Post-ROSC Transport With a Pressure of 78
A 55-year-old man collapsed at home. Bystander CPR began after 4 minutes, and ROSC was achieved after 12 minutes of CPR and two shocks. He remains comatose and intubated. BP is 78/46, HR is 118, SpO2 is 91% on 100% FiO2, and EtCO2 is 28 mmHg. A 12-lead ECG shows an anterior STEMI. Glucose is 240 mg/dL. He has one 18-gauge IV. The PCI center is 25 minutes by helicopter. Family says he is usually independent.
1. What are your post-ROSC priorities during transport? Give target numbers.
Read the worked answer
Priorities
- Oxygenation: titrate FiO2 to SpO2 94–98%; avoid hyperoxia.
- Ventilation: target PaCO2 35–45 mmHg and use EtCO2 as a trend; an EtCO2 of 28 mmHg may indicate hyperventilation or low cardiac output.
- Hemodynamics: target MAP at least 65 mmHg and systolic BP at least 90 mmHg.
- Temperature: begin targeted temperature management at 32–36°C or actively prevent fever, depending on protocol.
- Glucose: treat with insulin per protocol, generally targeting less than 180 mg/dL.
- Destination: activate the PCI center and transport for immediate coronary angiography.
Reasoning Post-arrest care is about preventing secondary injury. Hypoxia, hyperoxia, hyperventilation, hypotension, and fever all worsen neurologic outcome. The STEMI is the likely cause, so reperfusion is time-critical.
2. How would you manage his hypotension? Include a specific vasopressor plan and medication-safety issues with a single peripheral IV.
Read the worked answer
Fluids Give a cautious 250–500 mL isotonic bolus and reassess, because the STEMI may include a cardiogenic component.
Vasopressor Start norepinephrine at 0.05–0.1 mcg/kg/min through the existing peripheral IV while obtaining a second line. Peripheral norepinephrine is acceptable temporarily for short transport if the site is monitored for extravasation.
Push-dose epinephrine alternative Prepare 10 mcg/mL by adding 1 mL of 1:10,000 epinephrine to 9 mL normal saline; give 1–2 mL boluses and titrate to effect.
Medication safety
- Label every syringe with drug, concentration, and time.
- Have a second provider independently verify the concentration.
- Use a pump when possible and monitor the IV site.
- Avoid mixing vasopressors in the same line as other medications without flushing.
Reasoning The patient needs coronary reperfusion and adequate perfusion pressure. A single peripheral IV is a practical constraint, so the team must use clear labeling and concentration checks to prevent a dosing error.
3. He becomes pulseless again with a wide-complex tachycardia at 220 on the monitor. What do you do?
Read the worked answer
Interpretation Pulseless wide-complex tachycardia is ventricular fibrillation or pulseless ventricular tachycardia until proven otherwise.
Actions
- Start CPR immediately and defibrillate at the manufacturer's recommended energy (often 200 J biphasic).
- Resume CPR for 2 minutes; give epinephrine 1 mg every 3–5 minutes.
- Give amiodarone 300 mg IV after the second or third shock, or lidocaine if amiodarone is unavailable.
- Treat reversible causes: hypoxia, hypovolemia, tension pneumothorax, thrombosis, electrolyte abnormality.
- Confirm tube position and ventilation; avoid hyperventilation.
- After ROSC, maintain the post-arrest targets and continue to the PCI center.
Reasoning Defibrillation is the definitive treatment for shockable cardiac arrest. Medications and reversible-cause treatment support the shock but do not replace early defibrillation and high-quality CPR.