ROSC from in-the-field aystole

[EMEDPA]

At the rural sites I work at the medics frequently call us to get the sign off on a termination of code efforts. generally pretty straight forward: " 85 yr old male, hx of 2 prior mis and dm found down in asystole for unk down time, however still warm on arrival without rigor or lividity. cpr and acls for 15 min with no response. can we stop"?

"yes you can. thank you for your efforts."

they don't have to call per protocol, but they generally do so they can write" termination of efforts discussed with emedpa before code called" on their chart.

They all know I used to be a medic and won't give them a hard time any time they call with a reasonable request. a very few medics who I trust a bit less I question a bit more intently, but for most it's not an issue.

[polarbebe]

"Unless you've had thrombolysis of clot it isn't going downstream since it has already "wedged"."

 

Purely anecdotal from an intensivist/pulmonologist that I occasionally work with (greater than 20 years of experience) has seen enough people with PEs become symptomatic with syncope, hypotension, etc. then have symptoms resolve spontaneously with no significant intervention (thrombolysis, CPR, etc.). The mechanism is clearly unknown but he theorizes clot could break into smaller parts, pulmonary vasculature compensates or other unknown reason.

[Acebecker]

Ok, haven't read the initial article from the annals of internal medicine, but I thought this summary (please don't smoke me for the source of the summary) was interesting. 

 

http://sciencelife.uchospitals.edu/2015/10/13/advanced-ambulance-care-increases-mortality/

 

ALS may, in some cases, not be so helpful.  I think the problem is this: ALS provision is provider dependent.  You can have crappy medics who can't see what's happening and who revert to following protocols, or you can have excellent medics who actually understand physiology and medicine and who are helpful.  The article does not differentiate. 

 

I hope I'm not changing the subject too much.  If I am, please let me know and I will remove.

[winterallsummer]

My thought is he was probably found down close to his actual arrest, although this is almost never the case. Some percent of huperkalemia do not show on the EKG in classic ways. The K+ of 5.0 could have been innacurate for a variety of reasons. This is the most plausible theory IMHO.

 

Regarding cooling, the present literature only show that it helps in cardiac etiologies and that it does not help in neuro etiologies. Some people critic that study based on its design (the hospital routinely cooled all the pts, so the intervention was NOT cooling, and they recruited an average of under 10 or 15 pts a month I believe). There is some lower quality data suggesting it helps in neuro cases and some hospitals are routinely doing.