 arrest-related deaths from 2003–2005.[1]

Assuming that the 2003-2005 means January 01, 2003 through to December 31, 2005, that means 1,095/3 years or 365 in custody deaths per year. Almost an average of one a day. 2004 was a leap year with 366 days. Maybe leap days exert a protective effect against excited delirium. 🙄

Before the proliferation of such less-lethal techniques as CEDs, pepper spray and bean bag rounds, many subjects who were this aggressive met their death from the use of lethal force.[1]

In custody death is nothing new. These deaths just seem less preventable when they are the result of GSWs (Gun Shot Wounds), rather than the now he’s alive – now he’s dead – and he stays dead presentation that is typical for these patients.

Current research reveals excited delirium patients have abnormally altered levels of several neurochemicals in their brain—the most important being dopamine.(4)[1]

This can happen even among those not taking stimulant drugs.

Elevated levels of dopamine cause agitation, paranoia and violent behavior. Heart rate, respiration and temperature control are also affected by dopamine levels with elevation resulting in tachycardia, tachypnea and hyperthermia. For this reason, hyperthermia is a hallmark of excited delirium.[1]

Kind of like hyperventilation syndrome on crack cocaine.

As dopamine levels rise, in combination with the stimulant effects of drugs, the patient’s metabolic activity increases. This results in hyperthermia. The patient becomes acidotic as a result of muscle activity, which has been documented to elevate creatinine phosphokinase—a protein released from muscle death. Metabolic acidosis results in hyperkalemia, which can precipitate dysrhythmias. Therefore, when cardiac arrest occurs, it does so in an environment of severe acidosis and hyperkalemia.(6)[1]

Therefore, when cardiac arrest occurs, it does so in an environment of severe acidosis and hyperkalemia.

A study in Los Angeles reviewed 18 consecutive witnessed arrests from excited delirium. Despite receiving immediate ALS care, all patients died.(8)[1]

Despite receiving immediate ALS care, all patients died.

It may be a good idea to start treatment with calcium (chloride is preferred, but gluconate can work, too).

Why calcium?

1. If this is a case of hyperkalemia, there is no more effective initial treatment than calcium.

2. If this is a case of hyperkalemia, there is nothing that works as quickly as calcium.

3. Even with immediate ALS (Advanced Life Support), nobody seems to be able to resuscitate these patients, so there does not appear to be anything to lose. How can calcium possibly make things any worse?

The resuscitation rate for witnessed arrests should at least equal the resuscitation rate for the community as a whole. These patients do not respond to conventional ACLS (Advanced Cardiac Life Support). Therefore, these patients should not be treated as conventional cardiac arrest patients.

Given the expectation that these patients are hyperkalemic, is it responsible to treat these patients as anything other than hyperkalemic?

If hyperkalemia is left untreated, a sine-wave pattern, idioventricular rhythms, and asystolic cardiac arrest may develop.203,204[2]

ACLS Modifications in Management of Severe Cardiotoxicity or Cardiac Arrest Due to Hyperkalemia
Treatment of severe hyperkalemia aims at protecting the heart from the effects of hyperkalemia by antagonizing the effect of potassium on excitable cell membranes, forcing potassium into cells to remove it promptly from the circulation, and removing potassium from the body. Therapies that shift potassium will act rapidly but are temporary and thus may need to be repeated. In order of urgency, treatment includes the following:

Stabilize myocardial cell membrane:
· Calcium chloride (10%): 5 to 10 mL (500 to 1000 mg) IV over 2 to 5 minutes or calcium gluconate (10%): 15 to 30 mL IV over 2 to 5 minutes[3]

That is the initial treatment for hyperkalemia. That is what EMS should focus on.

Some people will say that we should start with sodium bicarbonate. Ignore them. They do not know what they are talking about. Every responsible organization should make it clear that calcium is the initial treatment for unstable hyperkalemia.

