Case #67 "Staying Alive’ and Keeping it Cool"
by Charlene Babcock Irvin, MD, FACEP
 

A 60 ish y/o obese female is brought into the critical care area (resuscitation area) unconscious. Her family told the triage nurse that she had been short of breath for a few days, refusing to go to the ED, and they could finally take her as she became more confused. She was assisted to the car, but in the car became unconscious. The family honked at the ambulance bay, and with the help of several techs (the patient was obese—weighing about 300 lbs) she was transferred to a gurney and transported directly to the critical care area.

Initial ABC’s on your arrival note the patient to be apnic and without a pulse. You start CPR, and set up for intubation. The patient is placed on the monitor and the initial rhythm is asystole.

1. What rate of CPR should you use? What is CCR? What is MICR?

2. After one round of epinephrine, Atropine and intubation, you get a pulse back. Blood pressure is 150/95 and HR=140. Is this patient a candidate for post resuscitation hypothermia?

3. Further history is obtained from the medical record, which notes a history of COPD, diabetes, hypertension and non-compliance. She was on home oxygen.

Physical exam after SROC (spontaneous return of circulation) revealed:

HEENT: Pupils fixed and dilated. Neck supple.

Heart: Regular rhythm. Tachycardic. No murmurs.

Lungs: Equal breath sounds. Significant wheezing. No rales.

Abd: Morbid obese, soft, no obvious masses. Bowel sounds decreased.

Ext: No rashes. Pulses present throughout.

Rectal brown guiac neg.

The first EKG showed diffuse ST depression/ ischemia and tachycardia (post Epi /Atropine and ROSC (Return of spontaneous circulation)), and cardiology was consulted. However, EKG repeated in 20 min showed improved ST segment changes. No clear STEMI identified. Accucheck normal, and VBG showed a pH of 6.9, pCO2 of 110, and p02 of 415 (Sat 100% on 80% oxygen by vent). CXR revealed tube in good position, and no infiltrate.

Cardiology ordered a stat echo (which showed a normal right ventricle (no dilation), mild pulmonary hypertension, no focal wall abnormalities, and cardiac output was estimated at 60%). CT head was neg. Other labs remarkable for WBC of 15.6, BUN of 30, Cr of 1.8 and Lactate of 12.9. Other labs normal (including cardiac enzymes). What do you think caused the arrest?

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