Question 1

WHAT ARE YOUR THOUGHTS AT THE BEGINNING OF THIS PATIENT ENCOUNTER AND WHAT ARE YOUR FIRST ACTIONS AT THE BEDSIDE OF THIS PATIENT? WHAT CAN YOU DO TO HELP MORE RAPIDLY FACILITATE THE MOVEMENT OF THE PATIENT TO YOUR COT AND INTO THE AIRCRAFT? WHAT RESPONSIBILITIES ARE YOURS AND WHAT ARE THE NURSES? DO YOU HAVE ASSIGNED ROLES? WHAT TIMES ARE YOU RESPONSIBLE FOR KNOWING AND DOCUMENTING IN GOLDEN HOUR?

The initial assessment of these patient’s should focus on a time-efficient history and physical, data collection, and transfer to the helicopter. As pointed out by many, the initial steps at the bedside involve having the nurse focus on the IV drips (if any of these are to be continued), while you gather the critical aspects of the history and physical and place the patient on the monitor and apply the defib pads. In this hypotensive patient with an inferior STEMI, stopping the nitro gtt, dopamine gtt, and starting a bolus of IVF is a good next step. Not pointed out by many, there are some crucial times to gather as you are initially sorting through the patient’s presentation. You’ll want to document time of arrival to the ED and the time of initial diagnostic EKG.

Question 2

JUST AFTER TAKEOFF, THE PATIENT TURNS TO YOUR PARTNER AND SAYS “I DON’T FEEL SO WELL…” AND PROMPTLY GOES INTO A VENTRICULAR FIBRILLATION ARREST. WHAT ARE YOUR PRIORITIES FOR THE MANAGEMENT OF THE PATIENT? WHAT INTERVENTIONS DO YOU NEED TO PERFORM AND WHO PERFORMS THEM? AND, HOW DOES THIS DIFFER INSIDE THE BACK OF THE HELICOPTER WHEN COMPARED WITH A CODE IN THE ED?

This is where things get tricky - the in-flight code. Running a code in-flight is exceptionally challenging, take a look at this post to see first hand just how difficult it can be. As Dr. Sabedra points out, early defibrillation is key as the patient has a shockable rhythm (thus the importance of having defib pads already applied to the patient). She also points out that the 2 top priorities of the management of this code should be on shocks and high quality CPR. Airway management should focus on minimal effort interventions. Early defib may result in early ROSC and obviate the need for any airway intervention. If you do need to intervene, an iGel or other such extraglottic device is a quick way to ensure delivery of effective ventilation and oxygenation. What about epi though? Drugs are certainly nice to have but take a back seat in the management of these patients. If you have the time to help pull up and administer drugs while the nurse delivers compressions, great. If not, focus on the things that matter the most, electricity, CPR, and appropriate oxygenation/ventilation.

Question 3:

THE PATIENT IS STILL IN CARDIAC ARREST AS YOU ARE LANDING AT THE RECEIVING CATH-CAPABLE HOSPITAL HELIPAD AND YOU AND YOUR PARTNER ARE STILL VALIANTLY TRYING TO RESUSCITATE THE PATIENT. WHAT ARE YOUR NEXT STEPS? IS THERE ANYONE THAT YOU WOULD CONSIDER CALLING? DO YOUR DESTINATION PLANS CHANGE AT ALL?

There are 2 critical aspects to this question as pointed out by Dr. Shaw. First, the Air Crew is going to be a bit fatigued after running this code. Having additional staff on hand to help with continued CPR is going to be huge. Second, this patient’s cardiac arrest is ultimately secondary to ischemia and blockage of a coronary artery. Coordinating with the receiving hospital and the cardiac cath lab is also going to be important. Some facilities will divert you to the ED where you can run the code further (and in this case it may be that you consider pushing lytics if all other options are exhausted). Some centers may be comfortable with taking the arresting patient to the cath lab, though this is still relatively uncommon.

Question 4

NOW, INSTEAD OF MAKING IT TO THE AIRCRAFT, THE PATIENT ARRESTS AS YOU ARE MOVING HIM ONTO YOUR COT WHILE STILL AT THE REFERRING HOSPITAL. YOU PERFORM GOOD QUALITY CPR AND ACLS AT THE OUTSIDE HOSPITAL FOR ~10 MINUTES, BUT THE PATIENT IS STILL IN CARDIAC ARREST. WHAT OTHER INTERVENTIONS COULD YOU CONSIDER? WOULD YOU CONSIDER STILL TRANSPORTING THE PATIENT IN THIS STATE?

As pointed out by Dr. Merriam, loading the patient in the helicopter while they are coding is not a good idea. If you are still in the ED of the referring facility, running the code further while you are there is going to be best for the patient and for the crew. For the refractory V fib or Vtac patient there are a number of ‘hail mary’ options available: double sequential defibrillation, pushing thrombolytics, and esmolol are all considerations in this scenario.