When cardiac arrest occurs secondary to hyperkalemia, it may be reasonable to administer adjuvant IV therapy as outlined above for cardiotoxicity in addition to standard ACLS (Class IIb, LOE C).[3]

Otherwise, there is no reason to believe that these patients will be resuscitated. Similarly, we should focus on calcium when treating cardiac arrest with dialysis patients.

To be continued in Excited Delirium Strikes without Warning – Part II.

Footnotes:

[1] Excited Delirium Strikes without Warning
by Keith Wesley, MD, FACEP
JEMS February 2011 Issue
Tuesday, February 1, 2011
Article

[2] Hyperkalemia
2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care
Part 12: Cardiac Arrest in Special Situations
Part 12.6: Cardiac Arrest Associated With Life-Threatening Electrolyte Disturbances
Free Full Text From Circulation with link to Free Full Text PDF Download

[3] ACLS Modifications in Management of Severe Cardiotoxicity or Cardiac Arrest Due to Hyperkalemia
2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care
Part 12: Cardiac Arrest in Special Situations
Part 12.6: Cardiac Arrest Associated With Life-Threatening Electrolyte Disturbances
Hyperkalemia
Free Full Text From Circulation with link to Free Full Text PDF Download

.

Up in the Air – Suspending Ethical Medical Practice I

In this week of holiday travel and the stress produced by the security theater of the TSA (Transportation Security Administration), it is reasonable to look at the stress that can be produced by medical theater.

An article in the New England Journal of Medicine describes a complication faced by five doctors in dealing with an in-flight cardiac arrest.

After 25 minutes of basic cardiac life support, there was still only pulseless electrical activity. The five physicians agreed that it was time to stop the code and declare the patient dead. But the flight attendant explained that if we stopped CPR, the airline’s protocol would require the cabin crew to continue it in our stead. “This is futile,” muttered the surgeon, and without discussion, he returned to his seat, leaving four of us facing a dilemma: If we turned the resuscitative efforts over to the crew, who would look after the passengers? But if we continued CPR, we would be treating a patient who had clearly been “overmastered” by his disease.[1]

There are a lot of comments in response to this. Two of the doctors continued CPR (CardioPulmonary Resuscitation), even though there was no good reason to continue CPR at this point.

The pilot announced that he was diverting the plane to a small airport. The crew calmed the passengers, addressed their other needs, and attended to landing preparations. As we descended steeply, the pilot ordered everyone to be seated. The anesthesiologist and oncologist complied. We were down to two physicians administering CPR. A flight attendant took over the use of the Ambu bag and required coaching on technique. I was instructed to hold onto my wife as she continued chest compressions, both of us half-strapped into stretched safety belts to allow us to continue CPR during the landing.[1]

Being transported in a car, a baby held in the arms of the baby’s mother is not considered restrained. The rapid deceleration from even 30 miles per hour is going to dramatically increase the weight of the baby to the point where the mother cannot hold onto the baby. The baby is no longer a baby. The baby is now a projectile.

Now, if a baby travelling at the speed of 30 MPH is too heavy for a mother to restrain, how much more futile will it be to attempt to restrain an adult travelling at several hundred MPH?

Futile CPR x futile attempts at restraint = Futile2?

I have never attempted to perform CPR during the landing of a plane, but I do not expect that it is any more effective than the ineffective CPR performed in a moving ambulance. The doctor and the flight attendant performing ineffective CPR were only endangering the other passengers and themselves. They are not just not restrained, but they are not even in seats that might act to partially restrain them.

Doesn’t the airline have a protocol requiring everyone, including flight attendants, to wear seat belts during take-off and landing?

Why does the ridiculous protocol trump the sensible protocol?

We had knowingly delivered medically ineffective CPR. But we did so because of practical concerns arising from the demands of the airline’s protocol. CPR was going to go forward whatever we decided, and we chose to continue it ourselves so that the four flight attendants could attend to their duties during an emergency landing.[1]

How is endangering everyone in the cabin a practical concern?

