She frequented a neighborhood park near the hospital. I’d see her times smoking a cigarette while she sat on the playground swings. Many nights, she slept on cardboard by the fence, sometimes she tied a tarp from the fence down to the grass to provide shelter on rainy nights. She was tall and gawky with red hair and looked a lot older than her thirty odd years because she had lost most of her teeth. Nothing makes a person look older than when their gums recede. I first saw her one morning this summer when the temperature was already up into the 90’s and the humidity made it hard to breathe. I asked her if she wanted a bottle of cold water, which she did, smiling in such a way you could see her youth hadn’t completely been obliterated from her body from the hard living she had put it through. I also gave her an orange and a couple bucks. She had a tattoo of a blue pony on her neck. It was faded, but the pony looked like a magical kid’s pony — the kind that could fly when it wasn’t being cuddled by a four-year-old.

I never found...

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Involve the family. When I started it was common practice to shoo the family out of the room. Not just on the scene, but in the ED. I no longer do that. I make certain to explain to a family member or members what we are doing and how things are progressing. If they choose to wait in the kitchen, I will keep them updated, but if they want to stand in the living room and watch, I will explain to them what we are doing. Sometimes, I will let them hold the patient’s hand or brush their hair.

If I am getting ready to cease a resuscitation, I will tell family members what is happening, and I will have them come in (if they are not already in the room) and say their goodbyes. The departing may be able to hear and take the voices of their loved ones with them.  If you need a reminder of why we do what we do, try this. Listen to the family’s good bye.

“Auntie May, I love you. I remember what you’ve done for me. Say hello to Uncle Jim. Tell him we miss him and we’ll be together again. I’ll take care of Jake and Mary. Don’t you worry. I love you, Auntie.”

Anticipate LOSC (Loss of Spontaneous Circulation). Once you have pulses back with ROSC (Return of Spontaneous circulation) anticipate you will lose them and have your plan in place. Premix your epi or norepi-drip and have it ready to go. Don’t start moving the patient immediately after getting ROSC. I usually wait 5 minutes to get the patient secure and make certain they are stable before starting to carry them down that windy staircase. If they arrest on the staircase, it will difficult both to recognize the lost of pulses and then to start compressions. While most know that a sudden rise in ETCO2 during an arrest signals return of pulses as the restored circulation sweeps the buildup CO2 in the distal portions of a body up to the lungs where it is ventilated off, the reverse applies when a patient loses pulses. ETCO2 45, you have pulses and a blood pressure back, you are all slapping each other on the back on a great job done getting the patient back, when you glance at the ETCO2. It is down to 14. Better get back on the chest. ETCO2 signals the loss of pulses as well as regaining pulses. Check out this trend summary of a patient who arrested three times.

If two identical twins are standing next to each other at a family reunion, and one chokes on a sandwich leading to cardiac arrest, and the second suffers a simultaneous VF arrest, and two medics arrive exactly 5 minutes later, and both patients are intubated at the same time, will their ETC02 numbers be the same or different?

Despite being identical twins, they will have different ETCO2 readings.  The twin who went into VF arrest will likely have an ETCO2 in the 20s with CPR.  The twin who choked on his sandwich will have an ETCO2 much higher –likely in the 70s or more.  His heart continued to beat for awhile while he slowly died of hypoxia from an obstructed airway.  The pumping heart pumped CO2 to the lungs where it built up.  Cardiac arrests due to respiratory causes usually have much higher initial ETCO2s than those who suffered sudden cardiac arrest.  (Patient who are hypercapnic as their norm are an exception.).  Those who suffered respiratory causes of their arrest will see their initial high...

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ETCO2 measures cardiac output. The better the CPR, the higher the cardiac output.  The higher the cardiac output, the higher the ETCO2.

While the American Heart Association  recommends you switch compressors every two minutes during a cardiac arrest to prevent compressor fatigue.  A fatigued compressor can’t maintain consistent CPR.  The compressor tires, the cardiac output declines.  Time to switch compressors.  Or so the AHA suggests.

I would accept this if you have two compressors of equal ability and talent at CPR,.  If on the other hand, you have two compressors of different strengths, go with the compressor who can achieve the highest ETCO2. I challenge my partners to do their best CPR and get the ETCO2 up as high as they can. Even if one compressor grows tired, if he is consistently hitting 28, while the fresh compressor can only get to 24, keep the strong one on the chest.

