Episode 103 - Arrest, ROSC, Repeat

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Welcome to the Heavy Lies the Helmet Podcast. So you're talking about this topic being intimidating. Why do you say that? I, from day one of residency, I've been intimidated by post-arrest care. I remember in third year, that was when we ran the trauma bay, ran the SHRU, the shock resuscitation unit. And the patients that were the scariest to me were the cardiac arrests. I can't entirely put my finger on it. And maybe it has something to do with.

There are other specialties involved. You know, we talked to cardiology right away, but different from a lot of the other things we do, I've never felt like the expert on this one. I've always felt like I am still very much in the Padawan stage, if you will. I feel like I do it so much. I feel really good about it because every post-arrest comes to the ICU. So I get... tons of swings at it so even if i wasn't very bright or astute

If you're at the drive-thru window long enough, you know what goes on the Big Mac. So I get lots of opportunities for sure. It seems like where I'm at now, we get tons of post-cardiac arrests as opposed to other things. There just seems to be a lot of volume of that.

I don't know if that's good or bad, but I can see why you'd feel like that because it was somebody that was dead before and they're alive now. It's like, hey, don't screw this up. Right. Right. And I appreciate that you said that because. I was always told the reverse of it. Well, they're dead. You can't make them deader. And I'm like, well, that's true. But sometimes they come back to life. You know that feeling where you get a pulse and you're like, oh, no.

Now what? Now what do I do? Like, I feel that way with every single cardiac arrest. I'm like, because, you know, like medical cardiac arrest and trauma, both of them are an algorithm. They're a different algorithm. But the arrest itself is very, for lack of a better term, pretty cookbook. And then you get pulses back and you go, oh, wasn't expected. I never expected no matter what. I'm always surprised. Right.

Yeah. Well, that's what's interesting about this topic, though. Because when people establish ROSC, there's high fives and everyone's like, yeah, we did it. And then... People walk out of the room or they think, you know, now the climb is over and we've gotten pulses back. And sometimes people don't really appreciate how easily these patients can rearrest, especially when you're not addressing the etiology and how this is such a crucial time in their course of care.

Because there's a lot of things that have to happen really quickly and you really have to monitor these patients closely. Right. It's not just ROSC and then we're at the finish line, checkered flag, and we're done for the day. Right. And we've gone from these are the things we knew to... need to do to get this person back to life, to these are the things that we need to do to actually give them the opportunity to have a life. My EMS chief at the fire department that I'm medical director for.

his favorite thing to say is, we're not in the business of saving lives. We're in the business of saving lifestyles. And I really, really like that. And I think that that post-arrest period, that's where the lifestyle part comes in.

And it's complicated, right? Because death is the final common pathway of every illness. So what could have led to that arrest is a million different things. And it's incumbent upon you as the person who resuscitates that dead person. Because getting them back is not enough. It's getting them to walk out of the hospital. So you have to really have an algorithmic approach to some extent once you get a pulse back or you're going to miss something really important.

And then they're going to rearrest and it will be largely because you didn't do something you should have done to keep that from happening. So, yeah, I think the stakes are really high for sure. And you also hope that. Now that we know the effects of epinephrine, establishing ROSC isn't always the greatest outcome because as just to reinforce what Amanda was saying, we're really trying to preserve neurological function. We want people to have a quality of life.

Hopefully the correct steps have been taken up to that point when you've established ROSC and you haven't just slammed the patient with epi thinking that's a win. We have to really think more broadly than that. Yeah, yes, for sure. There was a... One of the studies that I used to back up my being a naysayer of epi and traumatic arrest showed an increase in survival to hospital arrival.

but no improvement in survival to hospital discharge or neurointact survival. And so we actually, and I learned this in Albuquerque and I've brought it with me to Texas, we've actually increased our interval between epi. we do it Q10 minutes instead of Q3 to 5. Nice. And are you still giving one milligram just less often in an adult patient, obviously? Yeah. Yeah. Still the same, giving them the box, but...

That's another funny thing when I was in medical school, because you guys know that the epi comes in the little box on the code cart. And when we were learning about all the different epi concentrations. Why epinephrine is stated different than every other drug will remain a great mystery to me. One in a thousand, one in 10,000.

But we learned you give them the box when they're going in the box. Oh, there you go. A little crude, but as most things in pre-hospital medicine are. Well, I mean, how do you all want to prioritize this? We could... go down several pathways. I think one of the biggest things is even though the patient has established ROSC, we know again to reinforce what was already said that they are at a high risk of re-arresting.

So we want to make sure that we're optimizing hemodynamics and treating hypotension. You know, if only it was that algorithmic, because I see a lot of people miss those in, you know, maybe people who are less. savvy at critical care and cardiac arrest care, they're still, like Mike said, celebrating that they got a pulse back and then they just run out of the room or they don't really know what to do. And I think...