On solid ground, I believe that medical policy and protocols should preclude such dilemmas. The responsibility for deciding to stop CPR should rest with a physician who is focused solely on the good of the patient.[1]

What if focusing solely on the good of the patient, in this case a clearly dead patient, endangers others who are not yet patients? The others may end up being patients due to the actions of the physician, or the others may end up so dead that no resuscitation is even attempted on them.

Terminating Resuscitative Efforts in Adult OHCA
Terminating Resuscitative Efforts in a BLS Out-of-Hospital System
Rescuers who start BLS should continue resuscitation until one of the following occurs:

  • Restoration of effective, spontaneous circulation
  • Care is transferred to a team providing advanced life support
  • The rescuer is unable to continue because of exhaustion, the presence of dangerous environmental hazards, or because continuation of the resuscitative efforts places others in jeopardy
  • Reliable and valid criteria indicating irreversible death are met, criteria of obvious death are identified, or criteria for termination of resuscitation are met.
  • One set of reliable and valid criteria for termination of resuscitation is termed the “BLS termination of resuscitation rule” (see Figure 1).23 All 3 of the following criteria must be present before moving to the ambulance for transport, to consider terminating BLS resuscitative attempts for adult victims of out-of-hospital cardiac arrest: (1) arrest was not witnessed by EMS provider or first responder; (2) no return of spontaneous circulation (ROSC) after 3 full rounds of CPR and automated external defibrillator (AED) analysis; and (3) no AED shocks were delivered.[2]

    During landing, continuation of the resuscitative efforts places others in jeopardy.

    Termination of Resuscitative Efforts and Transport Implications
    Field termination reduces unnecessary transport to the hospital by 60% with the BLS rule and 40% with the ALS rule,25 reducing associated road hazards34,35 that put the provider, patient, and public at risk. In addition field termination reduces inadvertent paramedic exposure to potential biohazards and the higher cost of ED pronouncement.36-38 More importantly the quality of CPR is compromised during transport, and survival is linked to optimizing scene care rather than rushing to hospital.39-41
    [2]

    In the absence of an effective restraint system that permits CPR in an airplane during landing, those who do not regain pulses should be pronounced dead.

    The airline should have a protocol that specifically states this. Encouraging passengers or flight crew to endanger others, when CPR has not been effective, is endangering the passengers and the flight crew.

    This is irresponsible behavior by the airline.

    There are a lot of comments. Some provide good approaches to this. Others demonstrate that being a doctor and being sensible do not necessarily go together. I will address the comments in Up in the Air – Suspending Ethical Medical Practice II and later in Up in the Air – Suspending Ethical Medical Practice III

    Footnotes:

    [1] Up in the Air – Suspending Ethical Medical Practice.
    Shaner DM.
    N Engl J Med. 2010 Nov 18;363(21):1988-1989.
    PMID: 21083383 [PubMed – as supplied by publisher]

    Free Full Text Article from N Engl J Med with comments and links to Free Full Text PDF download

    [2] Terminating Resuscitative Efforts in Adult OHCA
    Part 3: Ethics
    2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care
    Witholding and Withdrawing CPR (Termination of Resuscitative Efforts) Related to Out-of Hospital Cardiac Arrest (OHCA)
    Terminating Resuscitative Efforts in OHCA
    Free Full Text Article with links to Free Full Text PDF download

    .

    Potentially Reversible Causes – Hypothermia

    I suppose that I should stop procrastinating and complete start the potentially reversible causes of cardiac arrest.

    Working through the potentially reversible causes mnemonic, COLD PATCHeD,[1] the first letter is C, the first word is COLD, so this should make it pretty clear that the C refers to being too coldhypothermia.

    C for Hypothermia.

    But first, let me describe someone progressing from a normal healthy 14 year old to an unconscious hypothermia patient. Almost the full spectrum of temperature change.

    At that age, many feel invulnerable. Riding a bicycle to the library is just a normal way to get around. Living on a long steep hill, riding much faster than the cars is inevitable tempting. Traveling fast in cold weather leads to wind chill factor effects. The wind chill factor means that the wind speed amplifies the feeling of cold. This also amplifies the process of heat loss.

