TNK in peri-arrest situation?

[ohiovolffemtp]

This past week I had a 53 y/o/m brought in by EMS with complaints of a 2-3 day history of "weakness" who arrested just as he was brought in to my department.  I coded him for just shy of 2 hours, with about 6 episodes of ROSC, usually after several doses of epi.  12-lead EKG done in one of these periods of ROSC showed significant  ST elevation in II, III, aVF - so likely inferior wall MI.  No cath lab at my rural hospital.  I considered TNK but was talked out of it by the day doc.  No period of ROSC lasted > 10-15 minutes.  Ultimately, after repeated arrests I had a discussion with the family who agreed that if the patient arrested again we should not resuscitate and pronounce, which I did.

My question: would TNK potentially (or likely) been of benefit?  We were into the "kitchen sink" level of medicine: epi, levo, dopamine, amiodarone drips with fluid resuscitation, bicarb pushes to try to support BP, correct acidosis, and deal with the pt's period of pulseless V-tach.  His primary rhythm was PEA.  Would anyone else have tried it?

[Apollo1]

I can see the argument being made for TPA, given your rural site and not being able to take straight to cath lab once ROSC achieved. However, do you think if given and successful he would have left neurointact or w/o any significant deficits? 53 yo I'd imagine would have a good amount of years left.

Out of curiosity, what was your attending's rationale for holding on TNK? The above or something else?

[ohiovolffemtp]

Early in the code, there might have been a chance of recovery of neuro function, later, doubtful.  That was what I counseled the family and led to their agreement that it was time to call it.

The day attending doc's rationale was that there wasn't clear evidence of benefit.

The studies I've been able to find are mixed, with a few showing clear benefit (small numbers of patients) and most showing no benefit of survival to discharge.

[MediMike]

I think you were probably in the right here.  Two possibilities in my mind w/ PEA as presenting rhythm:

1) If it was an occluded coronary artery then it may have worked, you had ST elevation and this is exactly what we would have done 20 years ago before there was a cath lab on every corner. If I recall the AHA guidelines continue to recommend lytic therapy if there will be no access to PCI within 120 minutes...and that's with a non-dying patient.

2) If it was a PE it may have worked.  As you know, PEs can present with inferior STE along with signs of RV strain etc.

I can't imagine a situation wherein it would not be worthwhile to attempt in your resource limited setting.  Giving that bolus of TNK could have either had a positive effect for the patient or at least let your team rest easy that everything had been accomplished.

Also in regards to neuro status...I don't know man.  I have hung up my hat on neuroprognostication based on anything but a CTH showing loss of grey-white or an MRI.  I've had folks with prolonged downtime, asystolic after OD presenting with sustained myoclonus who were extubated and eating soup the following day.  Hell we had a guy who had a flat-lined EEG who perked up 48hrs later.

Tough spot to be in bud, sorry you ended up there.

[LT_Oneal_PAC]

The phrase “they don’t get any more dead” comes to mind. Most of the things we do will not improve survival to hospital discharge and even less neuro intact discharge. I likely wouldn’t do it at the one hour mark, but at 53 I could be convinced up to 45 minutes with good uninterrupted CPR.

[EMEDPA]

I have done it once on a guy < 60  with a stemi likely related to simulant use in the field who coded 2 min before ED arrival. Arrived in PEA. We did standard acls plus tnk. Got pulses back and flew him to closest cath lab, where he promptly bled to death. That being said, I would do it again.