You make a great point. My three things are as soon as somebody says, you know, we've got a pulse. My first question is, what's the blood pressure? Get an EKG and get a chest x-ray. So I want to make sure that there's not something catastrophic going on in their chest. They don't have a big gigantic pneumo that we caused potentially by CPR, that they have a blood pressure because we have to address that or they're going to arrest again.

did an MI cause this arrest in the first place? And then, you know, there's tons of other things, but for me, that's my first three. I'm interested to hear what your guys' first three are, if they're different. No, I think that's good because we know that there can certainly be chest trauma when it comes to quality compressions. Especially when you have a frail elderly person, it is something that unfortunately happens. So you want to make sure there's not an obstructive shock component.

because that's obviously something we can easily address and then getting that 12 lead this patient may be a candidate for pci at this point so we want to make sure that we're activating those correct resources if we do identify an mi because that's the only thing that's going to fix them at this point

Otherwise, we're just going to be chasing our tail. I think that's step one. You get the vitals, you get the EKG, and then the next step after that is to optimize hemodynamics. Or the CAT scanner. Yeah, absolutely. I think the other thing that's important, and I would list this as number four, is get ready for rearrest. People that arrest tend to rearrest, and they have a tendency of doing it in the worst possible spot.

like the back of some sort of transport vehicle. Yeah, exactly. Exactly. Well, that's why you also, you encounter protocols sometimes where, and I'm also curious to hear your all's stance on this. is they want a certain amount of time to pass before they initiate transport in a patient that just arrested, whether it be some five minute, 10 minute interval of ROSC before transport is initiated, just because of a case of stability.

What are your thoughts on that? Is it important to take time before you do something like that or knowing that this is potentially a time sensitive manner? Do we just load and go at that point? I personally am not a huge fan of waiting. This is one of those conditions where I am not definitive care, especially if they arrested because of an MI. I can't do what they definitively need done.

And so I want to be working towards that goal constantly. One of the things that I do or I tell my crews to do that I think helps to mitigate that somewhat, regardless of what that first blood pressure is. I want an EpiDrip attached to the patient. It doesn't have to be running. It only has to run if we need it. But I want it attached so that at a moment's notice, we can get it running.

Because a lot of times you will get that drop in blood pressure that signals that you're about to rearrest. But I am not a fan of the idea of waiting to see if they rearrest because you're no closer to where they need to be. If and when that happens. You know, I was hoping that.

we weren't going to disagree on this about just hoping you weren't going to say oh yeah i always tell my guys to wait five or ten minutes but i agree you took the words right out of my mouth i agree completely in cardiac arrest I don't think if you have a high-functioning EMS crew, the ER doesn't really have much to offer the patient that the EMS crew doesn't have to offer during the cardiac arrest. Once you get ROSC, that changes. And it's not always even the ER, but if you.

can't do PCI, then you don't have what the patient needs. If they have some intra-abdominal, intra-thoracic, catastrophic situation, they need imaging to identify who do we call to fix this problem or it's going to happen again. I agree one million percent with you that got a pulse, got a blood pressure. Time to go. Yeah. And I agree with everything that you all have stated.

Are you always going to epi? Are you ever considering norepi in these patients? Or do you just think with it being a cardiac arrest that epinephrine is your first line vasopressor and inotrope? I think... I tend to pick epi just because it's what's fresh on my brain because it's what we've been using. But I admit I don't have any data to back that up. I'm definitely not opposed to nor epi. I think... That much like in the old days.

We used to start dopamine just because it was pre-mixed and in the code cart. I think lots of times we go to norepi because it's always pre-mixed and in the Pyxis, and epi takes a little bit longer to get there. Most people who post-cardiac arrest have poor inotropy, at least.

in the short run post-cardiac arrest. So I think epi is probably not a bad choice. I don't think nor epi is a terrible choice either, but I think if given the two, I would probably like epi as long as they're not having an MI. And I don't feel like I'm jacking up their myocardial oxygen consumption by that, you know, epi being such a strong inotrope and chronotrope also. So, yeah, I think that's reasonable. I think it's probably.

Good idea, along with lots of other things. You know, there's all kinds of really good evidence for things we do post-arrest. I think one of the most important things we can do post-arrest is be cautious about. Hyperoxia, because oftentimes hyperoxia leads to hypocapnia, which now leads to cerebral vasoconstriction and poor brain perfusion when they need it the most.

I guess that's probably the next thing worth talking about is make sure that if they don't need 100% FiO2, which is what you are likely giving them during the resuscitation, that we get that turned down to what they need and not make them. bring them in with a PCO2 of 10 or 15, which is not good for their brain. I'm so glad you brought that up, Dan, because I think we all have the tendency...

in a post-arrest situation to give them the maximum amount of everything, right? The maximum amount of blood pressure, the maximum amount of oxygen, and... It's one of the things that is definitely overlooked in that kind of scattering. We've mentioned this a few times, the scattering of hands. in the post-arrest period. I think it's really easy to overlook. One of the resources that I was looking at in preparation for this suggested a target of a SAT of about 94 to 98.

