I did a code last week which ended the longest drought of my career when it comes to cardiac arrests. When I came back from the EMS Conference in Baltimore all excited to try the new CPR, I had no opportunities. Not to sound morbid, but when I walked into the basement bedroom and saw the officers doing CPR, I thought “Finally, a code.”
The patient was in his late fifties. His family had been talking to him when he collapsed. I could see a dialysis catheter sticking out of his chest. He was asystole, no shock advised. He’d been down about ten minutes. I intubated him and put on the capnography – which revealed a good wave form and an ETCO2 reading of 17 to 23, which is a sign that he might indeed still be salvageable. While my partners took over CPR, I put in an EJ and started slamming the drugs. I gave him some calcium, and then as one of my partners was tiring doing the compressions I took over for a minute. I just started pounding away. Hard fast and deep. I felt like I was really priming the pump. I was John Henry against the steam drill. Then I looked over at the monitor and the ETCO2 number was 35. I stopped compressions and there was a rythmn. We checked his carotid and he had pulses. BP of 124/80. Wow, I thought!
We packaged him up, and as we got him outside, the capnography dropped down to 18 and we checked for pulses and they were gone. We gave him some more epi and got the capnography number back up and there were pulses again. We had a hard push up an outside hill to get back up to the driveway – it was either that or carry him up a steep flight of stairs and down some narrow furniture filled hallways in the house. We lost pulses again – and again it was flagged by the drop in the capnography.
On the way in – I had another paramedic with me – so we swapped back and forth doing compressions. I usually never do compressions because as the only medic on most calls, I am managing the airway or pushing drugs. Compressions are hard work. I kept yelling at the driver to slow down. He is the smoothest driver here and I couldn’t believe he was giving such a rough ride even though he was only going twenty – and then I realized it wasn’t so much he was giving a bad ride, but for the first time in years I was having to do compressions while standing up, trying to balance myself. It was hard – that and trying to do good deep, fast compressions. I kept switching back and forth with the other medic. At one point when the capnography was at 16, I told him if he could get it up to 20, I’d buy at Dunk’in Doughnuts. He started pounding away and slowly the number came up to twenty, and right on up – all the way to 28. If he slowed down the number dropped. Between us we kept the number in the high twenties, and then it shot up into the thirties and we had pulses back.
When we went to take the patient out of the back for some reason the wheels didn’t drop right and the patient slammed down on the steps and almost rolled off the stretcher. I looked at the monitor and was glad to see I still had a good capnography wave form so the tube hadn’t become dislodged.
Going down the hall the capnography number dropped again and we started CPR. They worked him awhile longer at the hospital, but he didn’t make it.
The capnography was very instructive. It did the following:
1) Confirmed placement of the tube.
2) Alerted us to ROSC three times.
3) Showed how well CPR could be done when we concentrated on it.
4) Confirmed continuously placement of tube.
Here’s the capnography trend summary showing the three episodes of Return of Spontaneous Circulation (ROSC).