Expanded case summary This should not exceed three pages of A4

Age: 69 Sex: Male Primary Presenting Problem: Respiratory

arrest

Underlying diagnosis: Post-cardiac arrest

Key aspects of initial assessment:

History: Witnessed cardiac arrest at home wife reported patient had

stopped breathing following a deep breath - no family CPR. 5-10 mins had
passed before CPR was commenced by paramedics on arrival. 4 x
adrenaline given. Initial rhythm: PEA. After 4th round of adrenaline ->
spontaneous return of circulation confirmed via carotid and radial pulses.
Arrest lasted for approx. 22 minutes. No respiratory effort noted on
admission to hospital.

Background of: COPD, osteoporosis, spinal surgery, chronic back pain

Examination:
Airway: Clear with no respiratory effort. Adjunct (i-gel) was inserted with
BVM to maintain airway and ventilation.
Breathing: RR via BVM: 10-12/minute (no respiratory effort by patient).
Ausc: crackles heard in lung bases, SaO2: UTR (95% on ABG @ 100% O2)
Circulation: HR: 115, HS1+2+0, BP 112/80mmHg, cool peripheries, CRT
>5s
Disability: GCS: 3/15, Pupils: fixed and dilated 5mm bilaterally. Temp:
36.6, BM: 6.1
Exposure: Abdomen soft + non-tender.

Investigations:
Oxygen saturations were measured to ensure that the patient was
ventilating adequately. An ABG sample was taken to give a more precise
measure of blood gases mainly O2 and CO2 levels as well measuring
glucose and lactate to ensure adequate tissue perfusion and reverse any
underlying pathology.

ABG results:
pH 7.025
PCO2 17.85
HCO3 34.2mmol/L
Lactate 13.1mmol/L

Initial management decisions:

- On arrival at home, the family requested for CPR not be
commenced. However, as there was no DNAR in place, the
 paramedics acted in the patients best interests and commenced
CPR until a discussion had taken place.

- The patient had a non-shockable rhythm (PEA). Therefore, as per

ALS guidelines for cardiac arrest, 4 rounds of adrenaline were
administered IV before a ROSC.

- Once the patient had been admitted to hospital, the DNAR was
discussed in further detail and all teams were in agreement that
further intervention would not be appropriate. DNAR form was
completed -> i-gel removed -> patient made comfortable with
presence of family -> end of life care

Transfers of care / referrals:

- Senior review (S/R) by ITU + Cardiac arrest team on arrival
- Poor quality of life/functional status and progressive deterioration
was noted
- Following discussion with ICU team and family, it was felt that
further intervention or escalation to ITU would not be appropriate.
DNAR form completed.

Key therapeutic interventions during critical illness:

- CPR, 4 x adrenaline IV treatment of cardiac arrest
- Ventilatory support -> to normalise arterial blood gas levels and
acid-base imbalance by providing adequate ventilation and
oxygenation

What were the roles of members of the multiprofessional team?

- Paramedics commenced CPR and administered 4 x adrenaline
before ROSC
- Nurses basic observations/ventilatory support, communication +
reassurance to family
- Doctors (ED + Cardiac arrest team) management decisions, in this
case the need of a DNAR -> end of life care
- ITU doctors decision on escalation of care -> patient not suitable
for ITU admission -> end of life care

Were any clinical guidelines used in the management of this

patient?
- ALS guidelines cardiac arrest were used. The guidelines state that if
there are no signs of life, CPR should be commenced immediately at
a ratio of 30 chest compressions:2 breaths. A defibrillator/monitor
should be attachment, whilst minimising any interruptions to CPR. In
this patient the monitor detected a non-shockable rhythm (PEA) and
hence CPR should be immediately resumed and 1mg IV adrenaline
 (10ml of 1:10,000) administered. Adrenaline should then be given
every 3-5 mins in alternate cycles. If a pulse is present -> start post-
resuscitation care

What ethical issues were raised in the management of this

patient?
- The patient was unconscious, hence lacked capacity to make
decisions. Best interests pathway was used with input from both
doctors and family members -> DNAR was eventually put in place.
The ethical issue that arose was when the family requested the
paramedics not not to perform CPR, despite a DNAR not being being
in place. Although the family may have been acting in the patients
best interests, the paramedics also have a duty of care towards the
patient and as there was no formal documentation to go by, the
most appropriate line of action was to promptly begin CPR.
Discuss your understanding in greater detail three items from the
case summary.

I learnt a great deal at how difficult it can often be to make end of

life decisions. Some indications for completing a DNAR form include:
o If cardiac or respiratory arrest is an expected part of the
dying process and CPR will not be successful, making and
recording an advance decision not to attempt CPR will help to
ensure that the patient dies in a dignified and peaceful
manner. (GMC guidance, 2016)
o In cases in which CPR might be successful, it might still not
be seen as clinically appropriate because of the likely clinical
outcomes. When considering whether to attempt CPR, you
should consider the benefits, burdens and risks of treatment
that the patient may need if CPR is successful. In cases where
you assess that such treatment is unlikely to be clinically
appropriate, you may conclude that CPR should not be
attempted (GMC guidance, 2016)
o If a patient is admitted to hospital acutely unwell, or becomes
clinically unstable in their home or other place of care, and
they are at foreseeable risk of cardiac or respiratory arrest, a
judgement about the likely benefits, burdens and risks of CPR
should be made as early as possible. (GMC guidance, 2016

Cardiac arrest mortality following CPR. In the UK, fewer than 10% of
all people in whom a CPR attempt is made outside hospital survive.
This is possible where the arrest is recognised immediately,
bystanders perform CPR, and an automated defibrillator is used
before the ambulance service arrive. Survival rates in excess of 50%
 have been reported under these circumstances. (Resuscitation
Council, 2016)

Is there anything that could have been done better for this
patient?
In retrospect, I wondered if a DNAR discussion with family/patient should
have been made at an earlier date. This may prevent unnecessary
distress to the patient/relatives. However, I do appreciate the difficult
nature of these conversations and of course timing is crucial.