Our target isn't even 100%. We really want to be really aggressive in turning down the FiO2. So I was doing some research on BVM rates when people are not on the ventilator. And that will be the first thing I will talk about is if you have the option, leave them on the ventilator during CPR. Turn up the peak pressure alarm so that the vent will continue to ventilate.

And then you can set the rate and forget it. Kind of like the Popeil's rotisserie chicken maker. Set it and forget it. Because the statistics show that the average rate of bag valve mask ventilations. during a resuscitation is somewhere between 40 and 50. It's called catecholamine-induced hyperventilation. So the more excited the person squeezing the bag is, the faster it goes. And that's not good for anybody.

It's going to give them carpal tunnel and it's going to give the patient hyperoxia. So if you put them on the vent, you don't have to worry about that. And it's one less set of hands in the way. It's one less person to get excited about being shocked. And let me just throw this out. You're not going to get shocked through the bag valve mask if you're holding it when they defibrillate the patient. I know we all want to believe that. We want to scream clear 35 times, but it's not a thing.

If you don't believe me, do a YouTube search. Look for a guy named Larry Mellick, who is a ER attending in Georgia now, I believe. who shows him putting his hand right on somebody's chest while they're being defibrillated and nothing bad happens. He doesn't look like Yosemite Sam with the dynamite going off, you know, where it blows the cigar up or anything. None of those things happen.

You mean TV was wrong about that? Maybe not wrong, just exaggerated. Just a little exaggerated. So is the whole idea of the potentially lower oxygen goal, is that because of we're... We know there are free radicals associated with hyperoxia and the fact that they've been in arrest and then they reperfuse that there's an increased risk of free radicals. Is that some of the...

Mindset behind that? I think that and I think what Dan mentioned earlier about cerebral perfusion. Right. Because kind of like I mentioned earlier, the arrest is the save the life stage. And the post-arrest is the save the lifestyle stage. So we've kind of transitioned from get the heart started to get the brain where it needs to be is kind of how I envision it. And so just like in... TBI, my favorite topic. I'll refer you back to episode number 95.

We want to make sure that we're maintaining cerebral perfusion pressure so that we can get enough oxygen up there to get all of that tissue that is in jeopardy to make sure that we are protecting it as best we can. Yeah, for sure.

And hypotension obviously playing a big factor in that because our cerebral perfusion pressures determined one of the components of that is our mean arterial pressure. So these aren't patients that we want to have a permissive hypotension. We want to make sure that we're addressing that early. And Mike, thanks for throwing in that free radicals. How can we not help but sound really smart when you throw around words like that?

Oh, totally. Free radicals are like cytokines. I feel like I should do some like magic spirit fingers when every time I say the word, because I'm not entirely sure how they work, but I know they're really important. Right. That's right. That's right.

So let's so we talked about oxygenation, talked about optimizing hemodynamics. Do we want to talk about targeted temperature management at this point? Yes. OK, because we've talked a lot about. preservation of neurological function. And some of that is why we do this thing called targeted temperature management. Used to be called therapeutic hypothermia. They've gotten away from that verbiage. Now we're calling it TTM.

What's cool about some of this is there's been some evidence changes when it comes to particularly our goal as far as how cold these patients should be. Let's start first with the evidence that got us to where we are. There wasn't a lot of it, and it wasn't that good. But we were searching for a way to measurably make a difference in people who were dead and are now alive.

We found these small studies and said, we should be doing this. This makes a difference. So then we started doing it. And then the studies kind of diverged. Some said 36. Some said 32 or 33. And then we had this big thing about, well, should it be 32, 33 or 36? Because getting people to 32 or 33 is not easy. And bad things can happen along the way to the freezer. So there was another study done, and most of this stuff was out of Europe. And they determined that.

You don't need to go to 32 or 33. 36 is probably fine. And there was a signal in there that said, you know, I mean, don't tell anybody and say it in hushed tones, but maybe. 36 really isn't the answer either. Maybe the whole point is avoiding hyper, avoiding pyrexia, making sure they don't develop a fever. And the most recent study then that was done after that signal shows that probably the key is.

Don't allow them to become febrile. And 37 is probably just fine as long as you don't let them go above 37. That's the word from the ICU. I know most of the time it's been my experience in the ER. The ER was never a big fan of the hyperthermia protocols because it's a lot of work and a lot of stuff to do on somebody that you've already.

done a lot of stuff on and let that send them and their Arctic sun and their little pads up to the ICU and let them do that stuff. We'll give them a couple of cold liters of fluid and get them out of here.

