“He just Died” | Figure 1

"He just Died"

Patient Description
82 y/o male, wife called 911 due to pt. going 'unconscious' at home.

Initial Assessment
EMS arrived on scene (ALS crew) found pt. to be in the living room in a hospital bed lying in semi fowlers position. Wife shares pt. just got home from being admitted to hospital x 6 weeks for 'swollen legs'.

Pt. was A/O to verbal stimuli. He appeared lethargic and his eyes were closed while walking toward him. He would not open his eyes when answering yes or no questions on introduction but still answered basic questions slowly. GCS was 14 (E=3 V=5 M=6). A-patent, B-regular, shallow around 12 bpm, C-unable to palpate radial pulses, carotid was weak, brady and regular. Skin was clammy and he was pale. Note pt. was wearing a depend for incontinence issues.

Vitals

• BP: 57/34 (auscultated 58/32) similar in L and R arms
• HR: 55, regular on 4 lead ECG
• SATS: 88% on 2LPM O2 via NC
• RR: 12
• Temp: 36.8
• BGL: 14.0
• Pt. was a negative COVID screen.
• Lungs were clear x 4 fields.
• No swelling or edema noted in legs.
• Pt. able to follow basic CNS commands w/ grips and push/pull in extremities. Good CMS noted as well.

History

• High cholesterol
• HTN
• CHF (EF of 28%) possible hx of a-fib as well, wife was a poor historian. DNR in place.

Medications

• Lipitor
• Propranolol
• ASA
• NKA

4 lead was sinus bradycardia @ 55. 12 lead was the same but noted inverted T waves in V1-V4 leads (possible ventricular ischemia?)

Family Report
Wife shares she called 911 because pt. went unconscious for about a minute x 1 episode and wouldn't respond to her at all. Wife also explains that pt. was told he may have lung Ca w/ mets to the bone while admitted to the hospital, however, they have not officially diagnosed him as of yet and he is awaiting more tests.

Actions Taken
O2 increased from 2LPM home O2 to 4LPM. SATS came up to the mid 90's. IV initiated 20g in right hand. NS bolus initiated 500mL over 1 hour (due to EF). Pt. was loaded onto the ambulance stretcher and prepped for transport. On extrication to the ambulance when outside, pt. opened his eyes and shared a short conversation with medics on the weather being cold. This was the most responsive the pt. had been seen up until this point. Pt. understood the need for transport and his current hypotension.

En Route Observations
En route to hospital, pt. eyes remained open and he was asking if his BP had come up at all. He was at a 45 degree angle at the head rest and his legs were elevated to a "Trendelenburg" position with pillows/blankets. GCS now 15. At this point BP was 72/40. SATS remained around 96%-97% on 4LPM O2 NC.

Incident During Transport
Halfway through transport (roughly 30 mins into this ambulance call) pt. went flaccid and his head fell to the right. His eyes remained open but he started breathing through his mouth (almost as if he was blowing air off through his mouth with his lips together). He was not blinking, unresponsive to verbal stimuli and painful stimuli (sternal rub). No changes on ECG monitor noted. Pt. then went apneic lasting 10-15 seconds. Unable to palpate a radial and carotid pulse. No seizure like activity noted.

EMS stated they were convinced that the pt. "just died". Then, spontaneously the pt. started breathing again and sat up asking again "Did my blood pressure come up at all?" Pt. re-assessed to find carotid pulse present but weak at 60bpm. SATS were 88% and climbing. BP re-assessed to be 100/60. GCS 15, RR 16. No changes noted on ECG. Vitals remained the same for remainder of transport. SATS came up to 96% remaining on the NC.

Questions for Consideration

1. What are some working diagnosis that come to mind?
2. What are some prehospital treatments that should be done?