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Chapter 2

Circling the Drain

Scott Weingart, MD, Amal Mattu, MD, and Rob Orman, MD
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Scott Weingart and Amal Mattu are our guests as we breakdown the critical decision points in a case of a patient with an acute anterior STEMI and cardiogenic shock.

 

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Dylan N., 9461270 -

I recently had a 55 y/o pt with a STEMI and V-fib arrest but I could not achieve enough stability to get the patient to the cath lab - even though that was just a long hallway away. He would regain pulses for 30 seconds or so, then deteriorate again. ECMO was not available. I thought afterward, should I have considered lytics? It was helpful to hear you discuss the topic of lytics in severe cardiogenic shock, a topic I've never really heard addressed before. Great info as always. Thanks!

Rob O., MD -

Hey Dylan. These cases are frustrating on so many levels. You feel like you're just on the edge of getting consistent ROSC, only to be foiled again. Are there any other details of the case you can share, such as, what was the convo with the cardiologist, what was the sequence of the resus, was there a debrief post event?

Dylan N., 9461270 -

The interventionalist was called shortly after the patient arrived, around 9 AM, I think. The patient had a hx of previous MI and we were able to obtain an ECG during one of his brief episodes of ROSC that showed an inferior STEMI. The cardiology team consented the patient's wife for cath, and we were all ready to go to the lab, but the episodes of ROSC became more and more transient. He had received amiodarone and we also added lidocaine as well. The interventionalist came to the bedside and helped with the code for a bit, but he really didn't have any further suggestions, and eventually the rhythm became PEA. Ultrasound confirmed no cardiac activity, and we pronounced the patient. Very frustrating case, especially as we were so close and family, including two young children, were present. Not much of a debrief took place afterwards, but this case probably could have used one.

Interestingly, I had another similar case with a more aggressive interventionalist a few weeks later and the patient went to the lab with compressions ongoing. The culprit lesion was opened and the patient got a balloon pump but died less than 24 hrs later from refractory shock. Again, ECMO might have helped, but neither my community hospital or our larger affiliated center is currently doing ECMO. We would have to transfer the patient out of network, which is done occasionally for various reasons, but I have yet to see it happen for cardiac arrest.

Rob C., RN/EMTP -

I was surprised the use of lido and amino was discouraged in a patient with so much ectopy. Does the depressant effect outweigh the benefit of possibly creating a more regular perfusing rhythm that raises the MAP and possibly decrease the ischemia?

Rob O., MD -

Rob! What you're asking is the golden question. I've asked several experts about this situation and there is always a pause, then a sigh, then resignation, then an answer that differs from the last person I asked. This is an evidence free zone and, to your point, giving the heart a little dysrhythmic relief might buy time to get to cath lab. The other side of that is that the heart muscle is dying in short order and who knows if any of these drugs would work, or possibly harm. Faced with this situation again, I would probably use lido

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