Once we've got pulses back, we're done. We want them upstairs, stat. The whole idea of TTM and getting these people on the Arctic sun is... is labor intensive and I think all of us know in our heart of hearts that we're not really sure that it's doing anything and This is the point where the rest of the department is burning down as a hot dumpster fire because we've all been in this room for who knows how long.

And so I think it very rarely gets done in the ED. At least that's been my experience. Maybe we throw like some ice bags in the armpits and groin and call that TTM. Do you know how many turkey sandwiches can be passed out in the time it takes to get somebody on the Arctic Sun? A whole lot of turkey sandwiches and Shastas, let me tell you.

So I don't think we clearly stated, obviously what Dan was speaking of, there's degrees Celsius when it comes to core body temperature. Also, this would be indicating patients that remain with a lower GCS. So we're not going to initiate this in a patient who becomes alert and conscious. Something I did want to talk about when it came to cooling, though, we used to do this. We used to administer a lot of chilled saline, and that was especially in the emergency environment.

That was an easy thing for us to initiate, but there's actually been some evidence that has come out that actually infusion of intravenous cold fluids really doesn't improve survival. It actually worsens hypoxia and potentially even worsens. re-arrest. They prefer other means as far as when we're talking about passive and active cooling. So like in our environment, Amanda, you had mentioned cold packs. So this would be an active form of cooling a patient.

We did an episode talking about hyperthermia, actually, Treat the Heat, episode 94. And one of the cool points that Dr. Hensley had brought out is that when we're applying cold packs, if this is something we are initiating, that it's actually better to do the palms of the hands and the bottoms of the feet as opposed to the groin and the axilla.

So something to think about. I would recommend not doing cold saline and actually applying to those other areas for effectiveness and less adverse effects. That's really interesting. I hadn't heard that. It makes sense, but I hadn't heard that before. knowing of course that the evidence is really let's be honest it's kind of sketchy all the way around right that that any provision of hypothermia is

Because it opens up the whole Pandora's box of now. So now we're going to put them in the cooler. And if we're going to take them to 36, then what do we do about shivering? And, you know, how are we treating that? Are we just paralyzing everybody? which is what a lot of places are doing. As soon as they go in the freezer, they're paralyzing them. And now you have a whole other host of issues because are they in non-convulsive status? And now they're paralyzed.

or you're essentially creating non-convulsive status because you're paralyzing them and you don't know if they're actively seizing, it just opens up a whole Pandora's box. So I guess what my advice would be is maybe it's time to revisit your post-arrest.

Targeted temperature management. Decide what the best goals for you are. Is it really 36 or is 37 make more sense? I think you should just look at the evidence again because there's a lot of new stuff out there. Yeah, I think the name of the game is normalization.

Dan touched on this when he mentioned that really, it seems like what our target is, is to prevent pyrexia. And just a quick plug, the other thing we want to try to keep normal is the glucose. Yeah, I feel like the glucose is one that gets missed a lot in post-arrest care. You know, again, it's one of those things that we're celebrating and maybe even distracted at this point, not even thinking about getting a finger stick on these patients and treating hypoglycemia. For sure.

I mean, how cool? It's just not cool, right? You know, there's so many other cool things you could do. It's just using the glucometer just is not a cool thing, so it's easy to forget. But it's really important because... Profound hypoglycemia can make you dead and can make you disabled. So it pays huge dividends, right? And profound hyperglycemia is just good for no one. So let's talk about sedation.

What is the optimal sedation post-cardiac arrest? The first thing I would say before we talk about what is the optimal sedation, the optimal sedation is not ever no sedation. Just because they're not doing anything, I hear this all the time and it makes my head want to spin around on its axis. Just because they're not doing anything is not a reason not to sedate them.

For God's sake, they don't have to be doing something to be citated. By the time they're doing something and screaming out, how long have they been tortured? I mean, you didn't know about it. So that's not.

an explanation for no sedation as they're not doing anything sedation is a problem i think across the board this is one of the things that we deal with constantly in transport medicine is under sedated patients And I think a lot of it is because the indication is not clearly understood because people want external signs of discomfort or what they perceive as external signs before administering such.

Now, when you talk about sedation, though, in a patient who's just had an arrest, do you have any hesitation when it comes to ketamine administration? I don't. My only hesitation would be if I think their arrest is from... something that is not going to play well with the sympathetic discharge that ketamine provides, then I'm a little more, I look for another agent, but largely I think ketamine's fantastic.

sedation. And I am not a guy that thinks ketamine for everything. But I think, yeah, I think ketamine, in fact, there's some evidence that says that ketamine is probably, ketamine and dex or presidex or dexametamidine are One of the optimal sedation packages post-arrest. I have been widely recognized as a hater of propofol. Which is not entirely an accurate characterization.

am, let's say, dialed in to the hazards of propofol. And I am cautious to administer it like our anesthesia colleagues sometimes are, who I have termed as the propofol assassins, where everybody gets induced with 200 of propofol. I don't think that's a very clever approach. But I use propofol all the time in the ICU. So I think propofol is okay. Now, if you have somebody that's got a big anterior wall MI and you put an ultrasound probe on their chest and they have a crappy EF.