    From the Wind Chill Chart,[2] we’ll use 60 miles per hour to calculate the wind chill, because the chart only goes that high. Traveling up to 60 MPH on that hill is not difficult. The big problem is drivers of automobiles, who don’t look before turning. It only takes one. That was not the problem on this day.

    A minute at zero degrees wearing a loose fitting down jacket, thin gloves, and no hat. Invigorating if you don’t prolong it. From the steep hill, there is a longer, more gradual hill. this allows you to prolong the contribution of gravity. Then the up hill part. This should cause enough heat production to ward off hypothermia, but not on this day. The energy is not there. The pedaling is not as coordinated as it should be. Lacking the energy to pedal and the coordination to ride, pushing the bicycle becomes the next best means of travel. Still up hill. Shivering. At that time, there are few businesses or residences in the area, but giving up on the trip to the library is not really an option, yet. The library is nice and warm. They even have a good selection of books. Worst case – call for a ride home from the library. Worst case.

    Switching to the side of the road facing oncoming traffic, since there is no possibility of riding any more. Now having trouble just walking in a straight line and way too tired. Don’t know how much longer this went on, but near the top of the hill, continuing was no longer an option. Not even shivering any more. The first house has some lights on inside. Knock on the door.

    Unable to speak without dramatically slurring the words. The door is slammed shut, but there is no energy to continue. Don’t have the coordination to keep moving. Don’t really care at this point, because that is what hypothermia can do to you. Slump to the ground and wait.

    Not really choosing to wait. Not caring. Not continuing.

    Some people show up and get dragged inside. This is different. Not the usual bicycle ride. Not the usual trip to the library.

    A mask is placed over the face. A bag being squeezed.

    Next thing I remember is waking up in the hospital. The doctor can’t figure out what is wrong.

    Doctor For Whom Temperature IS Confusing – What did you take?

    Young RM – I was cold.

    DFWTIC – Don’t lie to me. What did you take?

    Young RM – I was very cold.

    Repeat ad nauseam. Apparently the doctor went to a medical school that had not been introduced to the wonderful medical advance – the thermometer. If only there were an organization, like JCAHO, to make sure the clueless complied with a check sheet to be able to diagnose the obvious.

    Just kidding. Everybody should realize that JCAHO exists to help the incompetent continue their careers.

    I’d much rather have competent people providing care, than an organization that coddles the least common denominators. Least common denominators need to be remediated or terminated, but definitely not coddled.

    That day I had a scared housewife call 911 the local emergency number, because in that county it took until the Clinton administration for them to get the various corrupt volunteers fire chiefs to agree to allow such progress despicable usurpation of their fiefdoms. Fortunately, the housewife was the wife of one of the ambulance volunteers and familiar with the numbers for the various departments.

    Hypothermia comes from the Greek for low temperature. Cold. How cold is cold? When dealing with a hypothermic cardiac arrest, or severe hypothermia, a body temperature less than 86° Fahrenheit (less than 30° Celsius or centigrade). In EMS, we often do not carry a reliable thermometer, so how can we tell? Symptoms.

    Treatment priorities are:

    1. Stop the person from becoming colder.

    If the patient is at all wet, this means get the wet clothes off of him, dry him off, then worry about warming him up.

    You can try to warm the patient up while he is still wet. You can also try to fly by flapping your arms. Trying isn’t going to do it.

    If you don’t dry the patient off, you might as well just drive a stake through his heart. Unless he is dry, he is losing more heat into the moisture than you will replace. Except maybe if you set him on fire. Just make sure you turn the oxygen off, first. And open some windows, burning patient leaves a really nasty smell.

    What about #2? You only gave us one priority.

    As far as EMS is concerned, that is all that really matters, unless you have extended transport times.

    Assuming you have dried the patient off, they do not appear to be cooling down, now what?

    2. Assuming that you have done a good job of protecting them from getting colder. Warm them up.

    [youtube]PojH541L3ZY[/youtube]

    My apologies for the comments made, at 2:48 and 2:58of the video, by one of the people looking at this. It is not uncommon for people to use these words to demonstrate that they are overwhelmed by what is going on.

