We responded to agonal breathing for a 74 yo male. 

We found him in bed with actual agonal breathing – about 4 ineffective breaths per minute and NO palpable pulse. His wife said she saw him speaking about 20 mins ago. We, with the assistance of the Fire Dept, immediately got him on the floor and started chest compressions. The airway was manually opened and verified clear, an OPA easily inserted and ventilations assisted with BVM and oxygen. 

Initial rhythm on the monitor was Asystole. IV access obtained, the first 1:10,000 Epi administered and NS infusion initiated.  

During all of this, we try to get some more information from the wife. She states he has lung cancer, DMII and HTN. He has missed his last 3 Chemo treatments and has complained about “not feeling well” for several days. 

Blood sugar reads – “High”. 

Pulse check- pulseless. Rhythm check – Asystole. CPR continued. 2nd Epi administered. Airway secured via ET tube, verified and Capnography attached. We have good waveform, an ETCO2 value of 27 mmHg and “bagging” compliance is easy. 
I have a retired Flight Medic working at the Fire Dept and he takes over airway for me, verifies my findings and agrees the pt’s lungs are “easy to bag”. We start adjusting our ventilation rate to get to between 35-45 mmHg. 

My protocol is to work the pt for 20 mins on scene prior to initiating transport. At this point, we’re closing into that 20 minute mark and have accomplished nearly everything we want. I’m reviewing everything and trying to come up with any other reversible cause we can treat either now or en route to the ED. 

I then notice an odd change on the monitor. There is organized complexes seen overlapping the CPR rhythm. Chest compressions halted a moment and there’s irregular wide complexes with no pulse – PEA (picture not available), I’m thinking – this may be the Epi. 

We get him onto a backboard for movement to the stretcher and there’s another change on the monitor. This is also a wide complex rhythm however it’s very organized and regular. I check a Carotid pulse – present!, I verify a Femoral pulse – also present! 

I showed this to several people and got numerous answers. This is an Accelerated Idioventricular Rhythm. 

Life in the Fast Lane has some great info on this: Accelerated Idioventricular Rhythm (AIVR) • LITFL • ECG Library

Dr. Amal Muttu also has some great points about this: Tough Dysrythmias Part 1 | The Heart Course *Home-Study* ECG Workshop – YouTube skip to 40.10 for AIVR but I’d encourage you to watch the entire video. 

What makes this rhythm different than something like Hyper K or VT is that this rhythm appears at the time of reperfusion AKA ROSC. It’s seen commonly in the Cath Lab and this rhythm will self terminate on it’s own, usually within just a few minutes. The important thing to remember is – this rhythm does NOT need treatment itself! This is showing you blood flow has returned. It appears as a “Slow V Tach” however, this is much too slow for VT and Hyper K will not resolve on it’s own without treatment especially within just a few minutes. 

 

We captured a 12 lead: 

What should immediately grab your attention is the overall very low voltage. Especially post cardiac arrest, we should consider this to be a Pericardial Tamponade first. 
Criteria for “Low Voltage” – QRS less than 5 mm in the limb leads and less than 10 mm in the Precordials.

This is present in every lead. 
The rate here is ~150bpm – not uncommon during cardiogenic shock. 
There does appear to be P waves however they are very tiny.
The QRS is narrow and aberrant RBBB appearance is present. 
AVR does possibly have some ST elevation but this difficult to verify due to the small voltage. 
Leads I, II V3-V5 may have some ST depression. 

To be honest, this is not what I was expecting. This – in an overall sense – just does not look like an occlusion – at least to me. 
Several manual BP’s taken throughout transport – initially ~ 70/40. I mixed and started a Levophed drip – 16mg in 500ml NS and ran it at 7.5 gtts ( It’s what we have…). Best BP I got was 106/60. 

At the ED, we still have ROSC and the Doc does a POCUS – says it’s somewhat obscured but this is possibly a PE. 

We clean up and leave. About 2 hours later, we’re back at the same ED, I found one of the nurses that was in the room and ask about our pt. He says – our 12 lead looked like yours, we just knew it was a Tamponade. Chest X ray looked odd with a “reflection”. Personally, I don’t know much about reading X rays and have no idea what that means.  
They had to get the head of Radiology to come down. He says – this is a Hydro Pneumothorax. 

I’ve never seen or heard of this. When I researched it, apparently it’s not all that common – less than 200,000 a year. It’s completely new to me. Chest tube placed and about a liter of fluid removed, The pt also had right tracheal deviation.

Well I learned something new but what confused me was how easy this pt was to ventilate. I confirmed it, the Flight Medic confirmed it, the ED doc and the Respiratory tech also confirmed it.

If anyone has experience in this area, I would love to hear from you!

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