That's not somebody I'm going to give propofol to. Likewise, that's probably not somebody I'm going to give ketamine to either because I don't think they need that sympathetic discharge that the ketamine provides. So that's somebody that I would probably use dex on. when i approach post-intubation sedation i approach it just like i do conscious sedation in the emergency department or induction with rsi i think about what the situation is and then what the best agent is so for instance

If I'm doing conscious sedation in the ER and I have somebody that's got a hip or a shoulder out, I'll use propofol. If I'm going to do cardioversion, I always use Etomidate. Because I don't care. You know, I think that's a great agent. If I'm going to do a big painful abscess, then I'm more likely to use ketamine, for instance. So post-intubation sedation, if they are.

hypertensive, and they're agitated, then I think propofol is a great drug. Just be modest and moderate with it. Start low and work up. That's not somebody that you want to just bolus them with one per kilo of propofol and then start them on the drip because you're going to eradicate their blood pressure.

If I'm going to use ketamine for somebody that I don't want to use propofol because I think they have some cardiovascular dysfunction, then 0.2 mg per kg as a drip, kind of at a pain dose level. Nothing promotes anxiety like pain. So I think we should treat pain first. I don't like fentanyl for these people because I think it hangs around too long. So I think ketamine is a better agent for that. I certainly don't ever like benzos.

Because it's the delirium monster and makes the ICU patients crazy. And in old people, it stays around forever, which is a problem when you want to get them off the ventilator. So that, in a nutshell, is kind of my approach. I think dexametetomidine is a great drug unless they have had bradycardia. Their arrest was bradycardia induced and dex can cause bradycardia, especially at higher doses. So I'm cautious with that.

But I think dexametamidine is a great drug to be used as well. So that's kind of my approach. Now, a lot of the agents you mentioned obviously don't have an analgesic effect, though. And you talk about potentially hypotensive patient. If we're wanting to treat pain as well and we're not administering fentanyl.

My first question is, what are you doing then? And secondly, do you find that Dexmedetomidine or Presidex... is adequate for the transport environment because i find that it tends to have a hot like many of our sedatives there tends to be a higher dose demand in these patients when we're stimulating them And so they often require a second agent because the higher doses, again, there's always that risk of bradycardia, which I have definitely seen as a second, as an adverse effect of Presidex.

So, yeah, no, I think that's a fair question. So I'll use ketamine for pain. Ketamine is one of the few drugs that gives you a little double benefit. You can get, you know, at higher doses, you get sedation, lower doses, you get pain. Just be careful not to use middle of the road doses because then you get neither. You get the K-hole and that's a place that nobody wants to be. So, what I'll often do is bolus those people with the ketamine at 0.2 to 0.3 per kilo and then put them on a drip.

And the thing with DEX is, especially in the transport environment, sometimes it takes a little while to get to the happy place with DEX, especially if you started at like 0.2. I had a patient some time ago. That was climbing off the bed and he'd been on decks for like an hour. And I said to the person who started it, I said, how much decks is he on? She's like, this decks isn't working. I said, how much is he on? Point two.

Mike, you didn't give him enough dex for a gerbil. Turn that dex up to one and the ketamine will help you with a little bit of the bradycardia avoidance because it gives you a little sympathetic discharge. So that's kind of my approach. Just being careful to stay away from benzos. Benzos are the devil in my mind when it comes to delirium, for sure. You mean alcohol and pill form is not the best bet? That's a great representation of that.

That's always how I teach medical students and residents what benzo intoxication looks like and what benzo withdrawal looks like. It's just alcohol and a pill. That's all it is. You know, I told a patient the other day in the ER who... said to me, this is after we addressed her other things. She said, so I'm getting ready to go on vacation and I just have terrible anxiety. And could you write me enough Xanax just to get me through my trip to Mexico?

And I was like, I don't think no is an adequate enough response to that question. I said, you know, Xanax is one of my most hated drugs because of the addiction potential. I can't tell you how many people I've seen who have overdosed on it with alcohol, of course, and then they are intubated in the ER. Drunk-tubated, I think, is the term you use, right? And then...

We take, we extubate them in the ICU 24 hours later or whatever. And as the tube is coming out of the back of their throat and clears their teeth, the patient starts to utter, I take Xanax five times a day. I need some more. I need my Xanax. And they're like not even extubated yet. The tube's only half out. So the addiction potential is just huge with that. So, yeah, I'm glad you tell your medical students that because it's so true.

People rarely die from heroin withdrawal, but they absolutely die from benzodiazepine withdrawal. Yes, 100%.