    The last couple of minutes show the survivors being pulled to the side of the river. Earlier the video showed a couple of people with the appropriate life vests in a metal row boat paddling around, looking ready to capsize. They did not seem to rescue anyone. The video showed a bunch of people carrying an inflatable row boat, that similarly was not able to rescue anyone. If you use boats as a part of a rescue, will you be any better prepared? Maryland/DC/Virginia does not get weather like this often, so it is not surprising that they did not do a good job navigating around the ice. They describe it as the worst storm in decades.

    Notice the guy who jumped in the water, swam out to one survivor, and pulled her to shore. He was told to get behind the fire trucks. He is wet and needs to be dried off. He needs to be kept from getting cold. They sound as if (my interpretation of the comments) they are more worried about him making the professional rescuers look bad.

    Everybody who was rescued was rescued by someone who appeared to be breaking the rules.

    The helicopter probably should no have been there. Initially, visibility was very poor. They were involved, at least partially, in the rescue of every survivor. The by-stander, who jumped in and swam to the woman trying to drown, was just a by-stander. He was astute enough to realize that everybody was just going to watch her drown. No equipment was close enough to reach her. The only way for her to survive was for someone to jump in. It should have been someone with a life preserver on.

    It appears she was less than 20 feet from the side of the river. It also appears that she was incapable of staying afloat on her own. If this by-stander had not jumped in, what would everyone have said about her death? Maybe she would have been resuscitated, but that is assuming that somebody has a way of grabbing her. It does look as if there is one person in a turn out coat has a life preserver that he is dragging out to her. Would he have acted if the by-stander had not jumped in? Why wear turnout gear in the water? More mindless observation of rules.

    At 4:30 of the video – They were all just standing there looking at us with their lights going and their sirens going and all that. And eventually I realized they had no way to get to us.

    We do spend a lot of time exerting our authority by using our sirens. Not very helpful when the sirens cannot make a bit of difference, but that never seems to stop some people.

    Some additional reading on hypothermia (all provide excellent information):

    Hypothermia
    Circulation. 2005;112:IV-89 – IV-110.
    © 2005 American Heart Association, Inc.
    2005 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care
    Part 10.4: Hypothermia

    Hypothermia
    eMedicine
    Article
    eMedicine

    Hypothermia-Related Deaths – – United States – 1995 – 2002 and 2005
    MMWR – Morbidity and Mortality Weekly Report March 17, 2006
    55(10); 282-284
    Free Full Text . . . . . Free PDF (type 14 or 282 in the page window when the pdf opens, depending on which it accepts. It begins at 14/32 pages.)

    Other MMWR hypothermia pages

    Footnotes:

    [1] Potentially Reversible Causes of Cardiac Arrest – Another, Better, Mnemonic
    Rogue Medic
    Article

    Again, thanks to JB of JB on the Rocks for this.
    Cold (hypothermia), Oxygen deficit, ‘Lytes, Drugs, Pulmonary Embolus, Acidosis, Tension Pneumo, Cardiac Tamponade, Hypovolemia. I add epi and Distributive shock.

    [2] National Climatic Data Center
    Wind Chill Chart

    Updated 8/12/2011 for links and formatting.

    .

    Potentially Reversible Causes of Cardiac Arrest – Another, Better, Mnemonic

    In the comments to Potentially Reversible Causes of Cardiac Arrest – Arrhythmia, Jeff B of JB on the Rocks wrote,

    I use COLD PATCH rather than Hs/Ts…

    Cold (hypothermia), Oxygen deficit, ‘Lytes, Drugs, Pulmonary Embolus, Acidosis, Tension Pneumo, Cardiac Tamponade, Hypovolemia.

