Case 2
Case 2
58F with history of CAD s/p multiple remote DES, HLD, T2DM, Active smoker now admitted for UTI with sepsis.
Telemetry alarms “code blue” on hospital day 2.
On initial assessment, pulses are absent.
Labs
- Acid-base: pH 7.18, HCO₃⁻ 16, pCO₂ 48.
- Perfusion/electrolytes: lactate 6.5, K⁺ 4.9, iCa²⁺ 1.10.
- Context: glucose 152, hs-TnI 121 (ULN 50).
Rhythm Check
Post-ROSC EKG
Next step?
After ROSC: stabilize before you celebrate
- ECG as soon as feasible.
- O2 100% until reliable; then SpO2 90-98%.
- PaCO2 35-45 if comatose/ventilated.
- Avoid hypotension; MAP >=65.
- If unresponsive: temperature control >=36 hours.
- Search cause: coronary, PE, tamponade, hemorrhage, PTX, tox/metabolic.
Team interface prompt
The nurse who called the code saw the telemetry alarm and knows when the patient lost pulses.
Ask:
“What rhythm triggered the alarm, when did compressions start, and has the first shock happened?”
Close the loop on shock timing and post-ROSC ECG.
Teaching Points
Time to first shock is critical in VF
Role of antiarrhythmics is adjunctive, not primary
Persisting VF/pVT: follow device energy strategy; if unsure, maximum biphasic energy is reasonable. Protect compression fraction and confirm pads/contact. Do not teach routine DSED/vector-change as standard care.
VF/VT: Think.. acute MI (sudden, chest pain), electrolyte derangements, drug toxicity
Case summary
Label: VF/VT arrest with post-ROSC ECG and stabilization.
Key issue: shock early, protect compression fraction, then stabilize and search for the post-ROSC cause.