Kind of take another turn on this because you've mentioned something a couple of times. I think it's at least worth mentioning. So let's say that this arrest was optimized and we did everything we were supposed to to get pulses back. Is our patient intubated already if they weren't prior to? And if not, are we leaving in the supraglottic airway? Are you prioritizing intubation at this point now that we've established ROSC? What is your ALS process?

Ooh, I was thinking about this earlier. This is a great point. I am a fan of supraglottics and cardiac arrest for the actual performing of the cardiac arrest. My big rationale for that is that... There are things that we know make a difference in cardiac arrest, namely early electricity and high-quality CPR. And you note that a... A plastic cigar is not on that list. And so I'm a huge fan of put the superglottic in and then focus on the things that matter.

When we talked about our what are your first three or four things post-arrest, intubation still wasn't on the list. I think I would even argue that it's not a... pre-hospital or an ED task. Maybe it's an ICU task. Maybe that's where the supraglottic gets changed out. Because again, the supraglottic is, if it's doing a great job, if it's not broke, why fix it? I think it's a great point.

I have talked to all of our respiratory therapists and said, if you beat me to the coat on the floor, don't wait for me. Just throw in an eye gel. And we'll sort it out later. And once the iGel goes in, I'm a believer in waveform capnography. And as long as you have a strong waveform on that iGel, there is no hurry.

We got plenty of time to do lots of other things, and there's no shortage of things to do in the first hour of a ROSC. I don't think horsing around with switching out that ET tube is one of those things that you should be doing. Because really, if they have good waveform and they have good oxygenation, only bad things can happen when you switch out a supraglottic airway. It's like Woody Hayes. For those of us who are from the Midwest and have lived in Ohio, Woody Hayes was the...

prolific football coach for the Ohio State Buckeyes for a lot of years. And they used to joke that his offense was two yards and a cloud of dust. Meaning that he didn't like to pass. He only, he ran the ball all the time. And they said, Coach Hayes, why do you always run the ball? And he said, because when you pass, only three things can happen and two of them are bad.

Meaning interception or incompletion. So I think switching out supraglottics is similar. If they have good oxygenation, good waveform, only bad things can happen by taking that supraglottic out. Now you can't get it back in. They puke, weird things happen. So focus on things that matter. I think your take is absolutely perfect. Because again, it's something that people, they want to get the airway and not realizing the potential there that.

can definitely find yourself in a rearrest scenario just simply because now you've got a failed airway because you were so quick on the trigger the more important thing is to get them on the ventilator and ventilate them through that eye gel and not rushing for the intubation

And hopefully they didn't pause compressions to intubate them. Oh my goodness. But we won't go down that rabbit hole. Don't even get me started. That's why I noticed I didn't say, oh, it's fine in the ED when you have plenty of hands. Those hands don't seem to understand that they shouldn't stop compressing. And in part, they don't stop compressing because the person who's trying to intubate keeps yelling at them. Hold on. I almost got it.

Just hold off for just a few more seconds. I almost have it. Nothing good comes out of that either. Likewise, I like utilizing ultrasound for wall motion identification in cardiac arrest. However, much like intubation, let's not stop CPR for 30 seconds while we're trying to get a fantastic five chamber view or whatever else.

us ultrasound whackers decide is important. It's not that important. I personally, and Amanda, I'd be interested to hear what you think about this. I am an advocate when I'm working in the ER, if the nurses are savvy with it, I'll throw in an art line during CPR. And there's nothing provides a fantastic pulse check like an arterial line. Yes, I absolutely love the art line intra-rest because like you said, it's great for...

relieving us from the duty to do the pulse check. And that gets me on the side tangent. Sorry, Mike. Have your fingers on the pulse before you stop compressions. And so having an arterial line. It negates the need for me to say that until I turn blue myself. And my other question for you, Amanda, at your ER, which is the size of a small Midwestern town. Do you have ready availability of TEE and do you see people use that ever for intra-arrest ultrasound? I've seen some TEE intra-arrest.

It's not something that we routinely do on every case. We have a group of combined EM critical care folks, and I think they are the ones that use it the most, but it... The great thing about it is that, like you mentioned, we're not fighting for the ultrasound probe and the Lucas puck and which one gets primo location. So I'm seeing it some. I think it's increasing in. frequency, but it's not universal yet.

I took an ultrasound class about two years ago, and one of the guys teaching was from, I think, from South Carolina. And he said they were in a phase where they were putting TEE probes in on every single cardiac arrest. Because A, it gives you a good view and B, when you need it for aortic dissection or whatever, you're so savvy with the process that.

You're not hesitant to do it because you've done a thousand of them and it's just like dropping an NG tube, essentially. The thing about TEEs or transesophageal echoes is if you look at an image... of a transthoracic echo next to a transesophageal echo. Transesophageal echo is like high-definition TV versus dial-up. Unless you have somebody like our... echo sonographer in the ER at UC where she could.

give you high definition. When she's not even looking at the screen, holding on a conversation and holding the probe with a couple fingers, she could get a better image than I could with all my attention focused on the chest wall. So it just gives you a higher resolution picture. And just a shout out for using ultrasound specifically in your PEA arrests to tell you if you've got PEA or pseudo PEA. That I would say is one of the absolute. biggest and best indicators for pre-hospital ultrasound.