    I have been thinking about this for a bit, because the eD of the mnemonic I was using (PATCHeD) includes stuff that I think is important. My hesitation was not over the value of his mnemonic, it is much better than mine, just how to include the little, but not insignificant parts that I cover with eD. I was thinking that COLD PATCHeD would work, but just doesn’t feel right. It is the best I have been able to come up with. I will cover all of these in more depth, over the next month or so. Since the eD part is last, they will be covered last. The e part belongs at the beginning, since it is a reminder to cover the basics. The remaining D, since COLD moves on D farther up, is a way to transition to postresuscitation care, so it belongs at the end.

    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 for Oxygen deficit or hypoxia.

    L for 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 for Drugs (OD or OverDose, poison, wrong drug, wrong dose, . . .).

    This does an excellent job of making it easier to remember each of the Hs, by changing them to something more memorable.

    Jeff B comes up with some excellent ways of teaching all things that fall into the emergency medical field. My only complaint is that he doesn’t write about these enough on his JB on the Rocks blog.

    .

    Potentially Reversible Causes of Cardiac Arrest – Arrhythmia

    In my last post, Not Successful Resuscitation, I mentioned the potentially reversible causes of cardiac arrest. First a definition. These are conditions that can lead to sudden death as well as a more gradual death. In the case of a more gradual death, their potential for reversibility dramatically decreases. One of the reasons is that these conditions, conditions bad enough to kill you, can cause significant organ damage when they are present for an extended period. Acidosis is very destructive to the body, but if it is a sudden change, rather than a long term condition (especially one that is not responding to aggressive medical treatment), then reversing the acidosis may help to resuscitate the patient.

    Why only may?

    There are many factors that affect the ability to resuscitate a patient. As I mentioned, a gradual onset is not as easy to reverse. A gradual onset is because the illness is a chronic condition or a progressive condition.

    But if it is a progressive condition, that has progressed to death, how can it be a reversible cause of cardiac arrest?

    The potentially reversible causes tend to be sudden. That does not mean that a gradual onset rules out resuscitation, just that it becomes much more difficult to resuscitate these patients, and much more difficult to keep these patients alive if we do manage to resuscitate them. These causes tend to be overwhelming to the body. Still, a sudden onset of a potentially reversible cause of cardiac arrest may not respond to treatment, even if the patient is in the ideal treatment setting, because these causes are only potentially reversible.

    Then why spend so much time on them?

    All of resuscitation is about potentially reversible causes. VF/Pulseless VT (Ventricular Fibrillation/Pulseless Ventricular Tachycardia) are the easiest to reverse, the most likely to be reversed, and the easiest to diagnose.

    Diagnose? Paramedics can’t diagnose.

    Of course you can. You just can’t legally claim that you are diagnosing. This is purely a legal distinction. It has no basis in reality.

    Arrhythmia – shocking a shockable rhythm.

    Some of the arrhythmias that can cause cardiac arrest may be reversed by defibrillation. Some of the arrhythmias that can cause cardiac arrest will not improve with defibrillation. Asystole is an excellent example of an arrhythmia that will not respond to defibrillation. Asystole is caused by defibrillation. We shock patients because we want to cause asystole – temporarily.

    The defibrillation is designed to send enough current through the heart to stop the heart for less than a second. The purpose of defibrillation is to get rid of the dangerous rhythm that is controlling the heart, whether it is an organized rhythm, such as VT or SVT (SupraVentricular Tachycardia), or disorganized activity, such as VF.

    After the shock is delivered, and some asystole is produced, it is hoped that the heart starts again on its own and when the heart starts again, it is hoped that the sinus node will be controlling the rate and rhythm. If the patient’s normal pacemaker is not the sinus node (a couple of examples are atrial fibrillation or an implanted pacemaker), then the hope is that the normal pacemaker resumes its role of initiating a rhythm capable of keeping the patient alive.

    In western movies, during a big bar fight, the sheriff may fire a gun into the air. Everyone tends to stop, at least long enough to make sure the gun is not pointed at them. This pause in the commotion is what defibrillation is supposed to accomplish. The sheriff is telling the arrhythmia to move along. As in the movies, it does not always work as planned. If the arrhythmia/chaos does not go away with defibrillation, more defibrillation may be attempted. Even if the ceiling is shot full of defibrillations, there is no maximum number of defibrillations, as long as the patient is in a shockable rhythm. Antiarrhythmic medications may be added to the treatment (after some epinephrine, the most arrhythmogenic drug we use). The search for other potentially reversible causes of cardiac arrest will contribute to treatment.

