A 58 year old man is brought in by ambulance moribund with barely palpable pulse and a sinus tachycardia. A large pulmonary embolus is confirmed. 

(d) He  suddenly  collapses. He  is  pulseless  and  unconscious  with  a  persistent sinus tachycardia on ECG. What will you do?

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College Answer

{d) Ideally, intubate and ventilate with 100%  02, turn  up the noradrenaline, repeat fluid bolus, commence CPR if indicated and transfer immediately to the OT for surgery. In the absence of cardiac surgery 'facilities, one is left with a Trendelenberg operation by a general surgeon or continued medical therapy or risk lysis.

Discussion

This is a question regarding the management of a PEA arrest.

Another question - Question 15 from the first paper of 2011 - discusses the management steps, but with a different history of presentation. The steps are generic, and I will reproduce them here to simplify revision. Additionally, PEA is discussed in greater detail in the answer to Question 8 from the second paper of 2004.

Thus:

1) Confirm cardiac arrest

2) Call for help

3) Commence BSL (CPR) until help arrives;

  • 100 compressions per minute
  • Compression to a depth of 1/3rd of the anterior-posterior chest diamweter
  • Asynchronous ventilation of 8-10 breaths per minute if intubated, otherwise 30 compressions to 2 breaths.
  • Ensure the ETT is not malpositioned (chest examination, end tidal CO2 or calorimetry)

4) With help arriving, follow the non-shockable pathway of the ALS algorithm, which consists of CPR and 1mg adrenaline every 2nd cycle.

4) Work on resolving the cause of the arrest, using the "four Hs and four Ts" as a general guide.

References

References

The index of ARC guidelines is available from the ARC website.

It contains the relevant algorithm for managing a non-shockable rhythm.