Pseudo-PEA being like the Charmin commercial, if you don't think you have a pulse, but you do, right? So let's talk about some other maybe more nuanced things that we might do post-cardiac arrest.

Your heart likes magnesium. So think about magnesium. Hypomagnesemia is not good post-arrest. So if you can get rapid point-of-care magnesium, I think that's helpful. One other pro tip, anybody that's hypertensive post-cardiac arrest is under-sedated until proven otherwise. They are not in need of beta blockers. They are in need of sedation first. That's a fantastic point. I'm also glad you brought up the POC post-arrest or the point of care testing because...

I think one of the things that I wanted to bring up and discuss a little bit was the looking for the etiology of the arrest. I think we all expect to find it on the EKG, but it's not there 100% of the time. I actually had an arrest recently where the patient arrested because his initial potassium was 1.8. Turns out that's not enough. And so he actually, he had a wonderful.

torsad wave for those that aren't familiar. It's where you have VTAC that is, I wish you guys could see me drawing it on my screen right now. It's big and tall and then it gets short and then it gets big and tall again. And that is kind of pathognomonic for an arrest due to electrolyte anomalies. Yeah, that's a great point. And remember, you need magnesium to carry that potassium. So if you're treating hypokalemia, you need to look at hypomagnesemia as well.

No one should die without a couple grams of mag on board. That's exactly right. If the K, for you ICU and ER people, if the K is low, the mag's low. The end. And the way you remember that is you just always do it. If the K is low, the mag is low. Don't worry about checking it. Just give a mag. That's right. Yeah, that's right. Because remember, the majority of the magnesium lives in the bones, not in the serum. So checking it in the serum is just really makes you feel better.

If the K is low, the mag is low. Give the mag, for God's sake. In the ICU, if you wonder why. You give people, you're giving them K-Rotters all day long, and the next morning their K is low, and you just keep giving them potassium. You're like, why in the world is there potassium not coming up? It's because you're not giving magnesium. Give magnesium with it.

Yeah, because we carry iStats and with our cartridges, we can check potassium level, but we can't check magnesium level. But again, we carry magnesium. So if potassium is low, go ahead and treat it. You don't need that number. Correctamundo. While we're on the topic of different reasons that people go into cardiac arrest, will you guys humor me a brief soapbox? Of course. Narcan does not reverse.

cardiac arrest. Yeah, that's a good point. That's been discussed recently because there are providers out there who are routinely giving Narcan an intra-arrest. And I've heard the argument that, well, it has a bit of a, it causes catecholamine surge. So does epi. Don't introduce another drug. I'll say it again for the people in the back. Narcan does not.

reverse cardiac arrest. Thanks guys. So something else I wanted to talk about too, we've been speaking a lot in the context of medical ROSC. Does your pathway change in the trauma patient?

The traumatic arrest that you've established, Rosk? Oh, yes. Yes. My pathway absolutely changes. Now. All right. All right. I didn't know that we were going this direction. Now let me get loose. Let me stretch a little bit. Do a couple jumping jacks. But no, the pathway absolutely changes in trauma arrest. And the reason is kind of the same as what we've been talking about. You got to look at why they arrested.

Why do trauma patients die? There's a couple reasons. They die from hypovolemia and they die from obstructive shock. So they died because they were losing all their blood volume into their belly or they died because we put them on the vent and they popped a pneumo or their trauma caused them to pop a pneumo. And so, and there are tamponade. Yep.

There are obviously some exceptions to this, but those are the two big causes. And so, yes, my post arrest, my arrest algorithm is completely different. My post arrest algorithm is completely different. One of the things that you got to watch out for is the needles that we use pre-hospital when we are decompressing a pneumothorax. Those are very, very temporary. And you have to watch for recollection of hemo or pneumo. I've seen people come in.

post-blunt traumatic arrest with four or five needles all in a row on their chest. Perfect. That means that you were paying close attention to your patient and you prevented rearrest. because those needles are not going to last long they're going to get full of blood and tissue they're going to kink they're going to dislodge Some of the data suggests that only about half of the needles that we place actually make it into the pleural cavity.

So regardless of where we do it, I'm a huge fan of the anterior or mid-axillary approach as opposed to the mid-clavicular. That's one of the reasons because your needle's more likely to get in. But still, it's not guaranteed. And so if it's not guaranteed to get in, it just as easily can come out. So that's one of my big, big focus. And then the other one is volume. If you've got blood, give them blood. If you don't have blood and it's truly your only option, some judicious saltwater.

may be necessary, but I'm so glad that we touched on this as well. Now, I feel like I have met my contribution quota here. And if you're using the dreaded needle and you don't listen to Amanda and you don't go mid axillary and you decide to make it mid clavicular, make sure A, it's truly mid clavicular. And B, if you're ever in doubt, go lateral. Don't go medial. There's a lot more bad things live to the medial aspect. The parasternal needles in the chest are not favorable or helpful.

