You are down by five, and there are only three seconds left in the game with 80 yards to go. Do you just take a knee or take a shot down the field with a Hail Mary since there is nothing else to lose? Similar to professional football players, we are professional “resuscitationists.” When it comes to taking care of cardiac arrest patients, we cannot be limited to the playbook of advanced cardiovascular life support (ACLS). Occasionally, we, too, have to take a shot with our own version of a Hail Mary. Do we terminate the refractory ventricular fibrillation (VF) coding patient with an end tidal CO2 of 27 mmHg, or is there a new “play” we can try before we pronounce the patient?
Explore This Issue
ACEP Now: Vol 34 – No 11 – November 2015
ACEP Now features one article each issue related to an ACEP eCME CME activity.
Case
A 43-year-old father of two presents to the ED via advanced life support (ALS) in cardiac arrest with a presenting rhythm of ventricular fibrillation. According to the transporting paramedics, the patient had a witnessed arrest at home, and the family performed CPR until basic life support (BLS) arrived on the scene. An automated external defibrillator (AED) was immediately placed with “shock advised.” Two shocks were given by BLS prior to ALS arrival. The paramedics were able to intubate the patient and initiate ACLS. They report continued ventricular fibrillation, without return of spontaneous circulation (ROSC), from the time of arrival on scene until arrival in the ED. A total of 450 mg amiodarone, 5 mg epinephrine, two ampules of calcium chloride, two ampules of sodium bicarbonate, 100 mg lidocaine, and seven defibrillations were given prior to arrival in the ED. End-tidal CO2 has remained around 25 mmHg with high-quality CPR performed in the prehospital setting. All eyes turn to you upon arrival. “Doc, what else can we do? There are no more steps on the ACLS card but more epinephrine and defibrillations. Should we call it?”
The Opponent: Electrical Storm
Electrical storm (ES) is described in the medical literature as a rapidly clustering ventricular fibrillation that necessitates multiple cardioversions in which conventional antidysrhythmic drug therapy, as recommended by ACLS, fails to convert the patient to a life-sustaining rhythm. ES patients are commonly given antidysrhythmic medications serially while also receiving repeated shocks via an AED. However, despite heroic efforts made by all providers, most ES patients die.1 Refractory arrest secondary to ES is not a new
Pages: 1 2 3 4 | Single Page
3 Responses to “Emergency Interventions for Treating Cardiac Electrical Storms”
January 13, 2016
Steven SawyerI read this article this past weekend and knew that even though I had never seen a case of refractory Vfib I knew I would shortly. So I was not actually surprised when the 45 year old man brought in cardiac arrest had Vfib for which he had received two doses of epi and three shocks by ems. An LMA was in place and while cpr continued I had to wait to see the monitor. During a change in compression hands I saw the fine vfib and delivered another defib with epi and amiodarone to no avail. During the next cycle I had a chance to brief the team on the article I had read and get a copy so we could check the dose of Esmolol while maxing the amiodarone and applying the 5th shock. However, it turned out that we had no Esmolol in the ED. At this point it was 30 since being found down. I set the two defibrillators and performed the double sequential external defibrillation which initially converted from fine vfib to asystole After additional CPR and an additional attempt the code was called. It turned out that the pt had initially been over come with carbon monoxide which lead directly to his cardiac dysrhythmia. Had I known this I may have elected to remove the LMA and intubate for better oxygen support. But overall my team was fast and compliant with the strange instructions I gave. It just didn’t work this time.
March 7, 2017
günther krumpl0–100 mcg/kg/hr (0–0.1 mg/kg/hr)
Please correct the text in the publication to the right dose which should be
0-100 mcg/kg/min.
In addition I want to mention that 0 in 0-100 makes no sense, the starting dose of esmolol is 50. So it should say 50-100 …
April 14, 2017
Dawn Antoline-WangThank you, the article has been updated to indicate mcg/kg/min instead of mcg/kg/hr.