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CASE REVIEW | By James J. Augustine, MD, FACEP THE ATTACK ONE crew members have fnished dinner and are preparing to orient an EMT student who will accom- pany them for the evening's operations. The tones drop, and they are dispatched to an offce complex for a "possible heart attack." The paramedic tells the student that a complaint of a "possible heart attack" could be almost anything. "Frequently it's an uncomplicated medical problem," he tells the student, "but sometimes we get there and they're doing CPR. Especially in an offce complex, we just never know." Tonight it is a complicated medical problem. The 58-year-old man was working into the evening and reported to his coworkers that his chest pain began about an hour ago. He was sitting at his computer when he abruptly slumped over and was found to be pulseless. The workers around him lowered him to the foor and started doing chest compressions as they called 9-1-1. The offce had no AED. The only history the coworkers are aware of is that the patient has diabetes, because he is very proud of taking his blood sugars and adminis- tering appropriate doses of insulin as he works through the day. They are not aware of any heart problems other than the chest pain he reported prior to slumping over. The Attack One crew begins its organized system of chest compres- sions, hooks up the defbrillator and fnds the patient in ventricular fbril- lation. They administer the frst defbrillation shock, then immedi- ately resume compressions. The third shock converts the patient to a slow, wide rhythm, and he regains a faint pulse. After a minute he is back in ventricular fbrillation. He is defbril- lated again but has no conversion. The crew does a two-minute cycle of compressions and tries another shock. He converts, this time with a rate of about 100 beats a minute and a strong brachial pulse. After a minute, though, that deteriorates again to fbrillation, and the pulse disappears. Another defbrillation shock and no success, so compressions resume with plans to rotate among the Attack One crew, the student and the fre engine company that has arrived. The Attack One paramedic performs a rapid assessment. The patient is unresponsive and not breathing. He does not have a gag refex but is being bagged easily with an oral airway in place. His neck veins are not distended, and there are no signs of injury. So far they have administered no medications, so the paramedic gives a dose of lidocaine and sets up for an ongoing drip. The cardiac monitor shows a coarse fbrillation pattern. "Thanks for doing great compres- sions," the crew leader announces. "Give me a minute to intubate him, so we can protect his airway and use end-tidal carbon dioxide monitoring. As I do that, let's prepare him for transport. He keeps going in and out of fbrillation, so he needs to be moved quickly to the heart hospital, where they can fnd something that converts him and keeps him in a rhythm." The entire group starts to work in unison, including the coworkers, who are moving furniture and clearing the way out of the offce. A backboard is passed into the room, and the patient is strapped on. The endotracheal tube is in place and secured, and end-tidal values are in the mid-20s, so the patient is perfusing with the chest compressions. The stretcher is loaded, and the paramedic chooses to do one more defbrillation, which is again successful, converting the patient's rhythm to a fast narrow-complex tachycardia. He has a pulse, and for a few moments his carbon dioxide readings move into the 30s. "OK, everyone, his rhythm is back, so let's move him quickly to the ambulance and get going," the paramedic directs. "Everyone move quickly, but don't lose the endotra- cheal tube." The ambulance is head-in in a small driveway close to a side door into the offce building. This close location allows them to zip out the door, load Things That Go Bump in the Night A backing mishap illustrates the value of having a spotter 58-year-old male in cardiac arrest with recurrent ventricular fbrillation. ❯ Airway: Maintained with an endotracheal tube. ❯ Breathing: Positive pressure ventilation. ❯ Circulation: Pale skin, no pulses. ❯ Disability: Not responsive. ❯ Exposure of Other Major Problems: No signs of trauma. VITAL SIGNS Time HR RR Pulse Ox. EtCO 2 2023 0 0 NA NA 2029 0 0 NA 24 2035 0 12, assisted NA 26 2042 0 12, assisted NA 32 2050 0 12, assisted NA 30 AMPLE ASSESSMENT ❯ Allergies: None. ❯ Medications: Insulin, atenolol. ❯ Past Medical History: Insulin- dependent diabetes, hypertension. ❯ Last Intake: Dinner around 1800 hours. ❯ Event: Cardiac arrest. INITIAL ASSESSMENT "All EMS personnel must be involved in scene operation safety." 18 APRIL 2014 | EMSWORLD.com EMS_18-23_CaseReview0414.indd 18 3/13/14 2:32 PM