They will generally preclude three or four more invasive procedures, but that's not what we're looking for. If your needle bounces with every heartbeat, something bad has happened. Right. Don't take it out. If you're having to re-needle, do a finger thoracostomy as a bridge to chest tube placement, which is going to be the definitive form of care. If you are able to do that in your protocols.

The finger thoracostomy is absolutely the definitive procedure. It brings up the idea of pre-hospital chest tubes. I've been asked about that. I don't think they're necessary. It's getting the big hole in the chest that is the definitive procedure. I would leave the chest tube to the in-hospital providers. Yeah. And remember, if the patient, if you've established that this... is an obstructive shock etiology with the finger thoracostomy you just have to reopen you don't have to

Choose a different site. You can use that same site if you're not placing a tube. Absolutely. The other thing I hear people say, even ER physicians at times will say, well, I put a needle in. First, just to get the chest open, and then I did put it in a chest tube or whatever. If you can't do a finger thoracostomy almost as quickly as you can do a needle thoracostomy, then you need to do more finger thoracostomies. Buy yourself a rack of ribs and practice with it. I would...

If you keep a scalpel in your lab coat or in your flight suit or whatever, by the time you find the right size needle to jack in their chest and horse around with the landmarks, especially mid-clavicular. you could have your finger in their chest just as quickly. So just do the right thing the first time.

much bigger proponent. But I also agree that there is a lot more nuance to putting a tube in their chest than a finger. And that tube can find itself in the lung, in the fissure, in lots of places that... The sub-Q tissue.

Yeah, right, right. I think pre-hospital people don't want to open that Pandora's box. So I agree with you completely, Amanda. Yeah. And I'm especially much more... aggressive with this if it's right-sided because we fly an ec 145 configuration and reaching the right anterior side of the patient can be very difficult but if you've already established that it's much easier to relieve that tension so

I'm much more inclined to go to a finger thoracostomy, particularly on that side for that reason. Great point. And then also this gets into calcium administration as well. We know that calcium has been controversial.

But when we're talking about massive transfusion, obviously the calcium is going to bind to the citrate. So that's something we need to consider. Now, when it comes to medical return of spontaneous circulation, are you all routinely I mean, I think I know the answer to this, but I'm going to go and ask it anyways. Are you routinely giving calcium? Are you just checking those levels and treating your iCal depending on what it is? What are your thoughts?

The only time that I'm routinely giving calcium is when I'm staring at their dialysis fistula and I'm worried that it was a hyperkalemic arrest. Yeah. I have been sucked in and peer pressured. from time to time to give calcium during an arrest, but I always feel ashamed after I do it. There's no evidence for it.

None at all. In fact, there was one study done that said that mortality was increased. I don't believe that mortality was increased by given calcium. I think that was probably just a surrogate finding. You probably shouldn't be. Anything that you're given just because is probably not a good idea. You know, I've had people say, oh, let's give them D50 or let's give them Narcan. What's it going to hurt?

That's not a justification for doing something silly. You know, everything has an indication. Stick to the indications for God's sake. I know that feeling of shame well myself. Right. You just walk away. You kind of put your head down. You're like, yeah, I don't know why I did that. I shouldn't have done that. I don't know why I did it. Like, given kaxalate, you know, you're like, I mean, I don't know why I did that. Because nephrology pressured me. It was a terrible idea. I had to fight off.

The other day, I had a hospitalist wanting me to treat asymptomatic hypertension in a patient in the ED that was coming to the floor because the nurses in med-surg wouldn't like the blood pressure of 190. So we've got to bring that blood pressure down. And I'm like, I'm not, I'm just not. Well, can you just give a dose of hydralazine? I'm like, no, no, I am not. Do you know Dan Rao? Of all things. Dan Rao doesn't give hydralazine. I am not giving hydralazine.

So, you know, we all have those shameful moments, right? You just have to embrace it and go on, I guess. So just optimization of normalization, treating the ideology, and don't wait around. That's right. No horsing around. And have an approach. Because really, you could kind of almost create yourself a checklist for post-cardiac arrest care. What's the blood pressure? Get an EKG.

Quick chest x-ray or point-of-care ultrasound to ensure the lungs are up and you haven't created something terrible by mashing on this poor little 100-year-old lady's chest. Think about magnesium. Make sure that you're not ventilating at 100%. Make sure you're not hyperventilating at 50 breaths per minute with the bag valve mask. Make sure everybody gets some sedation, even if they're not doing anything. You know, just run down the list. You know, just think about things. Have an approach.

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