The agonal breath

[VentdependenT]

runnin a code today. No pulse. Pea. Good solid 20 min. by the book.

gets no love as a "new" July 1 fellow at the new big fat private tertiary care hospital. Proving myself daily...anyways...

ready to call it. Everyone agrees. A physician began to argue with me that because the pt was "breathing" that there must be a pulse and demanded pressors and that we hook pt up to vent. we had ultrasound to show this physician lack of doppler color on carotids and femoral artery and eventually threw probe on heart for the finale.

I had never had this sort of..uh..."discussion" before. It is clear that agonal respiratory movements can occur in pts without a pulse and that it can last several minutes before apnea. I wasnt about to argue and thought the visual lack of arterial flow would have been enough proof that this phenomena occurs. While switching to cardiac probe this dr tried putting in femoral aline to "see the pulse."

ive seen agonal breathing plenty of times in pulseless people and have heard the "Ooooh the pt is breathing! Stop CPR!"

Holy friggen poop man...holy poop.

thoughts? Anyone encounter this type situation with a health professional"

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[Hernandez]

There was a recent study that did show if you run a code >25 minutes, they do have slightly better survival to discharge.....and it is hard to call a code with them still.....moving. I do tend to keep going a little longer if angonal, not because it changes the outcome, but because its feels less.....wrong. If that makes sense...unless the nursing staff who is in the code with me and I know the pt well and know its futile, but not a code on the floor.

 

[VentdependenT]

There was a recent study that did show if you run a code >25 minutes, they do have slightly better survival to discharge.....and it is hard to call a code with them still.....moving. I do tend to keep going a little longer if angonal, not because it changes the outcome, but because its feels less.....wrong. If that makes sense...unless the nursing staff who is in the code with me and I know the pt well and know its futile, but not a code on the floor.

RV failure from long standing pulm htn. Septic (no longer in shock prior to code) from a groeshong (spelling) catheter. probably giant PE (or a baby one with that shot RV) Plates 20. Coags wacky. pt resuscitated prior, lactate from15 to 4 quickly. no pressors prior to code. lytes fine prior to code. Blood pouring out of ett...no pulse. Youd keep going with agonal breathing? It would just persist if your cpr was good...

But you didnt answer my question. Do you keep going JUST because of agonal breathing IF youve given resuscitation your best shot in a pt like this?

I read a recap of that article months ago in ACP hospitalist.

 

[Hernandez]

But you didnt answer my question. Do you keep going JUST because of agonal breathing IF youve given resuscitation your best shot in a pt like this?

If I and the staff know the pt and its like you describe, no, I'd stop even if agonal....., just walking in on a code, I'd keep going.

 

[VentdependenT]

If I and the staff know the pt and its like you describe, no, I'd stop even if agonal....., just walking in on a code, I'd keep going.

Word. Thanks

 

[gro2001]

RV failure from long standing pulm htn. Septic (no longer in shock prior to code) from a groeshong (spelling) catheter. probably giant PE (or a baby one with that shot RV) Plates 20. Coags wacky. pt resuscitated prior, lactate from15 to 4 quickly. no pressors prior to code. lytes fine prior to code. Blood pouring out of ett...no pulse. Youd keep going with agonal breathing? It would just persist if your cpr was good...

But you didnt answer my question. Do you keep going JUST because of agonal breathing IF youve given resuscitation your best shot in a pt like this?

I read a recap of that article months ago in ACP hospitalist.

If you know the patient well and based on the knowledge and the clinical situation you come to the conclusion that further resuscitation would be futile (sounds like that was the case), sure you can stop.

If you don't know the patient's situation too well and they are breathing (even agonally), then it's hard to stop without some objective data to prove (more to yourself) that they are truly pulseless and not just very hypotensive. In this case, you had ultrasound (in addition to the clinical picture and foreknowledge of the patient), which is pretty convicing.

Sounds like you did the right thing though.

 

[Bostonredsox]

If I have run a code for 20+ min and I Stick the US on and see a motionless LV with no pulse, I call it.