    Arrhythmogenic?

    Something that causes arrhythmias. I describe problems with the use of epinephrine in Epinephrine in Cardiac Arrest, More on Epinephrine in Cardiac Arrest, and Dead VT vs Not Quite Dead, Yet VT.

    What if the asystole is not temporary?

    This is not unusual. The current ACLS (Advanced Cardiac Life Support) algorithms are pretty easy to use.[1] If you are using an algorithm that no longer applies, you should switch to the algorithm that does apply. I will cover asystole in another post.

    Are there any other rhythms that should be defibrillated?

    SVT – if the patient is pulseless. Any rhythm that would be cardioverted, if the patient were alive, should be defibrillated if the rhythm is bad enough to produce a dead patient. Although this falls into the category of PEA (Pulseless Electrical Activity), it is a shockable rhythm and will respond best to defibrillation.

    One of the perversions of the algorithms is that they spend almost no time on Postresuscitation Support. There is no algorithm, flow sheet, or other easy to use chart. The 2010 ACLS Guidelines added an easy to use algorithm.[2] This is the AHA (American Heart Association), in the 2000 guidelines they were not discouraged by the possibility of an overly dense, extremely confusing 3 page tachycardia algorithm “overview” flow sheet. Pages 1, 2, and 3, followed by the individual pages for specific tachyarrhythmias. Fortunately they did learn from that, but there is still no algorithm to ease recall of postresuscitation care – something that is not well understood. That will be more than another post.

    There are methods of determining if the arrest is one that may be reversed by treatment. Again, this is something for another post.

    That is enough of the potentially reversible causes for this post. And I haven’t even started on the list of potentially reversible causes. 🙂

    The PALS (Pediatric Advanced Life Support) potentially reversible causes of cardiac arrest list is 5 H’s and 5 T’s:

    Hypovolemia; Hypoxia; Hydrogen ion (Acidosis); Hypo/Hyperkalemia; Hypoglycemia; Hypothermia.

    Toxins (Drugs); Tamponade, cardiac; Tension pneumothorax; Thrombosis (coronary or pulmonary – AMI or PE); Trauma

    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.

    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 for Oxygen deficit or hypoxia. L for 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 for Drugs (OverDose, poison, wrong drug, wrong dose, . . .).

    PATCHeD = PPE (Pulmonary Embolus); A Acidosis and AMI (Acute Myocardial Infarction); T Tension Pneumothorax; C – Cardiac Tamponade; H – Here it is still confusing, a whole bunch of Hypo’s and one Hyper. The Hypo’s: HypoVolemia; HypoThermia; HypoGlycemia; HypOxia; HypoKalemia; The Hyper: HyperKalemia; e – Everybody dead gets Epi. Just a reminder to continue CPR and other treatments. D Drugs (OD, poison, wrong drug, wrong dose, . . .); Distributive Shock.

    I will have to write a post on why each of 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.

    Footnotes:

    [1] 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science
    Volume 122, Issue 18_suppl_3;
    November 2, 2010
    Guidelines index

    Below is the link to the old guidelines:

    2005 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care
    Volume 112, Issue 24 Supplement;
    December 13, 2005
    Guidelines index

    [2] Post–cardiac arrest care algorithm.
    2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care
    Part 9: Post–Cardiac Arrest Care
    Systems of Care for Improving Post–Cardiac Arrest Outcomes
    Algorithm in JPEG format

    Part 9: Post–Cardiac Arrest Care
    2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care
    Free Full Text From Circulation with link to Free Full Text PDF Download

    Part 7.5: Postresuscitation Support
    2005 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care
    Free Full Text From Circulation with link to Free Full Text PDF Download

    Footnotes were added 5/11/2011 to include links to 2010 ACLS guidelines. Links were also updated.

    .

    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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