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Fairly early into an overnight shift the radio goes off. EMS is approximately 6min out with mid 30s male undergoing CPR. Per bystanders, the patient was going running from door to door, banging on doors and yelling for help. Shortly after being taken into police custody he was found to be pulseless. Had been undergoing CPR approx 10 min. King airway in place. No improvement with dextrose and naloxone.
The intern on and myself go to Room 9 to get set up. When EMS arrives about 10 minutes later, CPR is still ongoing and rhythm has been asytole/PEA throughout. The story remains consistent with him going from door to door yelling for help but now there is some variation as to whether he was cuffed and then lost his pulse, was found without a pulse, or if he got into a physical altercation with the neighbor and then lost pulse shortly after arrest. There are no signs of trauma and we elected to not invite additional chaos by calling a Level 1.
CPR is continued. King airway switched out for ETT. Accucheck 250’s. Central venous access and bilateral chest tubes placed with no rush of air or blood. Sats persist at 85% on vent, etco2 is in 60’s. He gets epi q3m. A dose of vasopressin and steroids. Istat has K 5.5. Lactate >20. Received 2-3 amps of bicarb. Received calcium. Upon rhythm checks he was primarily asystole except for 2-3 checks with a narrow pea that would not persist. Each time the ultrasound was placed on his heart there was no cardiac activity. My thought process at this time was that he was either excited delirium that I’m not going to be able to do much about or some kind of ingestion/overdose. We called pharmacy and asked for lipid emulsion. His ETCO2 had remained between 40-60 and we were about 40 minutes out from reported time of arrest. I decided if the lipids were unsuccessful that would be when we would call it.
They arrived about 15 minutes later and were infused. By now his etco2 had drifted down to 10 on the most recent pulse check. No changes occurred and TOD was called.
Great case and managed as aggressively as we could. I deleted your part in there saying he was afebrile, because he had a 101.something i believe. I will not comment anymore, would like to see what people think…
Grossman, I am impressed that you thought of throwing the lipid sink (LRT, lipid rescue therapy) at this patient! I have a few quick thoughts/comments about the matter (we/I could even expand this to a lecture at a further date if there is interest).
1) We carry 250mL of lipid emulsion 20% for initiation of LRT in the in the MAIN ER Accudose. This is a sufficient amount for the bolus- and enough to initiate an infusion until a larger supply arrives from pharmacy.
2) Some points on dosing:
Initial bolus of 1.5mL/kg over 2-3 minutes (~100-175mL). The bolus injection has been found to be critical to obtain rapid clinical improvement (a large mass of lipid is necessary to achieve therapeutic effect). Then, initiate a continuous infusion at 0.25mL/kg/min (~18mL/min). Repeat bolus once or twice for persistent cardiovascular collapse (at 5 minute intervals). You may double the infusion rate if BP remains low. Continue infusion for at least 10 minutes after attaining circulatory stability. Upper limit: 10mL/kg over first 30 minutes.
3) Tox center routinely recommends LRT for non-DHP CCB OD. Case reports have shown LRT success in lamotrigine, amitriptyline, and b-blocker OD.
4) Not indicated in non-differential cardiac arrest, but, giddy up if cardiac arrest following OD or suspected OD. Lipid emulsion is indiscriminate. Possibility of therapeutic medications being targeted as well as the toxicant.
5) ADE: ARDS, pancreatitis. Lipidemia can cause interference with lab measurements.
6) Check out lipidrescue.org for more info (Dr Guy Weinberg’s website). And while you’re at it, check out the clinical review over LRT in the Journal of Em Med published a few months back.
Interesting case.
Wow thank you for the thorough comment here Chrissy. Room9er has been down a few days getting ready for July, so I hope everyone reads this now that were back up. I did not know we had LRT in the ED. Thank you for the information!
This thought has never crossed my mind, however you gotta wonder what difference it would’ve made if it was the first thing you did. It appears to work great on tox cases, would love to see how it would unfold in the use of cardiac arrest as well. Excellent case and thought process. Certainly will try to use it at a later date if the opportunity arises.