A 47-year-old obese male suffered a cardiac arrest at home and paramedics were called. Paramedics performed CPR, secured the patient's airway with an i-gel, administered epinephrine and amiodarone, and defibrillated multiple times. Extraction of the patient was difficult due to his size and the home's layout, interrupting chest compressions. The patient remained in asystole and died in the hospital. While guidelines were generally followed, opportunities were identified to improve outcomes through different drug protocols, better airway devices, and mechanical CPR devices to maintain compressions during difficult extractions.

1. CARDIAC ARREST PATIENT
MANAGEMENT
Case study by David lord

2. AIM:
To present a case study of a patient and explain the
treatment of the patient, showing the evidence supporting
the treatments and examine any limitations or drawbacks
of the treatment as well as suggestions for improvements.

3. THE PATIENT:
• 47yr old male
• Call initially placed as “fall, unresponsive”
• Call upgraded to ?Cardiac arrest shortly before LAS arrival
• O/A – Family member performing CPR
• P/C – Patient GCS3 - AVPU
• HxPC – Patient had gone upstairs to go to bed, family member “heard a large crash” and
found the patient collapsed. Patient was placed in recovery position by family member
who stated the patient was unconscious but breathing at the time, patient then stopped
breathing whilst family was on the phone with LAS dispatcher.

4. PATIENT’S HISTORY
The patient’s family informed us that he had no cardiac history. The patient had been
released from hospital earlier that week following a chest infection and was taking a
course of antibiotics but no other regular medication. No known drug allergies. Non
smoker, no excessive alcohol consumption, no history of recreational drug use.
The patient is an obese middle aged male, leading a sedentary lifestyle which puts him
at significantly increased risk of developing an acute myocardial infarction amongst
other various cardiac problems (Walker, M. 2005).

5. PATIENT EXAMINATION
• No radial or carotid pulse present
• Breathing absent, no chest rise/fall or breath felt
• LP15 showed asystolic rhythm
• Patient had been incontinent of urine & faeces
• Patient had aspirated vomit into airway
OBS:
Pupils dilated but equal and responsive to light
Pulse: absent Resps: absent
Temp: 34.8°C SpO2: 78%
BM: 7.6 Colour: pale with facial cyanosis
BP: Unable to obtain

6. TREATMENT & RESPONSE
LAS took over CPR, airway suctioned to insert i-gel airway to administer high flow oxygen via BVM.
IV access gained to administer epinephrine & amiodarone.
After third dose of epinephrine administered LP15 showed rhythm changed from asystole to ventricular
fibrillation. The patient was shocked a total of 14 times but remained in VF.
The patient was checked for reversible causes:
Hypoxia Tension Pneumothorax
Hypervolaemia Toxins
Hypothermia Thromboembolism
Hyperkalaemia Tamponade
Of which only hypoxia was presenting which was being treated with high flow oxygen

7. TREATMENT & RESPONSE
Due to the layout of the building extracting the patient would be challenging,
additional crews were requested to assist. The patient was highly obese and located
on the first floor of the property with the only access being via a narrow spiral
staircase.
The only method of extraction available was the use of a carry sheet, this meant that
the LP15 and oxygen had to be disconnected and it would not be possible to
maintain chest compressions during extraction. Due to the narrow staircase it was
impossible for more than two LAS members at a time to carry the patient making
the extraction slow and potentially dangerous for LAS members as well as delaying
treatment/compressions for the patient.
Once the patient was extracted to the ambulance he was reconnected to the LP15
which now showed asystole. Despite further CPR & drug administration the patient
remained in asystole throughout transport to hospital where on examination he was
pronounced dead by the resuscitation team.

8. EVIDENCE BASED TREATMENT: DRUGS
The patient received treatment as per LAS guidelines for out of hospital cardiac arrests,
including full drugs protocol using adrenaline and amiodarone.
Adrenaline is administered as a vasoconstrictor, this increases aortic diastolic pressure and in
turn increases coronary perfusion (Perkins, G. 2014).
Recently there has been mixed opinions as to the benefits of adrenaline in out of hospital
cardiac arrests, currently the ongoing Paramedic2 trial being conducted by the University of
Warwickshire is studying the use of adrenaline against a placebo.
It is suggested that the use of high dose adrenaline in cardiac arrest cases decrease cerebral
blood flow, increase ventricular arrhythmia and myocardial dysfunction in the event of a ROSC.
This creates a paradox of better short term survival at the potential cost of long term outcome
(Burnett, AM. 2012).
The LAS crew treating this patient had opted out of the study so were using known adrenaline.

