Clinica Grind 9: #tPa

Post by Patricia Capone

It’s 3 am when you get a call from EMS. 60-year-old male, otherwise healthy, V-fib arrest. The patient arrives at the ED in V-tach arrest with LUCAS device executing compressions, successfully intubated by EMS with a few rounds of unsuccessful defibrillation in the field. IV access and end-tidal CO2 in the high 20’s to low 30’s established upon arrival. Another unsuccessful round of defibrillation in the trauma room.

Now what?

As Drew stood on his stool, as he always does when overseeing a trauma, he asked himself and his residents that very question.

They decided on dual sequential defibrillation. For those who are unfamiliar, the procedure involves shocking the heart back to back with two different shocking devices. The first set of pads are placed in the usual right upper chest and left lower chest position, while the second set of pads were placed anteriorly and posteriorly. There is mixed evidence on whether or not this technique is beneficial and in some cases can void warranties on AED defibrillators and monitors, however, in this case, it was the best option.

After a successful round of dual sequential defibrillation, they were able to get the patient back to a rhythm that was “semi-perfusing”, which Drew defines as an organized rhythm in which the patient was no longer in pulseless V-tach and showed some cardiac motion on ultrasound, weak palpable pulses, blood pressure, and MAP in the 40’s to 50’s. ECG is showing STEMI with borderline wide QRS complexes, T wave elevations in anterior leads, and reciprocal changes.

Problem: A patient with STEMI needs to be brought to the cath lab, but is not stable enough to transport and cath.

But wait…there’s more: The patient codes again! After a few rounds of CPR, another round of epinephrine, and two doses of amiodarone, they are able to get the patient back. This happens two or three more times, meanwhile, bloodwork comes back showing a pH of 7.25. End-tidal CO2 is in the high 20’s with good waveform, positive cardiac wall motion, pupils equal and reactive, and intermittent purposeful movement with compressions. At this point, all signs point towards the situation being salvageable if they can get the patient to the cath lab, but the patient still is not stable enough.

Thoughts from Andy and Tanner:

  1. Consult the interventional cardiologist
  2. Consider ECMO
  3. Consider compressions in the cath lab

What did Drew and the team do?

Drew called the interventional cardiologist on call and explained the situation. Knowing that ECMO was not an option at their facility, he discussed the cath lab option with the interventional cardiologist. They decided that the patient was not stable enough and that having to do compressions on the patient during the procedure would have a whole host of other risks like dissection of the LAD. However, given the positive prognostic indicators of the patient’s vitals and bloodwork, Drew wasn’t quite ready to call the code yet, so he explained to the consultant that he was going to push TPA. The consultant agreed that although this approach is unconventional in a facility with a cath lab, it would be the best course of action in this case because the patient was too unstable to cath.

TPA and other thrombolytics are still commonly used in places that are 90 minutes or more from a cath lab, so the idea was not crazy, just different. The decision was not one that Drew made lightly because he knew he would be committing his team to at least another 30 minutes of running a code, but he and the resident were convinced it was the right thing for the patient, so they got the rest of the team on board, pushed TPA and monitored for 30 minutes.

27 minutes after pushing TPA, the patient began exhibiting end-tidal jumped into the 30’s, MAP went from 40’s with compressions to 60’s and 70’s, more purposeful movement, improved cardiac wall motion, good palpable pulses, and the vasopressin and norepinephrine drip was able to sustain a blood pressure that was reasonable enough for the patient to be transported to the ICU.

After 18 hours of being in ICU, the patient coded again. The ICU team was able to get him back, but then the patient coded a second time, at which time the family decided to withdraw care. Unfortunately, the patient only lived a few more hours.

Some key takeaways:

  1. The job of the EM physician is not to predict the future, rather it is to do what is in the best interest of the patient given the information known at the time of care.
  2. Patients deserve for physicians to give them a chance if they have one.
  3. EM physicians work in extremes and have to push the envelope of medical knowledge sometimes. In order to do that you have to be ready, be smart, be current, and be confident enough in yourself.

For the full case presentation and discussion, check out the episode below!

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