Code Blue: Shop till you drop

Because I could not stop for Death—

He kindly stopped for me—

The Carriage held but just Ourselves—

And Immortality

Because I Could Not Stop for Death- Emily Dickinson

1500:  A 50 year old female who collapsed at a local retail store was brought in by EMS.   CPR was initiated at the scene.   She was found to be in pulseless ventricular tachycardia and she was defibrillated twice and received an initial dose of epinephrine.   No family members or friends were available to relate her medical history.   She has no prior hospitalization so no medical previous medical records are available.

1514:  CPR is in progress as EMS wheels her into the trauma room.

1515:  She is transferred from the EMS stretcher to the ER stretcher.  CPR is stopped for an initial rhythm check.

Initial rhythm:  AV dissociation

1517: A pulse is present but she has no visible respiratory effort so positive pressure ventilations are continued.    An additional IV is started in the right AC and blood specimens are obtained and IV maintenance fluids are started.

1518:  As you watch the monitor, you can see obvious slowing of the heart rate.   An epinephrine drip (1:1000 in 500ml) is being prepared for the patient.

15:19 At this point, no pulse is detected so CPR is resumed and she is treated according to the PEA algorithm and is given a dose of Epinephrine 1mg IV.   Alternatively, she could have been given Vasopressin 40 units IV.

Rhythm check: complete heart block

1522: A rhythm and pulse check show her to be in a complete heart block, however, she remains pulseless.   Would atropine and transcutaneous pacing have been a more effective intervention?  Atropine might have extended the block and is thus not recommended for complete heart block and atropine is no longer recommended for treating a slow PEA rhythm.  Transcutaneous pacing is recommended for unstable bradycardia.  However, this patient's bradycardia has deteriorated past being unstable and she now pulseless.  I personally have had only one other experience in this situation and we did try to pace the patient for a few minutes but when we did paused the pacemaker, the patient remained in a bradyasystolic rhythm.  Thus, this emphasizes the importance of finding the underlying cause of the PEA rhythm.   You will not fix the patient if you cannot fix the cause.

CPR rhythm with visible organized complexes

1523:  CPR is resumed.  You can still see that there are some organized complexes even during CPR.

1525: The patient is intubated using the Glidescope and tube placement is confirmed with end tidal CO2 and bilateral breath sounds.   Ventilations are adequate.  CPR is in progress

Rhythm check: accelerated idioventricular rhythm

1527: The patient remains pulseless and apenic.   CPR is resumed.   Epinephrine 1mg IV is given.   A fluid bolus in in progress.   Given the long arrest interval, 1 amp of Sodium bicarbonate is also administered.

Defibrillation with 360 J

1530: A change in the patient's rhythm was noted on the monitor.   She remains pulseless and apenic.  She is defibrillated at 360 J (recall that she received 2 previous shocks prior to arriving at the emergency room).  CPR is restarted after the defibrillation attempt.

Defibrillation with 360 Joules

1533: No change in the patient's rhythm so she is given Amiodarone 300mg IV and another defibrillation attempt at 360 J.

Defibrillation with 360 Joules

1536:  A rhythm check reveals a wide complex tachycardia presumed to be ventricular tachycardia.  She is defibrillated at 360 J and CPR is immediately resumed after the shock.

Defibrillation with 360 Joules

1539:  She remains in a refractory VT rhythm.   Epinephrine 1mg IV is given followed by CPR and another defibrillation at 360 joules.   CPR is resumed after the defibrillation.   Positive pressure ventilations remain adequate.

Rhythm check:  idioventricular rhythm

1542:  A rhythm check shows the patient to be in an idioventricular rhythm.   She remains pulseless and apenic.   CPR is resumed and Epinephrine 1mg IV is given.

Rhythm check: agonal rhythm

1545: A rhythm check after the defibrillation reveals the above rhythm.  CPR is resumed and another dose of epinephrine is given.

Rhythm check: agonal rhythm 

1550:  The nursing supervisor was unable to reach any immediate family.  No medical history is available on the patient.  After further discussion with the resuscitation team, it was felt that nothing else could be done.  No further measures are attempted.

Agonal changing to asystole

1605:  Agonal rhythm.  This agonal rhythm persisted for another 5 minutes.

Asystole

1610:  Asystole.