9. EVIDENCE BASED TREATMENT: DRUGS
The second drug used, amiodarone, is given during cardiac arrest to treat specific cardiac
arrthymias, mainly ventricular fibrillation and ventricular tachycardia. The UK Resuscitation
Council recommends that the first treatment for ventricular fibrillation or ventricular
tachycardia should be electrical defibrillation. If this is unsuccessful after three attempts
amiodarone should be given.
Amiodarone’s main effect is to slow down the metabolism of cardiac tissue. The drug also
blocks the action of hormones that speed up the heart rate (Gallimore, D. 2006). The
overall effect is to slow the heart. This is important in a cardiac arrest when the heart is
beating too fast to produce a normal circulation.
As amiodarone slows the heart it can induce bradycardia or asystole if not carefully
monitored, if necessary atropine can be given to reverse these effects (Gallimore, D. 2006).

10. EVIDENCE BASED TREATMENT:
AIRWAY MANAGEMENT
Endotracheal intubation is regarded as the gold standard for airway management it is
recognised that there is a high risk of misplaced intubation by paramedics (Ridgeway, S. 2004).
LAS guidelines restrict the use of intubation to certain personnel due to this risk the patient’s
airway was secured using an i-gel device.
The i-gel provides a level of ventilation near equal to intubation (Uppal, V. 2008) as well as
being quicker and easier to use with minimal risk of misplacement. The i-gel can however be
more difficult to secure than an ET tube and like all airway management tools is at risk of
becoming dislodged when handling the patient.

11. EVIDENCE BASED TREATMENT: CHEST
COMPRESSIONS
Due to the difficult extraction it was not possible to maintain chest
compressions throughout the patient’s treatment. LAS guidelines
recommend no more than 10 seconds without chest compression at any
time except for specific interventions.
This resulted in an extended period of no chest compressions or ventilations.
A possible solution for situations such as this would be the more widespread
use of the LUCAS device which provides automatic mechanical CPR.
Whilst the LUCAS does not provide a significant difference in survival rates
for out of hospital cardiac arrests (8.3% using a LUCAS compared to 7.8%
using manual CPR - Ruberttson, S. 2014), it does provide the benefits of
freeing up an extra pair of hands and continuing CPR in situations such as
this where manual CPR cannot.

12. CONCLUSION
The management of out of hospital cardiac arrests is a subject that is heavily researched
and constantly evolving as new evidence emerges.
LAS has the highest survival rating of out of hospital cardiac arrests in the UK (UK
Resuscitation Council, 2014) which indicates their current guidelines are effective, however
whilst the guidelines are effective there is still room for improvement and the outcome of
the Paramedic2 trial may set a new precedent for drug administration.
Intubation remains the gold standard of airway management but i-gel devices are quicker
and easier to use with minimal risk of misplacement.
Both patients and ambulance crews may benefit from more widespread use of mechanical
CPR aids.

13. REFERENCES
Burnett, AM. 2012. Potential negative effects of epinephrine on carotid blood flow and ETCO2 during active
compression-decompression CPR utilizing an impedance threshold device. Resuscitation. 2012;83 1021-1024.
Gallimore, D. 2006. Understanding the drugs used during cardiac arrest response. Nursing Times. 102 (23) 24
Perkins, G. et al. 2014. Is adrenaline safe and effective as a treatment for out of hospital cardiac arrest? British Medical
Journal. 3 (48) 24-35.
Ridgeway, S. et al. 2004. Prehospital airway management in Ambulance Services in the United Kingdom. Anaesthesia.
2004;59 1091-1094
Ruberttson, S. et al. 2014. Mechanical chest compressions and simultaneous defibrillation vs conventional
cardiopulmonary resuscitation in out-of-hospital cardiac arrest: the LINC randomized trial. Journal of the American
Medical Association. 311 (1) 53-61
UK Resuscitation Council, 2014. Consensus Paper on Out-of-Hospital Cardiac Arrest in England.
Uppal, V. et al. 2008. Comparison of the i-gel with the cuffed tracheal tube during pressure-controlled ventilation. British
Journal of Anaesthesia. 102 (2) 264-268
Walker, M. et al. 2005. Weight change and the risk of heart-attack in middle aged British men. International Journal of
Epidemiology. 24 (4) 694-703.