Tuesday, March 6, 2018

When to stop CPR

When to cease resuscitative efforts is a constant topic in the medical education and medical ethics communities. While certain scenarios are usually cut and dry, such as mortal wounds with significant destruction to vital organs, other scenarios such as end-stage disease generate uncertainty to the providers medical judgement. So here we go, the question and background presented to me:

85 year old female patient in cardiac arrest with comorbidity (simultaneous presence of two or more chronic diseases/conditions in a patient) of HCC (Hepatocellular Carcinoma, aka liver cancer), HCV (Hepatitis C Virus, author note: assumed to be the cause of HCC), and “large amounts” [exact volume unknown] of hematemesis (vomiting blood).

It was reported that CPR [Cardiopulmonary Resuscitation] and ALS [Advanced Life Support] measures were immediately started. Progress the “code” for an unknown amount of time and the patient converts into ROSC [Return of Spontaneous Circulation, the goal of CPR] and re-arrested a reported four times. Secondary [assumed] to the hematemesis, two units of packed RBC [red blood cell] were transfused to the patient without additional units being available per the blood center. Also note that the relative (relation degree unknown) of the patient asked for efforts to stop and “let her die in peace”.

 On the fifth presentation of cardiac arrest the senor physician called for a vote to either continue or cease resuscitative efforts. The vote resulted in the cessation of resuscitative efforts and the patient terminated. 
 Several questions are asked, as followed;
What are the guidelines for stopping CPR in cardiac arrest? 
At this time (2018), the American Heart Association, DOES offer guidelines to cease [AHA ACLS 2015 manual, page 117 “Terminating Resuscitative Efforts”] resuscitative efforts for in-hospital providers but no current algorithm exists, that I know of currently. Specifically to this event, the presentation of hematemesis requiring two units of RBC without additional units available from the network [as questioned, it was assumed the patient needed additional units], the repeated arrests, the almost certainty of severe secondary hypoxic brain injury, and wishes of the family should be a strong indicator to lead a provider to cease resuscitative efforts. It should be noted that the author is assuming that cardiac arrest means PEA/Asystole over the wording of arrhythmia, a poor prognosis on its own standing. It is also assumed that PETO2 is less than 10mmHg related to poor pulmonary perfusion secondary to hypovolemia, also a cited reason is cease resuscitative efforts [AHA ACLS 2015 manual, page 117 “Terminating Resuscitative Efforts”].

 Is it right to exhaust all efforts to resuscitate without consideration of quality of life post-event? 
 If this is the only aspect of the question without any consideration to other patients in the network, without prior wishes from the patient, and assumed resources at unlimited supply then we have to say “yes”. However we do not provide in a vacuum and we do have to consider other patients as well as the resources dedicated as part of you care plan. We also direct our efforts with the finite resources available. I might suggest reading the AHA journal article “Part 2: Ethical Aspects of CPR and ECC”; 2000 which I will link at the bottom. I will say that for this scenario everything appears to be checked off on the list for ceasing supportive efforts. Also consult your bioethics office at your establishment for additional guidance.

What is the medicological response of the efforts for this patient? 
 I cannot speak to a full physician provider level but I can speak to the paramedic level and as an ACLS instructor. Immediate CPR is given followed in tandem to aggressive airway suctioning with efforts to ultimately provide an advanced airway. I am applying a heightened focus on prevention of foreign substance aspiration given the ejection of total body blood volume, route of exit, and assumed subsequent drop in pulmonary perfusion. To simplify the statement, what is the point of making blood go round-and-round if I cannot get air to go in-and-out. At the physician level I would suggest chest tubes if not already in place.

  I need to note that I would require my team to place an IV/IO to provide large volume fluid bolus or ideally blood units if available. I would continue to follow the established ACLS algorithm with two minutes of CPR cycles with 1mg of Epi 1:10,000, each other two minute cycle I would withhold Epi. Consider your H&T’s (try not to eye roll), which in this case should be going off like a billboard light in the dark. Hypoxia, Hypovolemia, Hemothorax (I added that one), and Toxins (suspect because of your lab statement comment) secondary to the liver cancer.

   If these supportive measure are not maintainable (Hypovolemia) then working the arrest to the 20 minute mark with noted levels of your PETCO2 leads to the reasonable decision to cease CPR. I hope this answers the questions you presented and I am happy to answer more.

 If I cannot answer your question(s) I know which resources to contact to deliver appropriate answers.

American Heart Association - 2015 Guidelines (2018). “Terminating Resuscitative Efforts”, 117,

American Heart Association (2000) “Part 2: Ethical Aspects of CPR and ECC”, Retrieved 2018, http://circ.ahajournals.org/content/102/suppl_1/I-12

American Thoracic Society Journal (2015). “CEASE: A Guide for Clinicians on How to Stop Resuscitation Efforts”, Retrieved 2018, https://www.atsjournals.org/doi/full/10.1513/AnnalsATS.201412-552PS

 #WhentostopCPR
#CPR
#AHA

Monday, March 5, 2018

Thanks Russia

Thanks Russia for making up 90% of my site traffic.

Not sure how I feel about that? International blogger or cyber ragdoll?

#Nopeski

Buying a new old bike

   Ugh! Time to buy a bike again. I always get so overwhelmed with buying anything new. I always want to buy everything at once in some vain attempt to show that I know I am doing. Let's be clear... I don't.

   I don't know what all the bike parts are or the add-ons. Heck I was calling it the handle bar covers until some 9 year old at the store told me it was called "grips". #Facepalm

   We know I don't have a clue about bikes but I do know a deal when I see one. I figure the bike market is split into two markets. Knuckle draggers like me and the Lance Armstrong's out there. I don't need a $1,200 bike. What I need is a $50 bike and how did I decide $50.... that's all I had. But seriously on the resell market most stuff loses 2/3 of it's ticket value. So there you go! Now I have a bike.... with brakes and everything. :)

I know it's a boring post but to all you bike newbies out there, let's talk!

#BikeLife

Thursday, March 1, 2018

Two wheels

Is anyone else out of shape? I find myself sucking in my stomach A LOT. I shouldn't have to do that, right!? I think I am the heaviest I have ever been and I can tell it is getting in the way of things. Putting on socks, walking to the mailbox, even sex (sssshhhhhh). Things need to change and it start today! ... well yesterday....but today damn it and don't judge me.

I started biking to work, well mostly. We have light rail in central Texas and so I biked to the train station. My goals here are 1) Save money 2) Get healthy 3) Lose weight; on that last goal I would really love to have my six pack back. Baby steps! I would be happy with having flexibility, lower blood pressure, and seeing my toes again.....maybe other things. :p

I wanted to make a smart start so yesterday my girlfriend took me half way to the train station in the morning. I spent a total of 1 hour and 13 minutes biking to and then from work. How many calories is that? Better be a bunch cause I was a soggy mess on the train. I think someone asked me if I was having a heart attack. Felt like I should be having one and I could see the judgement from the skinny people on the train. Honestly there probably wasn't but in my head there was. Damn them all for not-really-thinking-that-but-in-my-head-they-are. Bastages!

Today I am doing the full Monty, I am talking full frontal male nudity. No, kidding, jesus!

No, I started from our house and made the FULL trip to the station this morning. Check back here later today for a report. I'm doing it! Yuuuusssss!