December 5, 2024

62-year-old woman presents after being treated at the scene for (PEA)

By Med-Challenger · 2 minute read

A 62-year-old woman presents after being treated at the scene for pulseless electrical activity (PEA) with epinephrine, which improved her blood pressure and increased her heart rate from 50 to 65 beats/minute. However, she remained apneic and was successfully intubated in the field. She now has a pulse between 60 and 65 beats/minute, her blood pressure is 80/20 mm Hg, and she has persistent apnea unless ventilated. The paramedics report that she did not require sedation either before or after intubation. Her pupils are miotic but symmetrical.

Results on computed tomography (CT) of her head are normal, as are initial findings on a basic metabolic profile and bedside glucose determination. She was thought to be down about 3 minutes prior to the arrival of emergency medical services.

Her blood pressure has changed only minimally after a trial of normal saline bolus 500 mL.

The first treatment of choice for this patient is which of the following?

Naloxone
Dobutamine
Norepinephrine
Dopamine

The correct answer is:

Naloxone

Educational Objective:

Appropriately implement the opioid algorithm used by the American Heart Association.

Key Point:

Between the years 2016 and 2017, opioid overdose cases have risen by 31% among those aged > 55 years (with the sharpest increase seen in the Midwest).

Explanation:

This patient should be treated with naloxone.

This case represents a real patient who presented with an undisclosed heroin overdose. She did not have track marks on her arms, so the heroin overdose in this older patient initially went unrecognized. Rather, her miotic pupils led to an initial diagnosis of pontine stroke. However, results on CT were normal and her sodium levels were within normal limits. Hypoxic brain injury was also considered, but lack of response to the fluid bolus finally raised the concern for toxic overdose. Once that was considered, it became clear that the symptoms of bradycardia, relative hypotension, miotic pupils, and persistent apnea all pointed to that diagnosis.

Thus, the patient was given naloxone and immediately awoke and then became combative.

This scenario underscores an important point to remember: Although they are useful, Advanced Cardiac Life Support (ACLS) guidelines cannot cover every case. The health care professional must always consider pseudo-electromechanical dissociation when an organized rhythm is present in the absence of a pulse. Drug overdose is one of the well known but easily overlooked causes of PEA.

Because opioid overdose is unresponsive to standard ACLS algorithms, the 2015 American Heart Association (AHA) guidelines added a new algorithm for opioid overdoses (see Figure).

image (35)

References:

Centers for Disease Control and Prevention. Opioid overdoses treated in emergency departments. Published 2018. Accessed August 20, 2018.

American Heart Association. Web-based Integrated Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care (This site blends the 2019 Focused Updates with the 2015 AHA Guidelines for CPR and emergency cardiovascular care). Part 10: Special Circumstances. (accessed on April 16, 2020)

Lavonas EJ, Drennan IR, Gabrielli A, et al. Part 10: special circumstances of resuscitation: 2015 American Heart Association guidelines update for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation. 2015;132(suppl 2):S501-S518.

Nikolaides JK, Thompson TM. Opioids (chapter 156). In: Wall R, et al. Rosen’s Emergency Medicine: Concepts and Clinical Practice. 9th ed., 2018:1943-1946.

Szpilman D, Bierens J, Handley A, Orlowski J. Drowning*.* N Engl J Med. 2012;366(22):2102-2110.

Vanden Hoek TL, Morrison LJ, Shuster M, et al. Part 12: cardiac arrest in special situations: 2010 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation. 2010;122(18 suppl 3):S829-S861.

This question appears in Med-Challenger Emergency Medicine Review with CME

Try for free and save. Ace your exams and meet your CME/MOC requirements for just $35 a month!

No matter your program, no matter the size, Med-Challenger for Groups and Institutions can better prepare your program or group, fulfill industry requirements, and increase test scores.