Use the ETCO2 level as your marker not an artificial two minute limit.

When intubating preattach the ETCO2 to the tube.  If you have a narrow stylet, this is possible.  Attach the ETCO2 to the monitor.  If I have trouble seeing the chords, I hand the tube to my assistant, then using my right hand apply crick pressure until I can see the chords, then I have my assistant replace his fingers where mine were, and I pass the tube.  Once the tube is passed, I look at the monitor.  If CPR is being done, this is what I will see.

The CPR is creating passive ventilation that registers on the monitor.  Once the ambu-bag is attached and the first ventilation given, the cpr wave form is replaced with the traditional form. 

Instead if you just see flat line (with CPR) you may not be in.

Unless you are certain the tube is good, don’t bother with checking belly and lung sounds just take it out and try again or insert a supraglottic airway.

Stay Tuned for cardiac arrest PEARL # 6  The Clock

Make certain the CPR and airway management are being done properly. When I started our protocol said to intubate immediately.  On arrival, I would turn my back on the code and take the two minutes it takes to get my intubation roll out, unzip everything, take everything out, open the packages, assemble everything and then finally approach the patient.  Now I watch the compressions and the ventilations.  If only one person is doing the bag valve mask (assuming we are not doing passive ventilations), I grab someone else to hold the seal while the other squeezes the bag.  Make certain they are not hyperventilating.  Try using a period ambu bag instead of an adult.  Make certain a properly seized oral pharyngeal or nasal pharyngeal airway is in place and that the airway is held open.  

Watch the CPR.  Are the hands positioned properly.  Are they compression to an adequate depth and at the proper rate.

Since compressions are what matters most, make certain your team is doing them properly.  You are the coach.  You are in...

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You can’t work an arrest if you don’t have space to do effective CPR. I often come into a bedroom where responders are trying to work a code, and I will flips beds up on their sides, clear out couches, or if the patient is wedged in the bathroom, haul them out into the hallway, stopping so there is an open door in line with their chest.  Ideally you need room on both sides of the patient’s chest for compressors and room at the top for the airway management and space for your supplies.  Make use of your help.  In this age of stay and play for cardiac arrest, if you are going to be there for awhile, make certain you have the best conditions for an effective resuscitation.  

Stay Tuned for next cardiac Arrest Pearl # 4 CPR Coach

Charge your defibrillator before looking at the rhythm. Whether you and your partner are the first person at the patient’s side or first responders or laypeople are already doing CPR on your arrival, initiate and/or keep CPR going while you apply your pads.  Then with CPR still continuing, charge the defibrillator.  Only then stop CPR to look at the rhythm.  VFIB or VT, shock!

If its not a shockable rhythm, simply dump the charge by pushing the speed dial button.

Make certain to tell the compressors you will not shock them as you charge.  When you order them to stop so you can see the rhythm, you want your gun loaded.  If you were a hunter and had a deer in your sights, you would want a bullet in your rifle, not to have to stop and load.  This should be the process all through the code.  Charge while CPR is in progress.  At the 1 minute fifty second mark, charge so that at two minutes when you see VF or VT, you can shock, instead of starting another ten seconds of CPR before being able to fire.

Limit...

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Cardiac Arrest.  Pearl #1  Recognize cardiac arrest.

This sounds obvious, but it is not always so.  Early cardiac arrest can present like a seizure or syncope.  The patient’s eyes may be open and they may have agonal breathing.  Get the pads on!  Too many times I have shown up on scene to see first responders tell me the patient just had a seizure or they are breathing, and everyone is standing around.  I admit when I first started, I didn’t always instantly recognize what was going on.  When I was precepting, we had a patient with chest pain who all of a sudden he started seizing.  I reached for the valium (our benzo at the time).  My preceptor shook his head.  “Look at your monitor,” he said.  VF. 

Get the pads on!  Even if the patient snaps out of it before you can act, always get them on the monitor.  Be vigilant.  Several times early in my career I have had witnesses tell me the patient had stopped breathing and needed CPR before coming around.  Those reports did not seem consistent with the alert, talking...

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